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Complex Continuing Care (CCC) and Rehabilitation Facility Medication Safety Self-Assessment™

The Complex Continuing Care and Rehabilitation Facility Medication Safety Self-Assessment is designed to:

  • heighten awareness of the distinguishing characteristics of a safe medication system in complex continuing care and rehabilitation settings;
    and to
  • act as a quality improvement tool; and
  • create a baseline of the facility's efforts to enhance the safety of medication and evaluate these efforts over time.

The self-assessment is divided into 10 elements or categories that most significantly influence safe medication use. Each key element is defined by one or more core distinguishing characteristics of a safe medication system. Representative self-assessment characteristics are provided to help you evaluate your success with each of the core distinguishing characteristics.

Completion of the MSSA for CCC/Rehab entails a two-step process:
  • completion of the interdisciplinary assessment (review and score of self-assessment items)
  • data entry (password required)
To enter your data, a password is required. You can obtain a password by sending an email request to mssa@ismp-canada.org.

The Complex Continuing Care (CCC) and Rehabilitation Facility Medication Safety Self-Assessment 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 facilities as part of their ongoing quality improvement activities. The aggregate results of this assessment will be used for research and education purposes only.

ISMP Canada is not a standards setting organization. As such, the self-assessment characteristics 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 criteria represent innovative practices and system enhancements that are not widely implemented in most facilities today. However, their value in reducing errors is grounded in scientific research and expert analysis of medication errors and their causes.


Part 1: Hard Copy Review (booklet or PDF file print-out)

1. Establish a interdisciplinary team consisting of, or similar to, the following:

  • Senior Administration Representative
  • Risk management and/or quality improvement professional
  • At least one staff nurse
  • At least one staff pharmacist
  • At least one staff 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 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 involved in medication use. The estimated time commitment is three interdisciplinary team meetings of one hour each, to complete the self-assessment.

2. To access the PDF file of the MSSA and information on the process to compile your data, send an email request to mssa@ismp-canada.org. When you are ready to enter your data online, you will request a password as outlined in the information package.

3. Read and review the self-assessment in its entirety before the assessment process begins. If possible, make copies of the self-assessment and send them to team members for review before the first meeting.

4. Complete the "Demographic Information" form.

5. Discuss each core distinguishing characteristic and evaluate the facility's current success with implementing the representative self-assessment characteristics. 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 characteristic has been reached, note one of the following choices next to each characteristic (the responses can be entered into the assessment page later, when you enter the password provided and click the "Enter MSSA Assessment" button at the bottom of the "Enter / See Results" tab).

A = This characteristic is applicable but there has been no activity to implement it
B = This characteristic has been formally discussed for possible implementation, but not implemented
C = This characteristic has been partially implemented in some areas of the facility
D = This characteristic is fully implemented in some areas of facility
E = This characteristic is fully implemented throughout the facility

If the item is not applicable to your facility, consider the following:
  • If there is no identified client need (e.g., items pertaining to IV administration in a facility that does not permit IV administration), select E
  • If the item is feasible for possible future implementation (e.g., computerized physician order entry), select A if no action has been taken

For representative self-assessment characteristics with multiple components, full implementation (score D or E) is evidenced only if all components are present. 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 characteristics with two distinct elements, each separated with the word OR, and labeled "a" and "b", answer either part "a" or "b" but not both.

Unless otherwise stated, representative self-assessment characteristics refer to medications prescribed, dispensed and administered to all clients typically seen in complex continuing care and rehabilitation facilities.

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


Part 2: Online Data Input

7. When you are ready to enter your data online, you will request a password as outlined in the information package.

8. Submit data from the completed self-assessment to ISMP Canada.

After the password is entered and accepted, data can be entered and submitted to ISMP Canada. The special, web-based assessment tool will immediately upload the information into a database maintained solely by ISMP Canada. No data will be maintained on the Internet assessment form after it has been submitted to ISMP Canada. Confidentiality will be assured.


Adverse Events

"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.

Area

Recognizing the differences in organization of various types of complex continuing care and rehabilitation facilities, "area" is generic terminology that can be interpreted and applied by the facility, specific to its organization, where medications are stored or administered (e.g., locations or physical units, groupings by medical conditions/diagnoses, etc.)

Client

Refers to patients or clients for whom care is being provided in the facility completing the assessment.

Conscious Sedation Refers to ongoing management of pain and/or agitation, with the use of narcotics/benzodiazepines, etc., usually in high doses, for clients recieving palliative care.
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 have a high risk of causing injury when they are misused. Examples include hypoglycemic agents, insulin, narcotic analgesics, warfarin, digoxin and sustained release (long acting, extended release) oral capsules or tablets and patches.
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.
MAR Medication Administration Record, the record that is used to document medication administration for each client.
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 client.
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."

Practitioner

"Practitioner" refers to professional staff such as physicians, pharmacists, nurses, and other licensed healthcare staff members.

Prescriber

"Prescriber" refers to professional staff such as nurse practitioners, clinical assistants, pharmacists, interns, physicians who prescribe medications in the healthcare facility.

Regularly Scheduled Medication

May also be referred to as "routine, maintenance, scheduled".

Root Cause Analysis

A quality improvement tool to help individuals and organizations retrospectively determine all of the root causes and contributing factors that led to an adverse event. It includes strategies for developing effective recommendations and implementing actions for system improvement.

Unit Dose

Term includes bubble, strip and unit-dose packaging.



