medication safety initiatives developed by ismp-canada · 10/1/07 a key partner in the canadian...

10/1/0710/1/07 A Key Partner in the Canadian Medication Incident Reporting and Prevention SystemA Key Partner in the Canadian Medication Incident Reporting and Prevention System®®

Medication safety initiativesMedication safety initiativesdeveloped by ISMP-Canadadeveloped by ISMP-Canada

David UDavid UPresident and CEOPresident and CEO

ISMP CanadaISMP Canada

22 ©© Institute for Safe Medication Practices Canada Institute for Safe Medication Practices Canada®®

ISMP CANADAISMP CANADA•• Independent national, nonprofit CanadianIndependent national, nonprofit Canadian

organizationorganization•• Established for:Established for:

the collection and analysis of medication errorthe collection and analysis of medication errorreports andreports and

the development of recommendations for thethe development of recommendations for theenhancement of patient safety.enhancement of patient safety.


ISMP Canada Vision ISMP Canada Vision

Collaborating nationally andinternationally to advance

safe medication use.


International CollaboratorsInternational Collaborators

• USA – ISMP• Spain – ISMP Spain• United Kingdom – NPSA• Australia –Clinical Excellence

Commission of New South Wales• Ireland – Reporting program


Top 6 medications reported in ISMPTop 6 medications reported in ISMPCanada Practitioner Report programCanada Practitioner Report program

31316767TotalTotal3.23.277HydromorphoneHydromorphone3.23.277HeparinHeparin4.14.199MethadoneMethadone5.15.11111InsulinInsulin6.56.51414MorphineMorphine8.88.81919PotassiumPotassium%%N (217)N (217)


ISMP Canada FocusedISMP Canada FocusedMedication InitiativesMedication Initiatives

•• Concentrated Electrolytes (Concentrated Electrolytes (KClKCl))•• High Potency Opioid NarcoticsHigh Potency Opioid Narcotics

(morphine, hydromorphone,(morphine, hydromorphone,fentanyl)fentanyl)

•• Anticoagulants (heparins, warfarin)Anticoagulants (heparins, warfarin)•• InsulinInsulin


Potassium Chloride Potassium Chloride


Potassium ChloridePotassium Chloride•• Focused initiative for the province ofFocused initiative for the province of

Ontario in 2003Ontario in 2003•• Key Intervention: Removal ofKey Intervention: Removal of

concentrated concentrated KClKCl solutions from all solutions from allpatient care areaspatient care areas

•• Significant changes made by hospitalsSignificant changes made by hospitals•• A re-survey to determine and addressA re-survey to determine and address

other barriersother barriers


ISMP Canada Medication Safety Support ServicePotassium Chloride Concentrate Follow Up Survey

10%

50%

15%

65%

14%

19%

0% 1%

8%

62%

39%

1%

96%

12%10%

95%

38%

26%

35% 35%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pharmacy Stores Cupboard Wards Clinics ICU RU ER NICU Peds

Locations of Concentrated KCl

Num

ber o

f Res

pons

es (%

)

Nov. 2002 Survey (n=135) Jul. 2003 Survey (n=104)


ISMP Canada Medication Safety Support ServicePotassium Chloride Concentrate Follow Up Survey

21%

42% 43%

71%

38%

24%

73%

86%

57%

71%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Buy Premix Make Premix Standards Guidelines Autosubstitution

Use of Pre-mixed KCl Solutions and Standardization in Ontario Hospital Sites

Num

ber o

f Res

pons

es (%

)

Nov. 2002 Survey (n=135) Jul. 2003 Survey (n=104)


Independent SurveyIndependent Survey

““Concentrated electrolytes were reportedConcentrated electrolytes were reportedto have been removed from patient careto have been removed from patient careareas by 72 % of all respondents and byareas by 72 % of all respondents and byalmost all respondents in Ontario (96%).almost all respondents in Ontario (96%).This reflects the success of safetyThis reflects the success of safetyinitiatives conducted by ISMP Canada withinitiatives conducted by ISMP Canada withOntario hospitalsOntario hospitals””

2003-2004 Lilly Survey2003-2004 Lilly Survey


Narcotic (Opioid) ProjectNarcotic (Opioid) Project


High Potency Opioid NarcoticsHigh Potency Opioid NarcoticsInitiative (2004-2005)Initiative (2004-2005)

•• To survey Ontario hospitalTo survey Ontario hospitaldetermining system safeguards fordetermining system safeguards fornarcotic distribution andnarcotic distribution andadministration in placeadministration in place

•• To assist hospitals in implementingTo assist hospitals in implementingsystem improvement changessystem improvement changes


Priority Recommendations:Priority Recommendations:


130 Ontario hospitals (94%)130 Ontario hospitals (94%)have begun to implementhave begun to implement

narcotic system safeguards!narcotic system safeguards!


