ISMP Canada completed a systematic literature review, compilation and evaluation of possible indicators and a consensus generation process involving a focus group with Ontario healthcare experts from various disciplines to identify and submit to the MOHLTC potential medication safety indicators for public reporting. From a list of more than 300 potential medication safety indicators, two analysts at ISMP Canada, worked independently to narrow the focus to 49, and subsequently to 12 candidate indicators. The selection criteria for evaluation of the indicators focused on data that: a) aligned with current patient safety initiatives in Ontario and/or Canada, b) are feasible or readily available, c) have acceptable validity and quality, d) are actionable, e) are understandable by the target audience, and f) are evidence-based.

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Medication safety is integral to overall patient safety in the OR setting. The OR is a unique environment where high-alert medications are frequently used and most procedures take place in a sterile field, requiring medications to be removed from their original packaging. Furthermore, medications may be prescribed, selected, prepared and administered by only one practitioner. In addition, medications may be administered in response to verbal orders, which can be error-prone. The OR is also a point of continuous patient transfer (i.e., the OR team assumes the care of a patient for short time period), with frequent hand-offs between the OR team and others, and transfer points are considered a time where there is increased risk for medication incidents (i.e., errors) to occur.

The OR Medication Safety Checklist was developed by an expert panel and in collaboration with the Canadian Anesthesiologists' Society and the Operating Room Nurses Association of Canada to help guide individual organization to assess system-based medication issues such as storage and use of medications in the OR setting. The pilot version of this checklist was reviewed and tested by 18 Ontario hospitals (4 of these hospitals were multi-site organizations). A post-pilot survey evaluation was completed by 9 of the participating hospitals. The survey results showed:

• 44% have implemented changes in their OR medication system as a result of the pilot
• 67% are planning or are in the process of implementing changes
• 89% indicated a plan for inclusion of the OR Medication Checklist as part of their quality improvement program

Version 2 of the OR Medication Safety Checklist includes learning from a recent Canadian event involving the inadvertent injection of concentrated epinephrine 1 mg per mL intended for topical application.

In an effort to combine OR safety initiatives in Ontario, ISMP Canada in collaboration with the OHA is providing the OR Medication Safety Checklist as part of the Surgical Safety Checklist Implementation toolkit distributed by the OHA to Ontario hospitals. The OR Medication Safety Checklist complements the Surgical Safety Checklist. Additionally, ISMP Canada staff presented to each LHIN to support medication safety in conjunction with roll out of the OHA Surgical Safety Checklist Implementation toolkit to Ontario hospitals. Presentations highlight for participants the key findings from reported events and literature regarding the inadvertent injection of concentrated epinephrine intended for topical administration.

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Medication reconciliation has long been identified as a system solution to enhance medication information communication for patients as they move from one health care setting to another. This project is also supported by the Ontario College of Pharmacists and complements the Ministry Meds Check program. ISMP Canada leads the national medication reconciliation initiative for the Safer Health Care Now program of the Canadian Patient Safety Institute.

For effective medication reconciliation processes, the first component is the skill of the person completing the medication history, usually on client/patient admission to a new facility. Training has been provided to over 500 pharmacists, pharmacy technicians, nurses, and pharmacy students to enhance their capability to take the Best Possible Medication History (BPMH) as part of the Ontario MedsCheck program. BPMH train-the-trainer education sessions for community pharmacists and hospital pharmacists were provided as well.

Another barrier is the effective transfer of the BPMH between Hospitals and Community Pharmacies. In consultation with the Ontario Public Drugs Program and Pharmacy Council, an initiative was undertaken with the goal to enhance the MedsCheck program. Stream A: Community pharmacists conducted best possible medication histories for 125 patients and documented time, barriers, and medication discrepancies. Baseline findings were 58 minutes to prepare for, complete and document the interview. Barriers encountered were the lack of pharmacist time in the usual workflow or scheduling process and insufficient patient awareness or acknowledgement of the MedsCheck service offered by pharmacists.

• 8 types of medication discrepancies with the 3 most common as:
  • Drug omission (33%) (mostly non-prescription and herbal medications being omitted)
  • Incorrect or omitted dose (19%)
  • Medications with no indication or drug commission (18%).
• 104 medication discrepancies documented.

Stream B: 10 hospitals participated in a project to link medication reconciliation programs in hospitals to the MedsCheck program in community pharmacies. Baseline data were collected on 140 pre-surgical patients. The average time to complete a BPMH was 12 minutes per patient. No patients brought a MedsCheck to the BPMH interview. After twelve months, the effect of the MedsCheck on the medication reconciliation process was evaluated. The average time to complete the BPMH when the patient brought a MedsCheck was not reduced, as expected, but remained the same. The sample included 113 MedsChecks from six hospital sites. There were 180 discrepancies between the MedsCheck and the BPMH taken by the pre-admission clinical staff. The majority of the discrepancies found were medication omissions (58.2%); these were followed by incorrect/omitted frequency (20.6%), medications with no indication (11.5%), incorrect/omitted dose (9%), and miscellaneous (0.6%). Discrepancies included prescription medications, non-prescription medications and herbal medications.