General Questions

Do we need senior administrative staff on our team?
A senior administrator is an important member of the team because the assessment contains many items that inquire about your facility's overall commitment to client safety. Furthermore, participation in the self-assessment provides senior administrative staff with insight into areas of risk in the medication use system.

How many interdisciplinary team meetings should we schedule?
Based on the experience of other users, we suggest you schedule a series of three meetings of one to two hours to complete the self-assessment. Some sites have completed the assessment in less time than this and some have run longer than one hour at a meeting, but most report not needing to meet more than three times. It is best to complete the self-assessment as a team rather than separate clinical areas; the team perspective offers broader insight into compliance.

My facility has a number of sites. Do I need a password for each one?
If your facility is homogeneous or is managed as a single entity, then it may be appropriate to conduct a single MSSA across the entire institution. However, if your sites are relatively autonomous and have different procedures and levels of technology, then separate MSSAs and passwords are probably in order.

How are individual items scored?
Each item has a specific weighting. If the characteristic is fully implemented, then the maximum score is achieved. Similarly, if the item is scored as E because there is no identified client need, maximum score will be applied reflecting no inherent risk since the service is not being provided. These scores should be taken into consideration when the facility is reviewing its final scores. The scoring is not the same for all items, as some identify situations representing a higher safety risk than others. These items have higher maximum scores. The scores may range this way:
    0,1,2,3,4 or
0,2,4,6,8 or
0,3,6,9,12 or
0,4,8,12,16

For some items there are no partial scores; a score is only achieved when there is full implementation, for example:
    0,0,0,0,8 or
0,0,0,0,12 etc.

The "absolute" scores are useful when comparing repeated self-assessments or for a specific group analysis; otherwise, the general findings as represented on the graphs are sufficient.

What if a question doesn't apply to the services offered in my facility?

  • If there is no identified client need (e.g., items pertaining to IV administration in a facility that does not permit IV administration), select E
  • If the item is feasible for possible future implementation (e.g., computerized physician order entry), select A if no action has been taken



Questions related to specific self-assessment characteristics

Item 29. What score do I enter if the pharmacy computer system updates occur less frequently than every quarter?
Self-assessment scores should not exceed level C (e.g., can not score D or E) if updates occur less frequently than every quarter.

Item 37. What is meant by "therapeutically necessary and appropriate"? We are fairly liberal with maintaining clients on the medications they are receiving before they enter the hospital for rehabilitation to decrease any chance of adverse effects from switching medications for a short stay. How would we answer this question?
The policy of maintaining clients on medications "taken at home" can lead to the rapid demise of the formulary system and add to possible errors due to the lack of proper practitioner education on the medications which are prescribed in an uncontrolled formulary environment. However, in the case of rehabilitation clients, it can be argued that changing a client's medication during a short facility stay may increase the risk of duplicate medications and/or confusion as to what medications to take when the client returns home. Facilities should have a policy on when it is appropriate to use non-formulary medications. Further, the Pharmacy and Therapeutics Committee should review non-formulary medication use and recommend additions and deletions to the formulary according to the medications most commonly prescribed in the community setting as well as safety concerns with these medications. If your facility addresses when non-formulary medication use may be appropriate and regularly updates the formulary to reflect current therapies and provides drug information to nursing staff , then answers of C through E may be appropriate for this question.

Item 38. What score do I enter if prescribers enter orders into a separate computer system that is not directly interfaced with the pharmacy computer system?
Self-assessment scores should not exceed level C (e.g., cannot score D or E) if prescribers enter orders into a computer system that is not directly interfaced with the pharmacy computer system, even if the vast majority of prescribers enter orders via computerized prescriber order entry.

Item 45. Are oral or injectable cytotoxic agents used for other purposes (i.e., non-oncology) included in the prohibition of verbal and telephone orders?
All cytotoxic agents prescribed for clients, regardless of the route of administration or indication, should not be communicated via verbal or telephone orders. This includes cytotoxic agents used for non-oncology indications (e.g., methotrexate used for rheumatoid arthritis).

Item 102. What is meant by "if applicable" for the expiration date?
This means if the expiration date is available from the manufacturer, or if the pharmacy has repackaged the product, the product is given an expiration date according to an established internal policy.

Item 172. What is meant by error rate in this question?
Many facilities may consider using the number of voluntarily reported errors as a proportion of total doses or prescriptions dispensed as the "rate" of errors within the facility for various comparisons. However, because error reporting is not consistent and hence does not represent the true incidence of errors, such a "rate" has no legitimate relevance or significance. Such calculations should not be used for internal or external comparisons.

Item 177. What is meant by the Board of Trustees' commitment to client safety and the facility's strategic plans?
This question relates to the atmosphere that everyone in your facility, including the Board of Trustees, shares a commitment to client safety and a non-punitive system-based approach to medication error prevention. Organizations with open error reporting policies which are non-punitive and which use the results of error analysis to institute system changes are, in our experience, ahead of the curve in safe medication use practices. Answers to these questions must be honestly agreed upon between the senior administrator on your task force as well as all other members of staff.

Item 195. Is it fully acceptable to use "aseptic" rather than "sterile" technique when preparing IV admixtures?
Yes.

Send an email to mssa@ismp-canada.org

  • to obtain a password in order to submit assessment results to ISMP Canada and have your results scored and weighted
  • to have your questions regarding the self-assessment answered
  • to conduct this assessment among facilities belonging to a company group or geographical region
Password: