Medication Safety Self-Assessment^® for Long-Term Care
(Canadian Version II)
Auto-évaluation de l'utilisation sécuritaire des médicaments^MD (AÉUSM) pour les soins de longue durée
(Seconde version canadienne)

The Medication Safety Self-Assessment^® (MSSA) for Long-Term Care was designed by the Institute for Safe Medication Practices Canada (ISMP Canada) to:

heighten awareness of the distinguishing characteristics of a safe medication system in the long-term care setting (e.g., nursing homes, homes for the aged, correctional facilities);
provide an assessment tool to evaluate the safety and risks of the medication management system in the long-term care setting;
create baseline measures of medication system safety and risks for the Long-Term Care Home/facility; and
act as a quality improvement program by identifying opportunities for improved medication system safety and by documenting the changes over time (i.e., documentation of continuous quality activity).

The self-assessment is divided into 10 key elements that most significantly influence safe medication use. Each key element is defined by one or more core distinguishing characteristics of a safe medication system which are further defined by representative self-assessment items to help evaluate the degree to which practice in the Home/facility meets each of the core distinguishing characteristics.

Completion of the MSSA for LTC entails a two-step process:

completion of the interdisciplinary assessment (review and score of self-assessment items)
data entry (password required)

You can obtain the password and the supporting documentation on data entry and report generation by sending an e-mail request to mssa@ismp-canada.org.

The Medication Safety Self-Assessment® for Long-Term Care and its components are copyrighted by ISMP and may not be used in whole or in part for any other purpose or by any other entity except for self-assessment of medication systems by Long-Term Care Homes as part of their ongoing quality improvement activities. The aggregate results of this assessment are used by ISMP Canada for research and education purposes only.

ISMP Canada is not a standard-setting organization. As such, the self-assessment items in this document are not purported to represent a minimum standard of practice and should not be considered as such. In fact, some of the self-assessment items represent innovative practices and system enhancements that are not widely implemented in most Long-Term Care Homes today, e.g., computerized prescriber order entry, bar coding. However, their value in reducing errors is grounded in research and expert analysis of medication errors and their causes. The process of completing the Medication Safety Self-Assessment® (MSSA), combined with the Home's/facility's record of medication-related error reports, provides Homes/facilities with the opportunity to identify areas of focus for setting priorities and enhancing safe medication practices. No Home/facility should expect to score high in all areas; as indicated, some of the practices described in the items are not yet widely implemented.

A number of Canadian provincial governments have supported the use of the MSSA for LTC (e.g., British Columbia, Alberta, Manitoba, Ontario). Data from LTC homes in these provinces are included in the user aggregate. ISMP Canada acknowledges and appreciates the support of the Ontario Ministry of Health and Long-Term Care for its financial support in the development of this program.

La version française du Medication Safety Self-Assessment® for Long-Term Care Facilities (MSSA-LTC), c'est-à-dire, l' Auto-évaluation de l'utilisation sécuritaire des médicaments^MD (AÉUSM) pour les soins de longue durée, est maintenant disponible sous format PDF seulement. Les utilisateurs qui sont inscrits à l'AÉUSM peuvent faire des copies de ce document protégé par des droits d'auteur afin d'effectuer leur auto-évaluation à l'interne.

En ce moment, la version française de l'auto-évaluation n'est pas affichée en ligne, à l'exception de la page bilingue décrivant les renseignements démographiques. Les utilisateurs devront sélectionner l'onglet Enter/See Results , taper le mot de passe confidentiel et faire la saisie des données selon le numéro de l'item et des cotes A/B/C/D/E. Tous les éléments associés aux résultats, tels que les graphiques, sont disponibles uniquement en anglais.

Votre compréhension est grandement appréciée. L'ISMP Canada souhaite que cette limitation n'empêche ni votre expérience ou apprentissage quant à l'utilisation de l'Auto-évaluation de l'utilisation sécuritaire des médicaments^MD pour les soins de longue durée.

Si vous avez besoin d'assistance avec le programme d'Auto-évaluation de l'utilisation sécuritaire des médicaments, veuillez écrire un courriel au mssa@ismp-canada.org.

