Medication Safety Self-Assessment: Focus on "Never Events" in Hospitals and Ambulatory Care Centers Instructions

Instructions for Completing the Self-Assessment

1. Establish an interdisciplinary team similar to the following:

  • Senior leadership representative
  • Patient or patient representative/advocate
  • Patient safety/quality improvement and/or risk management professional
  • Nursing director/manager
  • Pharmacy director/manager
  • Physician leader (e.g., chief of service)
  • Frontline staff (at least one of each of the following):
    • Registered nurse
    • Registered practical nurse
    • Pharmacist
    • Pharmacy technician
    • Pharmacy assistant, if applicable
    • Physician

Include representation from different services within the facility.

2. Distribute the self-assessment document before the team meeting so that team members can review and consider the questions in advance.

3. Discuss each self-assessment item and evaluate the facility's current success in implementing the item.

As necessary, investigate and verify the level of implementation for each item with other healthcare practitioners and staff outside the assessment team.

Possible responses:

  1. A There has been no activity to implement this item
  2. B This item has been formally discussed and considered but not implemented
  3. C This item has been partially implemented for some areas, patients, medications and/ or staff in the facility
  4. D This item is fully implemented for some areas, patients, medications and/or staff in the facility
  5. E This item is fully implemented throughout the facility
  6. NA Not applicable - use this option if the assessment criteria does not apply to your facility.

Facilities may want to consider assigning an individual to record any discussion generated around each assessment item and the rationale behind the selected choice. This information, meant for internal use only, can assist the team when reviewing scores for individual items or reassessing the facility at a later date.

Scoring Guidelines:

For all assessment items:

  • All assessment items refer to medications prescribed, dispensed, and administered to all patients or clients of the facility unless otherwise noted.
  • Choice of E (full implementation) is appropriate only if all components are present in all areas of the facility, for all patients, all medications, and followed by all personnel. If only one or some of the components of the item have been fully implemented in only some or all areas of the facility, select C or D.

4. For assessment items that are not applicable to your facility:

Some assessment items may not be applicable to all facilities; for these items, criteria for a "not applicable" response have been provided. For example, facilities that do not treat pediatric patients will have no associated risks.

5. Finalize your assessment.

You will be prompted to save your responses for each section before you proceed to the next section page. When all responses have been entered, you will be prompted to "Check MSSA for errors" and then to submit your results.

Once you have submitted your results you cannot edit them. The web-based survey tool will immediately download the information into a secure database maintained solely by ISMP Canada. No data will be maintained on the Internet survey form after it has been submitted. Individual results can be viewed or accessed only by the facility submitting them. Confidentiality is assured.

Individual results can be viewed or accessed only by the facility submitting them. The aggregate findings will be available for viewing by others once a minimum of three facilities have submitted results.

6. View/print your completed assessment.

Once your results have been submitted you will be able to view or print a report summarizing your results.

7. Compare your results to the aggregate.

Once your results have been submitted you will immediately be able to compare your results to the aggregate response. You can compare to the total aggregate or to demographically similar facilities using the filters provided.

8. Using aggregate data

Facilities can freely share their own results internally and externally to the organization as they deem appropriate; however, any comparison to the de-identified aggregate can only be shared externally to the organization with the written permission of ISMP Canada.

ISMP Canada and CPSI may use aggregate data for research and education purposes.