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Definitions of Terms
This glossary provides definitions for a minimum number of terms that are considered essential to the discussion of Medication Incidents in the context of a Canadian medication incident reporting and prevention system today. Revisiting the selected definitions will be required periodically to align with national and international patient safety initiatives as they develop.
Adverse Drug Event:An injury from a medicine or lack of an intended medicine. Includes adverse drug reactions and harm from medication incidents.
Adapted from Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, Sweitzer BJ and Leape LL, “The Costs of Adverse Drug Events in Hospitalized Patients. Adverse Drug Events Prevention Study Group,” Journal of the American Medical Association 277, 4 (January 22, 1997): pp. 307–11.
Developed by the collaborating parties1 of the Canadian Medication Incident Reporting and Prevention System. 2005.
Critical Incident:
An incident resulting in serious harm (loss of life, limb, or vital organ) to the patient, or the significant risk thereof. Incidents are considered critical when there is an evident need for immediate investigation and response. The investigation is designed to identify contributing factors and the response includes actions to reduce the likelihood of recurrence.
From Davies J, Hebert P and Hoffman C, Canadian Patient Safety Dictionary (Ottawa: Royal College of Physicians and Surgeons of Canada, 2003).
Harm:
Harm is defined as a temporary or permanent impairment in body functions or structures. Includes mental, physical, sensory functions and pain.
Developed by the collaborating parties1 of the Canadian Medication Incident Reporting and Prevention System. 2005.
High-Alert Medications:
High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error.
ISMP’s List of High-Alert Medications. Available at: www.ismp.org/Tools/highalertmedications.pdf.
Independent Double Check:
An independent double check is a process in which a second practitioner conducts a verification. Such verification can be performed in the presence or absence of the first practitioner. In either case, 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.
Institute for Safe Medication Practices Canada © January 2005. Adapted with permission from: Institute for Safe Medication Practices (US). The virtues of independent double checks – they really are worth your time! ISMP Safety Alert. 2003 March 6;8(5):1
Long-term care is defined as care provided in facilities offering accommodation for people who require on-site delivery of supervised care, 24 hours a day, 7 days a week, including professional health services and high levels of personal care and services (e.g., in nursing homes and residential continuing care facilities). The acuity of people receiving long-term care is generally less than that of patients in acute care or complex continuing care settings. Medications for residents in long-term care are usually provided by community pharmacies.
Definition adapted from: Long-term facilities-based care [Internet]. Ottawa (ON): Health Canada; 2005 [cited 2007 Dec 28]. Available from: http://www.hc-sc.gc.ca/hcs-sss/home-domicile/longdur/index_e.html
Medication Incident:
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, 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 parties1 of the Canadian Medication Incident Reporting and Prevention System. © 2001.
Similar Term: Medication Error
Medication Safety:
Freedom from preventable harm with medication use.
ISMP Canada, 2007.
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.
Developed by the collaborating parties1 of the Canadian Medication Incident Reporting and Prevention System. 2005.
Similar Terms: Near Hit or Good Catch
No Harm Event:
An incident occurs which reaches the patient, but results in no injury to the patient. Harm is avoided by chance or because of mitigating actions.
Developed by the collaborating parties1 of the Canadian Medication Incident Reporting and Prevention System. 2005.
An analytic tool that can be used to perform a comprehensive, system-based review of critical incidents. It includes the identification of the root and contributory factors, determination of risk reduction strategies, and development of action plans along with measurement strategies to evaluate the effectiveness of the plans.
From Hoffman C, Beard P, Greenall J, U D, White J. Canadian Root Cause Analysis Framework, Canadian Patient Safety Institute, Edmonton: March, 2006.
Safety:
Freedom from accidental injuries.
From Kohm LT, Corrigan JM, Donaldson MS, eds. To err is human: Building a safer health system. Washington, DC, National Academy Press, 1999.
System:
A set of interdependent elements (people, processes, equipment) that interact to achieve a common aim.
From World Alliance for Patient Safety. WHO draft guidelines for adverse event reporting and learning systems. Geneva (Switzerland): World Health Organization; 2005
1Collaborating parties for the development and implementation of the Canadian Medication Incident Reporting and Prevention System (CMIRPS) are: Institute for Safe Medication Practices Canada, Canadian Institute for Health Information and Health Canada.
