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Medication safety for pharmacy practice:
Incident analysis and prospective risk assessment

Wednesday, September 24 and Thursday, September 25, 2014
1.5 day workshop

This 1.5 day workshop provides pharmacists, pharmacy technicians and pharmacy assistants with background theory and hands-on practice in incident analysis (root cause analysis) and prospective risk assessment using failure mode and effects analysis (FMEA).

Day 1:
Incident Analysis - Root Cause Analysis (RCA) for Pharmacy Practice

The RCA portion of this workshop has been assigned 6.5 CEUs by the Ontario College of Pharmacists. The workshop curriculum is derived from the Canadian Incident Analysis Framework.

Porgram Abstract:

The program begins with an overview of the system approach in the management of error and introduction to human factors engineering principles. Root cause analysis (RCA) is a tool to help investigate adverse events and critical incidents in healthcare, identify and analyze root causes and contributing factors, and develop recommendations. Participants will learn how to conduct an RCA through interactive exercises and group work. The workshop will cover diagramming to support incident analysis, identification of contributing factor, summarizing the findings and developing and implementing recommended actions.

Day 2:
Prospective Risk Assessment in Pharmacy Practice
Using Failure Mode and Effects Analysis (FMEA)

The workshop curriculum is derived from the Canadian Failure Mode and Effects Analysis Framework and a version of the Framework customized for the pharmacy setting by ISMP Canada for the Alberta College of Pharmacists.

Porgram Abstract:

Failure Mode and Effects Analysis (FMEA) is a technique used to identify process and product problems before they occur. This half-day workshop builds on the principles learned in Day 1, with a change in focus to prospective risk assessment and process redesign. The workshop curriculum is customized for the pharmacy practice environment.

Through interactive group work, participants will learn how to diagram a process, how to identify potential failures, and how to redesign processes with consideration of human factors principles to decrease the likelihood of a failure impacting a patient.

FMEA is a team-based, structured process. It is forward-looking, in contrast to the retrospective approach of incident analysis and techniques such as root cause analysis. FMEA is based on the premise that all systems and processes contain embedded system failures.

Dates: Day 1 (Wednesday, September 24, 2014): 8:30 am to 4:00 pm
Day 2 (Thursday, September 25, 2014): 8:30 am to 1:00 pm
Location: ISMP Canada
Medication Safety Learning Centre
4711 Yonge Street
Toronto, ON, M2N 6K8
Cost: $850 per person, plus applicable taxes
For registration information, please select the Registration’ tab near the top of the screen.
Audience: Pharmacists, Pharmacy Technicians, Pharmacy Assistants, Pharmacy Students and Interns

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Medication safety for pharmacy practice:
Incident analysis and prospective risk assessment

Wednesday, September 24 and Thursday, September 25, 2014
1.5 day workshop

This workshop will be conducted by Julie Greenall, RPh, BScPhm, MHSc (Bioethics), FISMPC

Julie has more than 30 years of clinical and management experience in pharmacy practice. Julie joined ISMP Canada in 2004 and as Project Director, is responsible for coordinating, supervising and conducting medication system reviews, incident analyses and other consultation projects. Julie holds an active practice pharmacy license and in addition to her work with ISMP Canada, continues to work in a community hospital on a casual basis.

Since joining ISMP Canada, Julie has participated in numerous medication system reviews, root cause analyses of sentinel medication incidents and prospective risk assessment projects. Julie is a co-author of the 2006 Canadian Root Cause Analysis Framework and the revised Canadian Incident Analysis Framework released in 2012, in addition to numerous medication safety-related articles published in healthcare journals. Julie has provided educational presentations and workshops on a variety of medication safety topics across Canada and internationally.

Medication safety for pharmacy practice:
Incident analysis and prospective risk assessment

Wednesday, September 24 and Thursday, September 25, 2014
1.5 day workshop

This 1.5 day workshop provides pharmacists, pharmacy technicians and pharmacy assistants with background theory and hands-on practice in incident analysis (root cause analysis) and prospective risk assessment using failure mode and effects analysis (FMEA).

Day 1:
Incident Analysis - Root Cause Analysis (RCA) for Pharmacy Practice

Learning Objectives for RCA:

On completion of the RCA portion of the workshop, participants will be able to:

  1. Describe the impact of system factors on error potential;
  2. Apply basic human factors engineering principles in a health care environments;
  3. Describe the importance of each component of the incident management continuum;
  4. Complete a system-based analysis using a constellation diagram;
  5. Develop redesign strategies based on systems theory and basic human factors principles; and,
  6. Apply principles learned to support medication safety activities in their practice setting.

Day 2:
Prospective Risk Assessment in Pharmacy Practice
Using Failure Mode and Effects Analysis (FMEA)

Learning Objectives for FMEA:

On completion of the FMEA portion of the workshop, participants will be able to:

  1. Identify processes suitable for analysis using FMEA;
  2. Describe the steps required to complete an FMEA;
  3. Map out a process and identify potential failure modes;
  4. Develop redesign strategies based on systems theory and basic human factors principles; and
  5. Apply principles learned to support medication safety activities in their practice setting.

Contact Us

Mail:
ISMP Canada
4711 Yonge Street, Suite 501
Toronto, ON M2N 6K8
Email:
education@ismpcanada.ca
Phone:
416–733–3131 ext.0
Toll Free:
1–866–544–7672 ext.0
Fax:
416–733–1146

Directions to ISMP Canada

4711 Yonge Street
(Procter & Gamble building)

On entry to the building, check in with Security to obtain a visitor ID badge (next to the lobby elevators).

We are located in the Procter & Gamble Building - 4711 Yonge Street - North of the 401 on the East side of Yonge Street, South of Sheppard Avenue.

(416-733-3131 - ISMP Canada)

Driving Directions:

Note that parking is NOT available in the Procter & Gamble Building. Indoor paid parking is available at the Hullmark Centre (Yonge and Anndale – enter via Anndale).

Transit:

We are located on the "Yonge Line" - please get off at the Sheppard Station.