Hospital Medication Safety Self-Assessment® (Canadian Version II)

High Alert Drugs	Although most medications have a wide margin of safety, a few have a risk of causing injury when they are misused. These are 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 of high alert drugs include heparin, insulin, chemotherapy, concentrated electrolytes, IV digoxin, opioid 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 patient harm, but did not actually reach the patient or did not cause serious harm if it did reach the patient; a serious "near miss."
Practitioner	In this self-assessment tool, "practitioner" refers to professional staff such as physicians, pharmacists, nurses, and other licensed healthcare staff members.
Age-Specific Medications	Medications packaged in concentrations or volumes of varying sizes that are intended for ease of administration and control of waste for a specific age group (e.g., neonatal, paediatric, adult).
Error-Prone Abbreviations	Certain medical abbreviations, symbols, and dose designations that are considered “dangerous” and have often contributed to serious medication errors. A sample list can be found on the ISMP web site (www.ismp.org).
Failure Mode and Effects Analysis	A proactive risk assessment method based on the simultaneous analysis of possible failure modes, their consequences, and associated risk factors.
Human Factors	The interrelationships between humans, the tools they use, and the environment in which they work.
Independent Double Check	A process in which a second practitioner conducts a verification. Such verification can be performed in the presence or absence of the first practitioner. In either case, the most critical aspect is to maximize the independence of the double check by ensuring that the first practitioner does not communicate what he 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 (without seeing) any prior calculations.
Interface	A direct link between two information systems such that the information from one system is immediately available to the user of the second system, and is integrated in a way that supports clinical decision making (e.g., interfacing the laboratory and pharmacy computer systems would immediately provide corresponding laboratory data to the pharmacist while entering or reviewing a specific medication order). This may or may not include a bi-directional interface if two systems allow communication in both directions.
Machine-Readable Coding	Any encoded identifying mark (e.g., bar code) representing data that can be read with a computerized reading device, such as a scanner or imager.
Maximum Dose	The dose of medication that represents the upper limit that is normally found in the literature or manufacturer’s recommendations. Maximum doses may vary according to age, weight, or diagnosis.
Medication Delivery Devices	Equipment such as syringes, tubing, infusion pumps, implantable pumps, patient controlled analgesia pumps, automated compounding devices, robotics, and other related devices that are used for medication preparation, dispensing, and administration.
Mnemonic	A limited number of letters and numbers that are used to represent a specific medication (e.g., ASA80T may represent aspirin 80 mg tablets).
Moderate Sedation	The administration of any pharmacological agent, which will likely cause a medically controlled state of depressed consciousness. This state would be limited to short periods and utilized for diagnostic and therapeutic procedures that: 1) allow the protective reflexes to be maintained, 2) retain the patient’s ability to maintain a patent airway, respiratory rate and rhythm, and 3) permit expected responses by the patient to physical stimulation and verbal command.
Pharmacy and Therapeutics Committee	An interdisciplinary committee that convenes on a scheduled basis, or when necessary, to review the safety, use, efficacy, and monitoring of medications that will be available for use in the hospital. The committee also sets policy and procedures regarding the safety of the entire medication use process, on behalf of the medical staff and hospital administration.
Patient-Specific Medication or Dose	A ready-to-administer dose of medication that exactly matches the dose ordered by the prescriber for a specific patient. This may or may not correspond to the manufacturer’s unit dose package.
Root Cause Analysis	A retrospective process for identifying the most basic or causal factors that underlie the occurrence or possible occurrence of an adverse event.
Smart Pump Technology	An infusion pump with computer software that is capable of alerting the user to unsafe dose limits and programming errors if standard concentrations and dose limits have been programmed into the pump’s library. Smart pumps may also have the capability to block user over-rides and be bar code technology compatible.
TALL-Man Lettering	Enhancement of unique letter characters of drug names by use of upper case characters, and may include italics, colour background, or a combination of these elements to improve differentiation of look-alike drug names.
Turnaround Time	An interval that represents the period of time it takes for a medication order to be processed, typically from the time an order is written or electronically entered into a computer until the medication is available to a practitioner for administration to a patient.
Unit Dose	A single package that contains one dose of medication intended for one patient (e.g., a package with one tablet, one single-use vial of parenteral medication, 5 mL container holding one dose of liquid medication).
Unit-of-Use	A supply of medication that is intended for several doses of therapy, for a single patient (e.g., an inhaler, a tube of ointment or a 100 mL bottle of cough syrup).
WalkRounds™	A formal process in which a core group, including senior executives, conducts weekly visits to different areas of the hospital to ask specific questions about adverse events or near misses and about factors or system issues that lead to these events. [Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Patient safety leadership WalkRoundsTM. Jt Comm J Qual Safety. 2003;29:16-26.]