Establish an interdisciplinary team/task force consisting of, or similar to, the following:

Registered nurse (RN)
Registered practical nurse (RPN)
Contract service/consultant pharmacist
Physician
Person responsible for quality/risk issues
Senior administration/management representative

Participation of front line nursing staff and the consultant pharmacist enhances the validity of the results.

Each team member should read and review the self-assessment tool in its entirety before the assessment process begins, if possible. This will decrease the time needed at each meeting to reach a consensus. The interdisciplinary team's time commitment to complete the self-assessment is estimated at three hours.

Use a hard copy of the self-assessment document to complete the "Demographic Information" and to record your ranking for each item. By using a hard copy, rather than entering your findings directly into the database, you now have a document that you can easily review and then use to possibly go back to select items for reconsideration.

Discuss each core distinguishing characteristic and evaluate the Home's/facility's current level of implementation with each of the representative self-assessment items. As necessary, investigate and verify the level of implementation with other healthcare practitioners outside the team.

	A	The item is applicable, but there has been no activity to implement.
	B	This item has been formally discussed for possible implementation in the Home/facility, but is not implemented at this time.
	C	This item has been partially implemented in the Home/facility (e.g., by location, such as a unit or floor; by resident population characteristic, such as, disease/disorder or cognition, by drug category, etc.). Basically, implementation has begun somewhere in the Home/facility but has not fully progressed to the entire facility.
	D	This item is fully implemented in some areas of the Home/facility (e.g., by resident location, drug type, etc.).
	E	This item is fully implemented throughout the Home/facility (i.e., for all residents, prescriptions, drugs or staff). OR This item does not apply to the Home/facility because there is no resident need for such a service (e.g., no resident is ever administered a drug parenterally).

When a consensus on the level of implementation for each representative self-assessment item has been reached, record its ranking as A, B, C, D, or E.

Repeat the process for all core distinguishing characteristics (20 in total).

Written notes made during team meetings can be transferred to the online database by clicking on the note icon:

For example, notes on reasons that limit the full implementation of an item can be documented. Comments that may be a helpful reference to the team repeating the self-assessment at a future date can be added.

Enter your completed item rankings and data on the ISMP Canada secure website (https://www.ismp-canada.org/lmssa/index.php). Click on the Enter/See Results tab and enter your facility's unique and confidential password into the appropriate field. After the password is entered and accepted, results data can be entered. While entering data, the option to Save & Exit can be used after each section of the tool is completed.

Once data entry is complete, with all item rankings and the demographic information entered, the option to Finalise Assessment appears and can be selected. No changes can be made to your entries once you have finalised the assessment. The web-based program will immediately download the information into a database maintained solely by ISMP Canada.

10.

Entering the data into the web-based program allows you to compare your Home's/facility's results over time and against the aggregate (national, provincial, and regional) results of other respondents. The results are presented in tabular and graphic format and can be printed for sharing and discussing with others in the facility.

Data Security and Confidentiality

The self-assessment responses are encrypted when entered into our secure website. Access to the MSSA survey for your data entry is via a unique, confidential password. The password is sent directly to the contact person for each site; an email request can be sent to mssa@ismp-canada.org to request a password.

No data is maintained on the Internet survey form after it has been submitted to ISMP Canada. ISMP Canada is committed to protecting the privacy, confidentiality, and security of any information for which it is responsible.

