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Ontario Critical Incident Learning

Improving quality in patient safety

To advance the patient safety agenda, in August 2011 the Ontario Ministry of Health and Long-Term Care issued a directive that hospitals must report critical incidents involving medications and intravenous fluids to the Canadian Institute for Health Information National System for Incident Reporting (NSIR). A critical incident is an "unintended event that occurs when a patient receives treatment in the hospital that results in death, or serious disability, injury or harm, and does not result primarily from the patient's underlying medical condition or from a known risk inherent in providing treatment".

ISMP Canada has been identified as the lead organization for analysis of the reported incidents. A multidisciplinary team reviews each submitted critical incident report to ensure effective identification of the contributing factors. In addition, ISMP Canada will periodically conduct aggregate analysis of reported incidents to provide a more in-depth assessment of events involving a particular medication or care setting. On the basis of these analyses, ISMP Canada will develop and disseminate outcome-directed recommendations, with an emphasis on high-leverage actions that take into account human factors engineering principles and the need to design systems with integrated safeguards.


Analysis Reports:

  • Ontario Hospital Critical Incidents Related to Medications or IV Fluids Analysis Report - 2015, 2014, 2013, 2012

Knowledge Translation Projects:

Evaluation of ISMP Canada Activities:

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Collaboration with the Ontario Drug Policy Research Network (ODPRN)

ISMP Canada is collaborating with the Ontario Drug Policy Research Network (ODPRN) to disseminate medication safety-related studies. The ODPRN is a province-wide network of researchers who provide timely, high quality, drug policy relevant research to decision makers. The following ODPRN research minute publications provide summaries of selected medication safety-related studies.


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