ISMP Canada provides subject matter expertise to support a collaborative process and coordinated system for selecting medication safety indicators in Ontario. This work supports provincial directions towards increased public reporting and sharing of information with the public, and recognizes the interest in developing indicators related to medication safety.

Activities

1. Development of Medication Safety Indicators for Public Reporting. Project to identify three medication safety indicators that are feasible and suitable for public reporting in Ontario. These included venous thromboembolism prevention, acute myocardial infarction discharge medications, medication reconciliation.
   • Identification of Medication Safety Indicators in Acute Care Settings for Public Reporting in Ontario - September 2010
     From more than 300 potential medication safety indicators two analysts at ISMP Canada worked independently to narrow the focus to 49, and subsequently to 12 candidate indicators. The selection criteria for evaluation of the indicators focused on data that: a) aligned with current patient safety initiatives in Ontario and/or Canada, b) are feasible or readily available, c) have acceptable validity and quality, d) are actionable, e) are understandable by the target audience, and f) are evidence-based. Stakeholder consensus suggested medication reconciliation for potential indicator development in Ontario
2. Potential Medication Reconciliation Indicators for Public Reporting in Ontario - April 2012
   ISMP Canada was asked to support the direction of MOHLTC towards public reporting of safety indicators by facilitating the determination of a suitable medication reconciliation (MedRec) indicator. Based on available data on the current state of MedRec implementation, it was decided that an indicator specific to admission MedRec would be the most appropriate as this interface of care has the highest implementation rates and frontline experience associated with it.

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Medication safety is integral to overall patient safety in the OR setting. The OR is a unique environment where high-alert medications are frequently used and most procedures take place in a sterile field, requiring medications to be removed from their original packaging. Furthermore, medications may be prescribed, selected, prepared and administered by only one practitioner. In addition, medications may be administered in response to verbal orders, which can be error-prone. The OR is also a point of continuous patient transfer (i.e., the OR team assumes the care of a patient for short time period), with frequent hand-offs between the OR team and others, and transfer points are considered a time where there is increased risk for medication incidents (i.e., errors) to occur.

The OR Medication Safety Checklist was developed by an expert panel and in collaboration with the Canadian Anesthesiologists' Society and the Operating Room Nurses Association of Canada to help guide individual organization to assess system-based medication issues such as storage and use of medications in the OR setting. The pilot version of this checklist was reviewed and tested by 18 Ontario hospitals (4 of these hospitals were multi-site organizations). A post-pilot survey evaluation was completed by 9 of the participating hospitals. The survey results showed:

• 44% have implemented changes in their OR medication system as a result of the pilot
• 67% are planning or are in the process of implementing changes
• 89% indicated a plan for inclusion of the OR Medication Checklist as part of their quality improvement program

Version 2 of the OR Medication Safety Checklist includes learning from a recent Canadian event involving the inadvertent injection of concentrated epinephrine 1 mg per mL intended for topical application.

In an effort to combine OR safety initiatives in Ontario, ISMP Canada in collaboration with the OHA is providing the OR Medication Safety Checklist as part of the Surgical Safety Checklist Implementation toolkit distributed by the OHA to Ontario hospitals. The OR Medication Safety Checklist complements the Surgical Safety Checklist. Additionally, ISMP Canada staff presented to each LHIN to support medication safety in conjunction with roll out of the OHA Surgical Safety Checklist Implementation toolkit to Ontario hospitals. Presentations highlight for participants the key findings from reported events and literature regarding the inadvertent injection of concentrated epinephrine intended for topical administration.

Operating Room Medication Safety Checklist©

Medication Errors : What You Cannot Afford to Ignore in the Perioperative Setting Presentation

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Medication reconciliation has long been identified as a system solution to enhance medication information communication for patients as they move from one health care setting to another. ISMP Canada supports Medication Reconciliation provincially, nationally and internationally. ISMP Canada created Getting Started Kits for Medication Reconciliation in Acute Care, Long Term Care, Home Care for the Canadian Safer Healthcare Now! campaign and for the World Health Organization High 5s initiative and provides ongoing support to teams around the world.

Activities

1. Medication reconciliation at discharge - Provincial Pilot Project 2011/2012
   Tools for discharge medication reconciliation
   • Steps for Creating the Best Possible Medication Discharge Plan (BPMDP) - Discharge from an Acute Care Facility
   • Best Possible Medication Discharge Plan (BPMDP) Form
   • Best Possible Medication Discharge Plan Interview Guide
   • Discharge Medication Schedule/Calendar
   • Best Possible Medication Discharge Plan Checklist
2. Jump into MedRec: Improving BPMH Quality across the Continuum of Care, Best Possible Medication History (BPMH) Training
3. Optimizing Communication about Medications at Transitions of Care Provincial Roundtable - September 2010
   • Roundtable Report (English)
4. Linking MedsCheck to MedRec - Provincial 2009
   This project is also supported by the Ontario College of Pharmacists and complements the Ministry MedsCheck program.
   • Pilot Project Report (English)
   • MOHLTC MedsCheck Program (English) (Français)

Read more about Medication Reconciliation national and internationally.

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The Ontario Medication Incident Database (OMID), supported by the Ontario Ministry of Health and Long-Term Care, has been capturing medication incident reports submitted by Ontario health service organizations since 2004. The OMID is a component of the Ontario Medication Safety Support Service (MSSS) and ISMP Canada's Medication Incident and Near Miss Reporting Program. Learning from analysis of medication incidents collected helps identify priority areas for intervention, and will ultimately lower the rate of preventable hard from mediation use.