Adverse Event	Unintended injury or complication that results in disability at the time of discharge, death or prolonged hospital stay and that is caused by healthcare management rather than by the resident's underlying disease process.
Adverse Reaction	Adverse reactions are undesirable effects to health products. Health products include drugs, medical devices and natural health products. Drugs include both prescription and nonprescription pharmaceuticals; biologically-derived products such as vaccines, serums, and blood derived products; cells, tissues and organs; disinfectants; and radiopharmaceuticals. Reactions may occur under normal use conditions of the product. Reactions may be evident within minutes or years after exposure to the product and may range from minor reactions like a skin rash to serious and life-threatening events such as a heart attack or liver damage. http://www.hc-sc.gc.ca/dhp-mps/medeff/advers-react-neg/index-eng.php; accessed January 31, 2012
Area	Recognizing the differences in organization of various types of long-term care facilities, "area" is generic terminology that can be interpreted and applied by the Home/facility, specific to its organization, where medications are stored or administered (e.g., locations or physical units, groupings by medical conditions/diagnoses, etc.).
Best Possible Medication History (BPMH)	BPMH is a history created using 1) a systematic process of interviewing the patient [resident]/family, and 2) a review of at least one other reliable source of information to obtain and verify all of a patient's [resident's] medication use (prescribed and non-prescribed). Complete documentation includes drug name, dosage, route and frequency. The BPMH is more comprehensive than a routine primary medication history which is often a quick preliminary medication history which may not include multiple sources of information. The BPMH is a 'snapshot' of the patient's [resident's] actual medication use, which may be different from what is contained in their records. This is why the patient [resident] involvement is vital. http://www.ismp-canada.org/medrec/; accessed April 4, 2012
Computerized Medication Administration Record	A paper medication administration form, usually generated from a pharmacy dispensing computer system, forwarded to the LTC facility. Staff document, by pen on this form, the doses of medication administered. Staff may also need to make changes to the form manually to reflect drug order modifications.
Computerized Physician/Prescriber Order Entry (CPOE)	Computerized physician or prescriber order entry (CPOE) is the process of entering medication orders or other physician instructions electronically (into a computer system) instead of onto paper. The use of a CPOE system can help reduce incidents related to poor handwriting or transcription of medication orders. This order entry can be performed by any healthcare practitioner acting within their scope of practice. If they are not a prescriber, their order entry is followed by a verification process by another practitioner, e.g., a check against a handwritten order documented on a paper health record.
Dangerous Abbreviations, Symbols and Dose Designations	Abbreviations, symbols and dose designations that have been identified as easily misinterpreted or involved in medication incidents leading to harm and should be avoided in medication-related communications. The list is available from http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2006-04Abbr.pdf
Dosing Window	When a first dose is administered at a nonstandard time, nurses need an agreed-upon method of converting subsequent doses to the standardized schedule. Many [facilities] have guidelines for this purpose. These "dosing windows" or "staggered dosing times" provide a matrix for determining the safest time to administer the second dose according to when the first dose was administered. Patients usually are back on a standard dosing schedule by the third dose… Schedules must sometimes be changed to accommodate patient procedures or to prevent the administration of incompatible medications at the same time. Cohen M, editor. Medication errors. 2nd ed. Washington, DC: American Pharmaceutical Association; 1999
eMAR	Refers to electronic medication administration record and indicates that the record and medication administration documentation are kept on-line. Often this technology/software is linked to CPOE and used with barcoded labels on medication packaging, as well as patient/resident barcoded identification bands.
Failure Mode and Effects Analysis (FMEA)	A team-based, systematic and proactive approach for identifying the ways that a process or system can fail, why it might fail, the effects of that failure, and how the process or system can be made safer, i.e., a proactive risk assessment.
Health Record	A longitudinal collection of personal health information of a single individual, entered or accepted by healthcare providers.... The record may be made available at any time to providers, who have been authorized by the individual, as a tool in the provision of healthcare services.... The transmission and storage of the record is under strict security. Adapted from Morris A. The electronic health record in canada: the first steps. Health Law Rev. 2005;14(2):14-18; www.law.ualberta.ca/centres/hli/userfiles/2_Morris.pdf; accessed April 5, 2012
Healthcare Practitioner	An individual with formal training who is authorized to perform specific healthcare-related tasks (e.g., physician, nurse, pharmacist, pharmacy technician, healthcare aide). 2012 ISMP International Medication Safety Self Assessment^® for Oncology
High-Alert Drugs	Drugs that bear a heightened risk of causing significant resident harm when they are used in error. Although mistakes may not be more common with these drugs, the consequences of an error are clearly more devastating to patients/residents. Adapted from ISMP's List of High-Alert Medications. © 2012; www.ismp.org/tools/highalertmedications.pdf; accessed April 18, 2012
