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Medication Safety Self-Assessment® for Hospitals
(Canadian Version II)


Frequently Asked Questions (FAQs)
Related to Specific Self-Assessment Items
(listed in numerical order)

14. What does "and available in the pharmacy computer for reference" mean?
A patient's comorbid and/or chronic conditions should be contained in the pharmacy computer system for
pharmacists to have easy access to review this information as orders are processed. If the information is available
in a separate system that must be accessed, then the answer to this item should not exceed response C.

29. What score do I enter if the pharmacy computer system updates occur less frequently than every

Self-assessment scores should not exceed level C (i.e., cannot score D or E) if updates occur less frequently than
every quarter.

30. Does this mean that anyone can screen medication orders in a computer system?
The intent of this item is that all new patient medication orders are entered and screened against the patient's total
medication profile in an electronic system by a pharmacist before the medication is dispensed and administered
unless it is an emergent lifesaving situation (e.g., cardiac arrest). In a hospital without 24-hour pharmacy service
this process should be performed by a licensed healthcare professional when a pharmacist is not available.

31. What score do I enter if ongoing patient profiles in the pharmacy computer system are purged
more frequently than every five years?

Self-assessment scores should not exceed level C (i.e., cannot score D or E) if records are purged more frequently
than every five years.

39. What is meant by “therapeutically necessary and appropriate”? We are fairly liberal with
maintaining patients on the medications they are receiving before they enter the hospital to decrease any
chance of adverse effects of switching medications for a short hospital stay. How would we answer this

In our experience the policy of maintaining patients 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 professional staff education on the
medications which are prescribed in an uncontrolled formulary environment. Hospitals must have a strict policy
on the use of non-formulary medications that requires prescribers to state the reason why a non-formulary
medication is needed. The P&T committee should review non-formulary medication use and recommend
additions and deletions to the formulary according to the medications most commonly prescribed in the
outpatient setting as well as safety concerns with these medications. If your hospital has this strict control over
non-formulary use then answers of C through E may be appropriate for this question.

40. 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 (i.e., 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 physician order entry.

48. Do respiratory therapy medications need to be included on the MAR and documented when
administered on the MAR for full implementation?

Yes, all medications should be listed and documented on the MAR for full implementation and scores of D or E.

51 & 52. Explain what is meant by “uncommon uses and atypical doses”.
Medications that are prescribed for indications or at doses that are not supported in the approved labelling or in
the recent literature would be considered uncommon uses or for atypical doses. A medication being prescribed
for a non-Health Canada approved indication or in a recommended dose that is supported in peer-reviewed
literature would not be considered an uncommon use.

99. What is meant by “if applicable” for the expiration date?
If the expiration date is available from the manufacturer or if the pharmacy has repackaged the product, the
product should be labelled with an expiration date according to an established internal policy.

100. Storage and distribution of formalin.
Formalin should not be stored or distributed by the Pharmacy Department. In the rare circumstance where
formalin may be required as a therapeutic preparation (e.g., diluted formalin used for bladder instillation in cases
of intractable hemorrhagic cystitis), the pharmacy should sequester the chemical from all other medications,
prepare and dispense dilute solutions for patient-specific use only with an appropriate warning label, and ensure
that the preparation is independently verified by a second practitioner. Note: If formalin is handled by
pharmacy for any reason, the score cannot exceed “B”.

163. What is meant by error rate in this question?
Many organizations attempt to calculate an error rate (using the number of voluntarily reported errors as the
numerator and a denominator such as total doses dispensed) to compare the "rate" of errors in their organization
and for unit to unit comparisons.

168 & 169. What is meant by the board of directors’ commitment to patient safety and the hospital's
strategic plans?

These items relate to an organizational atmosphere where everyone, including the board of directors, supports
patient safety and a non-punitive system-based approach to medication error prevention. In our experience,
organizations with open error reporting policies and that use the results of error analysis to institute system
changes that may involve capital investment, are ahead of the curve in safe medication use practices. Answers
to these questions must be honestly agreed upon amongst all task force members.

199. How do I answer this item if allergy information is transferred from prior admissions but
practitioner verification is only needed for certain medications?

Your answer should not exceed a C for this item. The intent of this item is that if your system allows allergy
information from a patient's prior admission to automatically populate a new patient profile, the information
must first be verified before medication orders are processed. ISMP has received error reports when allergies
from prior admissions populate the pharmacy computer system without further verification, and pharmacists
dispense medications assuming that current allergies have been entered.

207. What does adequately monitor and manage mean in this item?

Adequately monitor and manage refers to the ability of the healthcare organization to provide necessary and
current laboratory information, up to date drug alerts, and appropriate monitoring equipment in order for
practitioners to adjust medication therapy, prevent adverse drug effects (including errors), from occurring or to
help mitigate their adverse effects.

231. Explain the examples given for an effective means of measuring medication safety?
These are methods used by hospitals to provide a more accurate measurement and to track risk reduction
strategies. They may include:

Observational methods of error detection - A determination of error frequency based on the number of errors
detected during direct observation of performance. This measurement is used to obtain a numerator, which is
then divided by a volume indicator such as the total number of medication doses that should have been
administered, total patient admissions, or number of associated procedures, which becomes the denominator.

Tracking risk priority numbers from failure mode and effects analysis (FMEA)
- A process of assigning a hazard
score, called a risk priority number, to a specific FMEA for a process, incorporating change strategies into the
process, and re-performing the FMEA to determine if the risk priority number has changed.

Triggers - A list of laboratory values, medications, procedures, and other measures (e.g., INRs or aPTTs above
a critical value, one time dose of an antidote, emergency returns to OR) that may indicate an error has occurred.
These may be tracked electronically during order entry or manually via electronic printouts and chart review.