Ontario has achieved a high level of stakeholder participation in and commitment to medication incident reporting and learning. From January 1st 2010 to September 30th, 2011, the OMID received 9,715 medication incident reports submitted voluntarily by Ontario health service organizations and by individual practitioners.

As of October 2011, all hospitals in Ontario are required to begin reporting medication and IV fluids critical incidents through the National System of Incident Reporting (NSIR). ISMP Canada, in collaboration with the Canadian Institute for Health Information (CIHI), the Ontario Hospital Association (OHA) and Health Quality Ontario (HQO) provides support for the new provincial requirement and the Excellent Care for All Act.

ISMP Canada is encouraging Ontario hospitals to report medication incidents to the CIHI National System for Incident Reporting (NSIR) and will continue to provide support for analysis and communication of learning.

Sincere appreciation is expressed to the many healthcare professionals who have demonstrated support for a culture of safety, exemplified by their willingness to share information about medication incidents and related findings.

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The Medication Safety Self-Assessment® (MSSA) was developed for Hospitals, Long-Term Care, Community Pharmacy and Complex Continuing Care/Rehabilitation Facilities. The MSSA is a comprehensive tool that can help organizations evaluate the strengths and weaknesses of their medication use processes and identify opportunities for improvement. Most importantly, this tool facilitates the development of a plan to improve medication safety within an organization. This proactive approach permits the identification of actions required to ensure the safety of medication practices.

• 115 Ontario hospitals have completed the MSSA, and 103 hospitals have completed it more than once. Hospitals repeating the assessment demonstrate higher scores on the repeat assessment, indicating that system improvements have been implemented. For some hospitals, the MSSA has become part of the facility's quality improvement program.¹ Ontario results have been consistently about 5% above the Canadian aggregate.
• 686 Ontario long term care homes have completed medication safety self-assessments and 184 of those assessments were completed in 2011-2012. A total of 408 homes have completed at least one assessment and 278 of those homes have completed the assessment more than once.
• In Ontario, 10 of 20 complex continuing care/rehabilitation facilities and 40 community pharmacies have completed the self-assessment. Additionally, 360 (with 39 repeating the process) LTC homes have completed the MSSA.
• 51 community pharmacies in Ontario have completed the MSSA program for Community Pharmacist/Ambulatory Care and 1 pharmacy has repeated the program to measure improvement. The medication safety self-assessment for community pharmacist/ambulatory care fulfills Standard 6: Safe Medication Practices for the Standards of Practice for Pharmacy Managers in Ontario.

Analysis of MSSA results assists in providing direction for future provincial safety initiatives. Of interest, approximately 80 safe practice characteristics from the hospital MSSA have been adapted for inclusion in the Accreditation Canada required organizational practices.

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The optimal management of hospital use of thromboprophylaxis has been well-documented and published. The project goal was to increase compliance with the use of evidence-based clinical practice guidelines in thromboprophylaxis (deemed the #1 priority for patient safety intervention by AHRQ in the US). A comprehensive, national web-based survey on anticoagulants to which 99 Ontario hospitals responded, identified the degree of adherence to best practice guidelines. A subsequent chart audit in 8 Ontario hospitals to establish baseline performance of thromboprophylaxis practices reinforced the need for a system improvement intervention. An average of 86% of patients having hip fracture surgery received prophylaxis; 51% of general surgery and only 31% of general medicine patients received appropriate prophylaxis. According to the practice guidelines for these groups of patients, the target was 100% compliance for all groups. Post-intervention results included:

• 13% increased rate of compliance for General Surgery patients
• 25% increased rate of compliance for General Medicine patients

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This high alert drug category was selected based on a number of critical incidents reported to ISMP Canada that resulted in patient harm, as well as on feedback from Ontario hospitals at an Ontario medication safety conference held in July 2003. Twelve months after the interventions were introduced to Ontario hospitals, a follow-up survey identified successful implementation or action in 94% of responding hospitals. These safeguards included removal of high potency opioids from patient care areas, standardization of doses and solutions, and implementation of independent double-checks for patient controlled analgesia and epidurals.

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In response to a number of patient deaths in Ontario (and other parts of Canada and the USA) due to unintended intravenous administration of potassium chloride (KCl) concentrate, ISMP Canada provided solutions and support to hospitals to prevent further mishaps. ISMP Canada's follow-up survey demonstrated significant achievements among Ontario hospitals, with a decrease in availability of concentrated KCl in patient care areas from 62% to 26%. An independent national survey conducted in 2004 reported that 96% of Ontario hospital respondents had removed KCl concentrate from patient care areas, citing Ontario as the most successful province in this safety initiative.²

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¹ Hofman L, Greenall J, McBride J, Jelincic V. Assessment of Risk in Medication-Use Systems: Learning from the Medication Safety Self-Assessment. Can J Hosp Pharm 2007; 60(1) 49-52

² McKerrow R, Johnson N, Hall KW, Roberts N, Salsman B, Bussieres JF, Macgregor P, Lefebvre P, Harding J. (Eds.). 2004. "2003/2004 Annual Report, Hospital Pharmacy in Canada: Medication Safety" [15th Hospital Pharmacy in Canada Survey]. Eli Lilly Canada. P;. 55-57. Retrieved March 9, 2007. http://www.lillyhospitalsurvey.ca/hpc2/content/rep_2004_toc.asp.