Findings indicate that linking community MedsCheck to hospital medication reconciliation requires:

• Reliable quality of the MedsCheck,
• Staff and physician buy-in,
• Coordination of resources and time to implement.

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Development of a confidential, secure Ontario Medication Incident Database has been supported by the Ontario Ministry of Health and Long-Term Care for the last 6 years. Reports are primarily submitted through an interface with Analyze-ERR® software, which was developed by ISMP Canada as a method for health care facilities to collect and analyze medication incidents, to identify trends and safety gaps in the medication system, and to voluntarily submit de-identified reports to ISMP Canada. This program has provided users with a unique opportunity to cultivate a culture for error reporting and learning.

Patient safety efforts fundamentally require reporting of incidents. Each incident report offers value by identifying sources of risk that might otherwise go unnoticed. Incident reports can provide learning that can then be shared such as through safety bulletins. Additionally, reports assist ISMP Canada through the MSSS advisory group to determine areas of focus for provincial medication safety initiatives and tools need to be shared with Ontario health care professionals and health care organizations to avoid recurrences.

Sincere appreciation is expressed to the many healthcare professionals who have demonstrated support for a culture of safety, exemplified by their willingness to share information about medication incidents and related findings.

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The Medication Safety Self-Assessment® (MSSA) was developed for Hospitals, Long-Term Care, Community Pharmacy and Complex Continuing Care/Rehabilitation Facilities. The MSSA is a comprehensive tool that can help organizations evaluate the strengths and weaknesses of their medication use processes and identify opportunities for improvement. Most importantly, this tool facilitates the development of a plan to improve medication safety within an organization. This proactive approach permits the identification of actions required to ensure the safety of medication practices.

113 Ontario hospitals have completed the MSSA, and 96 hospitals have completed it more than once. Hospitals repeating the assessment demonstrate higher scores on the repeat assessment, indicating that system improvements have been implemented. For some hospitals, the MSSA has become part of the facility's quality improvement program.¹ Ontario results have been consistently about 5% above the Canadian aggregate.

In Ontario, 10 of 20 complex continuing care/rehabilitation facilities (4 have repeated the process) and 40 community pharmacies have completed the self-assessment. Additionally, 360 (with 39 repeating the process) LTC homes have completed the MSSA.

Analysis of MSSA results assists in providing direction for future provincial safety initiatives. Of interest, approximately 80 safe practice characteristics from the hospital MSSA have been adapted for inclusion in the Accreditation Canada required organizational practices.

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The optimal management of hospital use of thromboprophylaxis has been well-documented and published. The project goal was to increase compliance with the use of evidence-based clinical practice guidelines in thromboprophylaxis (deemed the #1 priority for patient safety intervention by AHRQ in the US). A comprehensive, national web-based survey on anticoagulants to which 99 Ontario hospitals responded, identified the degree of adherence to best practice guidelines. A subsequent chart audit in 8 Ontario hospitals to establish baseline performance of thromboprophylaxis practices reinforced the need for a system improvement intervention. An average of 86% of patients having hip fracture surgery received prophylaxis; 51% of general surgery and only 31% of general medicine patients received appropriate prophylaxis. According to the practice guidelines for these groups of patients, the target was 100% compliance for all groups. Post-intervention results included:

• 13% increased rate of compliance for General Surgery patients
• 25% increased rate of compliance for General Medicine patients

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This high alert drug category was selected based on a number of critical incidents reported to ISMP Canada that resulted in patient harm, as well as on feedback from Ontario hospitals at an Ontario medication safety conference held in July 2003. Twelve months after the interventions were introduced to Ontario hospitals, a follow-up survey identified successful implementation or action in 94% of responding hospitals. These safeguards included removal of high potency opioids from patient care areas, standardization of doses and solutions, and implementation of independent double-checks for patient controlled analgesia and epidurals.

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In response to a number of patient deaths in Ontario (and other parts of Canada and the USA) due to unintended intravenous administration of potassium chloride (KCl) concentrate, ISMP Canada provided solutions and support to hospitals to prevent further mishaps. ISMP Canada's follow-up survey demonstrated significant achievements among Ontario hospitals, with a decrease in availability of concentrated KCl in patient care areas from 62% to 26%. An independent national survey conducted in 2004 reported that 96% of Ontario hospital respondents had removed KCl concentrate from patient care areas, citing Ontario as the most successful province in this safety initiative.²

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¹ Hofman L, Greenall J, McBride J, Jelincic V. Assessment of Risk in Medication-Use Systems: Learning from the Medication Safety Self-Assessment. Can J Hosp Pharm 2007; 60(1) 49-52

² McKerrow R, Johnson N, Hall KW, Roberts N, Salsman B, Bussieres JF, Macgregor P, Lefebvre P, Harding J. (Eds.). 2004. "2003/2004 Annual Report, Hospital Pharmacy in Canada: Medication Safety" [15th Hospital Pharmacy in Canada Survey]. Eli Lilly Canada. P;. 55-57. Retrieved March 9, 2007. http://www.lillyhospitalsurvey.ca/hpc2/content/rep_2004_toc.asp.