Medication Safety Self-Assessment^® for Hospitals
(Canadian Version II)

1. Establish a multidisciplinary team consisting of the following individuals (at a minimum):

• Senior administration Representative
• Risk management and/or quality improvement professional
• At least one staff nurse
• At least one staff pharmacist
• At least one staff physician

Your team should be provided with sufficient time to complete the self-assessment and charged with responsibility to evaluate, accurately and honestly, the current status of medication practices in your facility. Because medication use is a complex, inter-disciplinary process, the value and accuracy of the self-assessment is significantly reduced if it is completed by a single discipline involved in medication use.

We suggest you schedule a series of three meetings of one to two hours to complete the self-assessment.

2. Before the self-assessment begins, have everyone read and review the survey in its entirety. The copyright allows you to make copies of the self-assessment for internal use.

3. Complete the "Demographic Information" form.

4. Discuss each core distinguishing characteristic and evaluate the hospital's current success in implementing the self-assessment items.

As necessary, investigate and verify the level of implementation for each item with other health care practitioners outside the task force.

When a consensus on the level of implementation for each self-assessment item has been reached, mark one of the following choices next to each item (the responses can later be entered into the ISMP Canada website, www.ismp-canada.org):

A = There has been no activity to implement this item
B = This item has been discussed for possible implementation, but not implemented
C = This item has been partially implemented in some or all areas of the organization
D = This item is fully implemented in some areas of the organization
E = This item is fully implemented throughout the organization

For self-assessment items with multiple components, full implementation (a score of D or E) is appropriate only if all components are present. If only one or some of the components have been partially or fully implemented throughout the organization, self-assessment scores should not exceed "C".

For self-assessment items with two distinct elements, each separated with the word "OR" and labelled (a) and (b), answer either part (a) or part (b), but not both.

Unless otherwise stated, self-assessment items refer to medications prescribed, dispensed and administered to all inpatients and outpatients typically seen in most hospitals, such as patients admitted to the emergency department and ambulatory surgery/procedure units.

5. Take advantage of the web-based program, which allows comparison with results of other respondents on both a national and regional basis. (If you have completed more than one self-assessment, these results can be compared on-line.) Once the self-assessment has been completed, e-mail mssa@ismp-canada.org to obtain a password.

Submit data from the completed self-assessment to ISMP Canada electronically through our secure web site (https://www.ismp-canada.org). The Medication Safety Self-Assessment page has a tab entitled Enter Survey See Results. On this page is the field to enter your password and access the MSSA.

The special, web-based survey tool will immediately download the information into a database maintained solely by ISMP Canada. No data will be maintained on the Internet survey form after it has been submitted. Confidentiality is assured. The aggregate findings may be used for research and education purposes only.

General Questions
- See also: Frequently Asked Questions starting on page 53 -

Do we need senior administrative staff on our team?
A senior administrator is important at these meetings because the assessment contains many items that challenge or inquire about your organization's overall commitment to patient safety. Furthermore, participation in the self-assessment provides senior administrative staff with insight into areas of risk in the medication use system.

How many team meetings should we schedule?
We suggest you schedule a series of three meetings of one to two hours to complete the self-assessment. Some sites have completed the assessment in less time than this and some have run longer than one hour at a meeting, but most report not needing to meet more than three times.

What if an item doesn't apply to the services offered in my hospital?
If an item does not apply to services offered in your hospital then an answer of E may be appropriate since your hospital would not be prone to errors in medication dosing for certain patient populations. This version of the self-assessment includes instructions where this might apply.

May I make copies of the Self-Assessment document?
You may make as many copies of this document as are required for the team to complete the MSSA. You are not authorized to make copies beyond this number. You may not modify or alter the content in any way. Furthermore, you may not modify, transmit, post, or use the contents of this document for personal, public, or commercial purposes unless you have obtained written permission from ISMP Canada.

My facility has a number of sites. Do I need a password for each one?
If your facility is homogeneous or is managed as a single entity, then it may be appropriate to conduct a single MSSA across the entire institution. However, if your sites are relatively autonomous and have different procedures and levels of technology, then separate MSSAs are probably in order.

Are there situations where the MSSA is not appropriate for a facility?
This MSSA version is intended for acute care hospitals. As such, it may not be applicable for use in a long-term care facility or one with a large outpatient component. New self-assessment tools are now also being developed by ISMP Canada for Community/Ambulatory Pharmacy, for Complex Continuing Care, and for Long-Term Care.

How are individual items scored?
Each item has a specific weighting. If the characteristic is fully implemented, then the maximum score is achieved.

The scoring is not the same for all items, as some identify situations representing a higher safety risk than others. These items have higher maximum scores. The scores may range this way:
0,1,2,3,4 or
0,2,4,6,8 or
0,3,6,9,12 or
0,4,8,12,16

For some items there are no partial scores; a score is only achieved when there is full implementation, for example:
0,0,0,0,8 or
0,0,0,0,12 etc.

The "absolute" scores are useful when comparing repeated self-assessments or for a specific group analysis; otherwise, the general findings as represented on the graphs are sufficient.

How can I use our self-assessment results?
Refer to page 49, where a description is given and examples are shown of how to review and use the findings of your hospital’s self-assessment.