Link to ISMP Feedback

Medication Safety Self-Assessment® for Community/Ambulatory Pharmacy™


Definitions (for Purposes of the Self-Assessment Tool):

Adverse Events

In this self-assessment tool, “adverse events” are unintended injuries or complications resulting in death, permanent or temporary disability or prolonged facility stay that arise from health care management. This definition is based on studies by Baker and Norton and on various definitions discussed in The Canadian Patient Safety Dictionary.

Failure Modes and Effects Analysis
Examination of a product or system to identify all the ways in which it might fail.
High Alert Drugs Although most medications have a wide margin of safety, a few drugs have a risk of causing injury when they are misused. These may be termed "high alert drugs". Although errors may or may not be more common with these drugs than with others, their consequences may be more devastating (Cohen MR, Kilo CM. High-alert medications: Safeguarding against errors. In Cohen MR, ed. Medication Errors. American Pharmaceutical Association, Washington, DC, 1999). Examples include heparin, insulin, cytotoxic agents, concentrated electrolytes, IV digoxin, opiate narcotics, neuromuscular blocking agents, and adrenergic agonists.
Implement Accomplish or achieve in practice, not just policy, to carry into effect.
Potentially Serious Medication Error
A medication error that has the potential to cause serious client harm, but did not actually reach the client or did not cause serious harm if it did reach the client; a serious "near miss."