• 79% havereviewednarcoticstorage areas

• 57% areprovidingpharmacypreparation

• 36% arepurchasingpremixes

Narcotics (Opioids) SurveyNarcotics (Opioids) SurveyResultsResults


Ontario hospitalsindicate an

overall reductionin patient careareas stockinghigh potency

narcotics!

• Morphine 50 mg/mL:availability reduced in5 out of 6 patient-careareas

• (55% reduction inMed/Surg)



Ontariohospitals

indicate anincrease in IDCpolicies for ALL

adult andpaediatric

administration!



ThromboprophylaxisThromboprophylaxis Pilot PilotProject ObjectivesProject Objectives

•• Develop and implement interventionsDevelop and implement interventionstoolkit to improve compliance withtoolkit to improve compliance withevidence-based CPG forevidence-based CPG forthromboprophylaxisthromboprophylaxis in hospital patients in hospital patients

•• Evaluate impact of project interventionsEvaluate impact of project interventions•• Document process and health careDocument process and health care

outcomesoutcomes


Remove High Potency Heparin Remove High Potency HeparinProducts From Nursing UnitsProducts From Nursing Units

•• Identify targeted heparin productsIdentify targeted heparin products•• Develop alternative approaches toDevelop alternative approaches to

address apparent needs of heparinaddress apparent needs of heparinproductsproducts

•• Plan coordinated strategiesPlan coordinated strategies•• Conduct pilot to implement strategiesConduct pilot to implement strategies•• Measure safety and process changeMeasure safety and process change

successsuccess•• Implement strategies to all CanadianImplement strategies to all Canadian

hospitalshospitals


Proactive Risk Assessment ToolProactive Risk Assessment ToolDevelopment InitiativeDevelopment Initiative

•• Failure Mode and Effects AnalysisFailure Mode and Effects Analysis(FMEA) module(FMEA) module

•• Tools for various risk assessmentTools for various risk assessmentneedsneeds

•• More human factor engineeringMore human factor engineeringprinciples as triggersprinciples as triggers


Root Cause Analysis FrameworkRoot Cause Analysis Framework•• Pan-Canadian RCA FrameworkPan-Canadian RCA Framework•• A tool for reviewing critical eventsA tool for reviewing critical events•• A team based and multi-disciplinaryA team based and multi-disciplinary

approachapproach•• Determine what happened, how and why itDetermine what happened, how and why it

happened and what can be done to reducehappened and what can be done to reduceits likelihood of recurrenceits likelihood of recurrence

•• Workshops offered to learn how to conductWorkshops offered to learn how to conductRCA internallyRCA internally

•• ISMP Canada also undertakes RCA forISMP Canada also undertakes RCA forfacilities on requestfacilities on request


Medication ReconciliationMedication Reconciliation


MedicationMedication

ReconciliationReconciliation

Across theAcross the

Continuum of CareContinuum of Care


Hospital Medication Safety Self-Hospital Medication Safety Self-AssessmentAssessment

•• Developed by ISMP US;Developed by ISMP US;adapted for use inadapted for use inCanada 2001 and 2006Canada 2001 and 2006

•• Based on more than 20Based on more than 20years of:years of:

ResearchResearch Error ReportsError Reports RCA and ConsultsRCA and Consults Expert OpinionsExpert Opinions


Purpose of MSSAPurpose of MSSA

•• Promotes distinguishing characteristicsPromotes distinguishing characteristicsof a safe medication systemof a safe medication system

•• Facilitates assessment of medicationFacilitates assessment of medicationsystemsystem

•• Identifies opportunities for improvementIdentifies opportunities for improvement

•• Creates a baselineCreates a baseline

•• Evaluates improvement efforts over timeEvaluates improvement efforts over time


Medication Safety Self AssessmentMedication Safety Self Assessment

•• 10 key Elements10 key Elements•• 20 Core Distinguishing Characteristics20 Core Distinguishing Characteristics•• 236 items236 itemsResponses ranges fromResponses ranges fromA - No activity to implement this itemA - No activity to implement this item

ToToE - Fully implemented throughoutE - Fully implemented throughout



Key Element # 1 Key Element # 1

Patient InformationPatient Information



Core distinguishing characteristic # 1Core distinguishing characteristic # 1Essential patient information is obtained,Essential patient information is obtained,is available in useful form, and isis available in useful form, and isconsidered when prescribing, dispensing,considered when prescribing, dispensing,and administering medicationsand administering medications



Item #6:Item #6:Orders cannot be entered into theOrders cannot be entered into thepharmacy computer until the patientpharmacy computer until the patient’’ssallergies have been properly entered andallergies have been properly entered andcoded (patient allergies is a requiredcoded (patient allergies is a requiredfield)field)


website: website: www.ismp-canada.orgwww.ismp-canada.orge-mail: e-mail: [email protected]@ismp-canada.orgPhone: Phone: 416-733-3131416-733-3131

medication safety initiatives developed by ismp-canada · 10/1/07 a key partner in the canadian...

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