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

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);
act as a quality improvement tool; and to
create a baseline of a Long Term Care Home's/facility's efforts to enhance the safety of medication use and evaluate these efforts over time.

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.

Alberta has implemented the use of the MSSA for Long Term Care as has the British Columbia Interior region. In Ontario, the Ministry of Health and Long Term Care is supporting an initiative to have all Ontario Long Term Care Homes use the tool.

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 a multidisciplinary team/task force consisting of, or similar to, the following:

Senior administration/management representative
Person responsible for quality/risk issues
Registered nurse (RN)
Registered practical nurse (RPN)
Contract service/consultant pharmacist
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 Home/facility. Because medication use is a complex, interdisciplinary process, the value and accuracy of the self-assessment is significantly reduced if it is completed by a single discipline. Participation of front line nursing staff and the consultant pharmacist enhances the validity of the results. The meeting time commitment by the multidisciplinary team to complete the self-assessment is estimated at three hours.

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.

Complete the "Demographic Information".

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 health care practitioners outside the task force.

When a consensus on the level of implementation for each representative self-assessment item has been reached, note 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	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 some areas of the Home/facility (e.g., by location, resident population, prescription type, drugs or staff)
	D	This item is fully implemented in some areas of the Home/facility (e.g., by location, resident population, prescription type, drugs or staff)
	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

An item may be rated A if it is feasible for future implementation, but it has not been discussed; the same item would be rated B if formal discussion had taken place and/or it is in the planning stages. For example, #116 states that specifically trained practitioners are employed to enhance detection of medication errors, oversee analysis of their causes, and coordinate an effective error reduction plan. This item would be rated A if there are no plans for such a position or role nor has there been any discussion regarding such or it could be rated B if formal discussion has taken place but such a role has not been implemented. However it would not be rated E, i.e., as not applicable to the Home/facility, because it identifies a best practice that would provide an opportunity for future system enhancement.

An item may be rated C or D if partially implemented. For example, #101 states that current resident photographs are available with the resident-specific Medication Administration Record (MAR) to assist in identifying residents by staff before administration of medication. It would be rated as C if this practice is partially in place in some or all resident areas. This could be rated D if it is fully implemented in a certain area of the Home/facility, e.g., secure areas where residents, due to various types of dementia, are unable to identify themselves by name, but not fully implemented in other areas.

For representative self-assessment items with multiple components, full implementation (score D or E) is evidenced only if all components are present. The item may also imply implementing and/or addressing practices by more than one discipline (e.g., #43 where labelling, packaging and nomenclature problems should be identified by both pharmacy and nursing staff). If only one or some of the components has been partially or fully implemented throughout the organization, self-assessment scores should not exceed level C.

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

Unless otherwise stated, representative self-assessment items refer to medications prescribed, dispensed, administered, and outcomes monitored for all residents typically seen in long term care.

The MSSA is a self-assessment tool; it is not a measurement of performance, but a measurement of inherent system safety. For each self-assessment item, you are not just looking at how your system currently functions, but also how the system should function in order to increase safety, given the opportunity and the resources. As noted in the introduction to the MSSA, some of the self-assessment parameters are not yet widely implemented, but they reflect a level of practice to which all Homes/facilities should aspire.

To illustrate the above point, for Homes/facilities that do not yet have a unit dose medication system, any items referring to unit dose should be scored A or B, not E. Computerized prescriber order entry (CPOE) questions should be scored A or B but not E unless fully implemented. For both these examples, an opportunity exists to enhance the safety of the medication system by adopting this in the future.

For some Homes/facilities the score of E may be used to reflect services they do not provide because there is no resident/client need and, therefore, no safety risk, e.g., IV administration of drugs or palliative sedation. However, computerized prescriber order entry (CPOE), bar coding, unit dose, computer-generated MARs would apply to all resident populations.

The MSSA provides a measurement of inherent system safety. When you choose E for a question related to a service that is not provided, the score for the core characteristic group will increase.

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

Notes can be added to each item, by clicking on the note icon

. For example, for A, B, C, D responses, reasons that limit full implementation can be documented, and you can add comments that may be a helpful reference to your team when repeating the survey at a future date.

Submit data from the completed self-assessment to the ISMP Canada secure website (https://www.ismp-canada.org/lmssa/index.php).

The survey responses are encrypted when entered into our secure website (http://www.ismp-canada.org). The Medication Safety Self-Assessment® page has a tab entitled Enter / See Results. On this page is the field to enter your password and to access the MSSA survey for your data entry. A 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.

After the password is entered and accepted, data can be entered and submitted to ISMP Canada. While entering data, the option to "Save and Exit" can be used as each section of the tool is completed. The option to "Finalize Assessment" would be selected only when all data have been entered. The special, web-based survey will immediately download the information into a database maintained solely by ISMP Canada. 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.

Entering the data into the web-based program allows you to compare your own results over time and also compare your results with the aggregate (national and regional) results of other respondents. You will be able to see your results immediately on data submission by clicking on the appropriate tabs (Print results, View results, Compare aggregate). The Print Results option allows the user to view and print all the questions and responses, gives the percentage scores for the key elements and core characteristics that match the graph results, and shows each item, the score chosen (e.g., A, B, etc.) and the related numeric score (e.g., 0/4, 1/4, etc.). Compare Aggregate provides graph information of the Home's/facility's results versus the aggregate score for the participants in that group, provided three or more Homes/facilities with the same demographic information have submitted results. The information can be graphed based on Home/facility size (number of beds), Home/facility type, etc. View Results allows the user to view the questions and the alphabetic scores submitted.

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 health care management rather than by the resident's underlying disease process.
Area	Recognizing the differences in organization of various types of long term care Homes/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.).
Failure Modes 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.
High Alert Drugs	Drugs that bear a heightened risk of causing significant patient harm when they are used in error. Examples include hypoglycemic agents, narcotic analgesics, warfarin, digoxin
Home	Refers to long term care facilities which are Homes for residents; different levels of care and support may be provided.
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. 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. For example, 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.
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.
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.
Practitioner	Professional staff, such as physicians, pharmacists, nurses, and other licensed health care staff members.
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".
Root Cause Analysis	An analytical 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.
Unit Dose	Refers to the packaging of medication containing one dose of a medication ordered for a specific resident.

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.

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 and/or substitute decision maker contact". What if the information we receive is not current and/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 score 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 score this question?
If prescribers do not consistently sign orders or fax back signed copies of orders consistent with the Home/facility policy, the score 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 score ourselves as compliant?
The use of medication samples provided by a physician is not a safe practice. The medication may not be recorded in the pharmacy profile; side effects or interactions with other medications may not be identified; 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. This practice should be discouraged and would probably be scored as an A or B.

Item 69. There is a reference to non-prescription medications as stock. What does this mean?
In some provinces, the Ministry of Health may provide, at no charge to the Home/facility, a supply of selected non-prescription medications. If this is not the practice in your region, score this point as E.

Item 100. This item states that residents assist health care 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 score ourselves as compliant, i.e., as E?
If there are groups of the population that cannot respond appropriately, then you may be able to score either C or D, but not E. For residents who are unable to confirm their name an accurate method of identification is critical.

Item 116. We do not have the fiscal resources to employ specially trained, dedicated practitioners to enhance the detection of medication errors and coordinate an error reduction plan. Should we score this as E?
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 scored 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.