Home/Facility	Refers to long-term care facilities which are homes for residents; different levels of care and support may be provided. Correctional service institutions are included, as they are long-term residence and care facilities. Each province uses different terminology to describe this healthcare sector, e.g., residential care, continuing care, long-term care.
Implement	Accomplish or achieve in practice, not just policy, to carry into effect.
Independent Double Check	A process in which a second practitioner conducts a verification step, i.e., two individuals separately check each component of the work process. For example, one person calculates a medication dose, a second individual independently performs the same calculation and the results are checked for match. Such verification can be performed in the presence or absence of the first practitioner. The most critical aspect is to maximize the independence of the double check by ensuring that the first practitioner does not communicate what he or she expects the second practitioner to see, which would create bias and reduce the visibility of an error. An error in calculation is more likely to be detected if the second person performs all calculations independently without knowledge of (seeing) any prior calculations.
Maximum Dose	The dose of a medication that represents the upper limit that is normally found in the literature or in manufacturer recommendations. Maximum doses may vary according to age, weight, diagnosis, or comorbidity. Adapted from the 2012 ISMP International Medication Safety Self Assessment^® for Oncology
Medication Device	Equipment such as infusion pumps, implantable pumps, syringes, pen devices that contain medication (e.g., insulin, epinephrine), tubing, patient-controlled analgesia pumps, and other related devices that are used for medication preparation, dispensing, and administration.
Medication Incident	Any preventable event that may cause or lead to inappropriate medication use or patient/resident harm while the medication is in the control of the healthcare professional, patient/resident, or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labelling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. Adapted with permission from the National Coordinating Council for Medication Error Reporting and Prevention, What Is Medication Error? Developed by the collaborating parties (ISMP Canada, Health Canada, CIHI) of the Canadian Medication Incident Reporting and Prevention System. © 2001.
Medication Incident: Near Miss or Close Call	An event that could have resulted in unwanted consequences, but did not because either by chance or through timely intervention the event did not reach the patient/resident. Developed by the collaborating parties (ISMP Canada, Health Canada, CIHI) of the Canadian Medication Incident Reporting and Prevention System. 2005.
Medication Reconciliation	This is a formal process in which healthcare providers work together with patients [residents], families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care. Medication reconciliation requires a systematic and comprehensive review of all the medications a patient [resident] is taking (known as a BPMH) to ensure that medications being added, changed or discontinued are carefully evaluated. It is a component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient [resident]. http://www.ismp-canada.org/medrec/; accessed April 4, 2012
Medication Management	Medication management refers to medication-use processes involving promotion of medication safety, medication selection and procurement (i.e., formulary considerations), labelling and storage, ordering/prescribing and transcribing, preparing and dispensing, administration, and monitoring. Adapted from Accreditation Canada; http://www.accreditation.ca/accreditation-programs/qmentum/standards/managing-medications/; accessed April 4, 2012
Multidose Drug Packaging	A ready-to-administer and labelled resident-specific dose of one or more medications required for one administration time on a specified date. i.e. dose of all oral solid medications required for one administration time such as 8 am. for one person on a specific date.
Prescriber	Professional staff, such as physicians, interns, nurse practitioners, and pharmacists who prescribe medications in the Home/facility.
Regularly Scheduled Medication	May also be referred to as "routine", "maintenance", "scheduled".
Senior Administrative Representative	The title and responsibilities of this person may vary from Home to Home, facility-to-facility. This could be the Director of Care, Administrator, Manager, General Manager, Vice-President, Nurse Manager, etc.
TALLman Lettering	TALLman lettering is a method used to assist in the differentiation of look-alike/sound-alike drug names by using mixed case letters to help draw attention to the dissimilarities of these confusable names, e.g., vinCRIStine and vinBLAStine). A list of look-alike drug names with recommended TALLman lettering can be found at: http://www.ismp.org/Tools/tallmanletters.pdf. Adapted from ISMP Can Saf Bull. 2010 Nov 11; available from http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2010-08-TALLmanforOncology.pdf; accessed April 28, 2012, and from 2012 ISMP International Medication Safety Self Assessment^® for Oncology
Transition of Care	The movement of a patient from one level or area of care to another (e.g., moving from an intensive care unit to a general hospital unit; transferring from a hospital to a nursing home). 2012 ISMP International Medication Safety Self Assessment^® for Oncology
Unit Dose	A single package that contains one dose of a medication ordered for a specific resident (e.g., a package with one tablet/oral solid dose, one single-use vial of parenteral medication, 5 mL container holding one dose of liquid) and labelled with the drug name and strength.

