ISMP Canada Web-based Analyze-Err Program

One of the goals of ISMP-Canada is to collect, collate and analyze actual and potential medication errors reported by practitioners so that recommendations and strategies of reducing medication errors can be disseminated to others. We believe in a non-punitive and voluntary approach to medication error reporting and we strongly encourage people to freely report errors so that we may learn from them. Please include as much information about the incident as possible. Thank you for sharing information so that others can learn from the experience.

INFORMATION SUBMITTED WILL BE KEPT STRICTLY CONFIDENTIAL AND PROTECTED. Please do not supply identifying information (e.g., patient name or date of birth, hospital name, or healthcare provider names).

Required fields are titled in red, total nine fields.

Web ID: Assigned by ISMP Canada

1-Incident

2-Outcome

3-Medication(s)

4-Follow Up

5-Patient

6-Reporter

7-Contributing
Factors

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Date of Incident:

Time of Incident:

Incident Description/ HowDiscovered:

Stages Involved:

Prescribing	Order Entry/Transcription
Dispensing/Delivery	Administration
Monitoring	Other

Type of Incident:

Discovered By:

Care Area Type:

Severity/
Outcome:

	NO ERROR - Circumstances or events that have the capacity to cause harm
	NO HARM - An incident occurred but the incident did not reach the patient (An "error of omission" does reach the patient)
	NO HARM - An incident occurred that did reach the patient, but did not cause patient harm
	NO HARM - An incident occurred that reached the patient and monitoring was required to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm
	HARM - An incident occurred that may have contributed to or resulted in temporary harm to the patient and required intervention
	HARM - An incident occurred that may have contributed to or resulted in temporary harm to the patient and required initital or prolonged hospitalization
	HARM - An incident occurred that may have contributed to or resulted in permanent patient harm
	HARM - An incident occurred that required intervention necessary to sustain life
	DEATH - An incident occurred that may have contributed to or resulted in the patient's death

Intervention:

I may be contacted by ISMP Canada for follow-up about this medication incident:	Yes
	No

if yes, please provide contact information

Name:

Practice Setting:

City:

Province:

Postal Code:

email:

Phone:

File Note:

Critical patient information missing

Critical drug information missing

Miscommunication of drug order

Drug name, label, packaging problem

Drug storage or delivery problem

Drug delivery device problem

Environmental, staffing, or workflow problem

Lack of staff education

Patient education problem

Lack of quality control or independent check systems

Select Key Medication Use System Element from each button on the left, then select contributing factor(s) from the window below.

Hold down the control key 'Ctrl' to select more than one item, or to remove all choices.

Permission to use the Taxonomy of Medication Errors copyrighted by the National Coordinating Council for Medication Error Reporting and Prevention is gratefully acknowledged. Select components have been adapted, with permission, for use by the Canadian Medication Incident Reporting and Prevention System (CMIRPS). The collaborating parties of the CMIRPS are: Canadian Institute for Health Information; Health Canada; and Institute for Safe Medication Practices Canada.