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Focus on "Never Events" in Hospitals and Ambulatory Care Centers

The Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI) are excited to launch this new Medication Safety Self-Assessment (MSSA) program focusing on "never events".

Never events are patient safety incidents that result in serious harm or death, and that can be prevented by using organizational checks and balances.

The Medication Safety Self-Assessment: Focus on "Never Events" in Hospitals and Ambulatory Care Centres (MSSA – Never Events) was designed to help Canadian healthcare practitioners in hospitals and ambulatory care centres to identify and address system vulnerabilities underlying critical incidents associated with high-alert medications, with a specific focus on never events.

Content has been derived from material developed through the Canadian Medication Incident Reporting and Prevention System (CMIRPS), including ISMP Canada Safety Bulletins and MSSA programs for hospitals and long-term care and CPSI's Global Patient Safety Alerts. Information from materials developed by ISMP in the US has also been incorporated, including from the ISMP Medication Safety Self-Assessment for High-Alert Medications.

This program is designed to support hospitals and ambulatory care centres in:

• Raising awareness of medication-related never events;
• Identifying high-leverage strategies to reduce the likelihood of never events and other critical incidents with high-alert medications;
• Creating a baseline measurement of the current implementation of recommended strategies to avoid never events; and
• Evaluating progress over time through periodic repeated measurement.

The assessment includes a total of 108 items, divided into 13 sections. Section I focuses on known never events and Section II on general strategies for safety. Sections II-XIII focus on selected high-alert medication classes. Not all items will be applicable in all settings.

Within each section, the assessment items are presented in an order that reflects the medication use process, beginning with patient engagement and then following the steps in the medication use process: prescribing, order processing/transcription, dispensing, administration and monitoring. Some sections also include "Supporting System Elements", such as Staff Competence and Education, and Quality Processes and Risk Management. Not all sections include items from each of these steps.

ISMP Canada and CPSI are not standard-setting organizations; the assessment items in this document are not intended to represent a minimum standard of practice and should not be considered as such. In fact, some of the items represent innovative practices that may not be widely implemented; however, their value in reducing errors is grounded in scientific research and expert analysis of medication errors and their causes. Healthcare practitioners in hospitals and ambulatory care centres may choose to use this assessment as an important resource for informing and prioritizing their actions for quality improvement.

This assessment is also aligned with the World Health Organization Global Patient Safety Challenge: Medication Without Harm.

The MSSA – Never Events and its components are copyrighted by ISMP Canada and may not be used in whole or in part for any other purpose or by any other entity except for self-assessment of medication systems as part of ongoing quality improvement activities.