How many team meetings should we schedule and do we need senior administrative or management staff on our team?
From the experience of the Homes/facilities that have already completed the assessment, our suggestion is to schedule three team meetings of one hour in length. (Of course, your meetings can be scheduled to accommodate various staff commitments.) Some Homes/facilities have completed the assessment in less time than this and some have run longer than one hour at a scheduled meeting; but none reported needing to meet more than three times. Team members have included a physician, staff RN and RPN, consultant/contracted pharmacist, management level personnel and others who work with the medication use system. The Home's/facility's Medical Advisory and Therapeutics Committee or a Resident Safety Committee may be the appropriate team to complete the assessment.

What if a question doesn't apply to the services offered in my Home/facility?
Answer A if it could apply to services in your Home/facility, has not been discussed, but could be discussed in the future. If a question doesn't apply to services in your Home/facility because there is no resident need, then an answer of E would be appropriate. It is important to carefully consider every question in light of long-term planning for improvements to medication system safety.

What is meant by "senior administrative representative" as a member of the team?
The title and responsibilities of this person may vary from Home to Home, facility-to-facility. This could be the Director of Care, Administrator, Manager, General Manager, Vice-President, Nurse Manager, etc. If recommendations are made as a result of doing this audit, your team will benefit from someone with decision making authority to assist with resource allocation, if needed, to implement recommendations.

Why are some of the items "greyed out" (i.e., items 7, 46, 119, 125)?
Based on findings from the pilot use of this self-assessment in long-term care Homes/facilities across Canada, some items have been inactivated. These need to remain in the database to allow for data comparison.

Questions Related to Specific Self-Assessment Items

Item 1. What does access to laboratory values while working in their respective locations mean?
The work site for physicians, nurses and pharmacists should not limit the practitioner's access to needed laboratory value results while they perform their responsibilities for caring for a specific resident. This generally translates into having secure access to electronic information, i.e., an electronic resident health record, whether from a remote office or on-site.

Items 7, 46, 119, 125. Why are some of the items "greyed out"?
Based on findings from the pilot use of this self-assessment in long-term care Homes/facilities across Canada, some items have been inactivated. These need to remain in the database to maintain item numbering, thereby allowing for data comparison against historical findings.

Item 12. This item states that "Information is available to the clinical team related to the current pre-admission assessment including past medical history; current medications; allergies; resident's language preference; mental status; ambulatory status; current weight; family or substitute decision maker contact". What if the information we receive is not current or contains more information, how do we answer this question?
The objective is to have as much current information as possible so that medications may be safely prescribed, dispensed and administered. If the information is not consistently current and complete at time of admission, the appropriate rank would be C. If there is consistent information for a particular population, e.g., for those residents admitted to a high security area, an answer of D might be appropriate.

Item 38. Physicians may not come into the Home/facility for several days after a telephone order has been given. The Home/facility policy requires signing within 72 hours. How do I rank this question?
If prescribers do not consistently sign orders or fax back signed copies of orders, consistent with the Home/facility policy, the rank cannot be higher than C.

Item 68. This item indicates that the use of samples is prohibited. Our physicians sometimes provide samples to residents to try a new medication and save the resident or family money during the trial process. Since the medication is provided by the physician, may we rank ourselves as compliant?
No. You would rank this item as an A or B. The use of medication samples provided by a physician is not a safe practice. The is because the medication may then not be recorded in the pharmacy profile; side effects or interactions with other medications may not be identified; and storage conditions prior to the samples being brought to the Home/facility are unknown. In addition, when reviewing medication therapy, the pharmacist may not be aware that the medication is being administered.

Item 69. There is a reference to non-prescription medications as stock. What does this mean?
This refers to non-prescription drugs kept as non-resident-specific stock on the unit. These medications may be provided by the pharmacy or by the Ministry of Health (at no charge to the Home/facility) in some provinces. Stock management may best be supported by an inventory control system. If your facility does not maintain any stock non-prescription medications, rank this item as E.

Item 80. "Sufficient lighting" can be very subjective. How can we rank this item if different staff have different opinions?
Yes, lighting levels are subjective, even if you abide by human factors and published standards. It will be the staff who will guide the ranking of this item. They may require additional lighting for safe preparation and administration of drugs at any time of day.

Item 100. This item states that residents assist healthcare workers by showing staff their name bracelet and stating their name clearly before medications or treatments are administered. We have psychogeriatric or special units where residents would not be able to do that; also some residents experiencing dementia may not respond appropriately. If this practice occurs on other units, may we rank ourselves as compliant, i.e., as E?
No. If there are groups of the population that cannot respond appropriately, then you may be able to rank this item either C or D, but not E. For residents who are unable to confirm their name, an accurate method of identification is critical and a second method of identification would be required, according to Accreditation Canada practices.

Item 109. There are a couple of staff members who repeatedly make mistakes and cause medication incidents. We have a policy where a staff member with 10 incidents against them undergoes a performance review and this is documented on their file. How should we rank this item?
You would rank yourselves with an A. The intent of this item is to focus on system or latent failures that contribute to medication incident occurrence, rather than on the individual. Incident reporting and analysis help identify the system failures. Linking incident reporting to disciplinary action (or performance) will discourage reporting. If, through examination of a medication incident, it is found to have resulted from an individual's performance linked to wrongdoing, malicious, illegal or inappropriate behaviour, or if there is drug diversion, breach of confidentiality or other misconduct, then alternate means of handling such issues, e.g., police, are required. Staff performance gaps will likely involve a number of areas and be identified by other means; remedial action would then follow.

Item 111. Our home/facility is part of a corporate group where incident reports and their numbers are compared Home to Home/facility to facility. How should we rank this item?
You would rank yourselves as A or B. The numbers of incident reports do not represent severity or frequency of incidents, as incident reporting is voluntary. Comparing incidents among sites may discourage reporting. Furthermore, different Homes/facilities have different resident and practitioner populations and are therefore unique. Identifying weaknesses in a Home's/facility's medication-use system is most useful for that Home/facility. On the other hand, sharing of information and learning of similar weaknesses among facilities may allow all sites to collaborate in developing solutions. Learning about advances in medication-use safety at one site can be of benefit to others.

Item 116. We do not have the fiscal resources to employ specially trained, dedicated practitioners to enhance the detection of medication incidents and coordinate an error reduction plan. Should we rank this as E?
No. There may be a possibility to employ a person, who has an interest or special training in this area, as a full time position or to appoint someone on staff to take on this responsibility. Alternatively, several Homes/facilities may be able to share such a resource. This question would be better ranked as A or B to recognize the need for future enhancement of resources, since this is an important step in increasing the safety of the medication system.

In order to submit assessment results to ISMP Canada and have your results scored and weighted, participating facilities must first obtain a password from ISMP Canada. Questions regarding the self-assessment may be directed to mssa@ismp-canada.org.

Facilities belonging to a group or region may arrange to conduct this assessment by contacting ISMP Canada.

Les établissements participants doivent obtenir au préalable un mot de passe de l’ISMP Canada afin d’assurer la transmission, la cotation et la pondération des résultats. Toute question reliée à l’auto-évaluation peut être envoyée à l’adresse suivante : mssa@ismp-canada.org.

Les établissements qui font partie d’un groupe ou d’une région peuvent effectuer cette auto-évaluation en contactant l’ISMP Canada.