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Increasing Patient Safety in Community Pharmacies2What is SafetyNET-Rx?Who is Involved?Why is SafetyNET-Rx important to me?Medication Safety Self Assessment-CAPCommunity Pharmacy Incident Reporting (CPhIR) toolHow to implement SafetyNET-Rx in your PharmacyIntroduction to SafetyNET-RxWhat is SafetyNET-Rx?3Continuous Quality Improvement (CQI) Program designed to enhance patient safety through a community pharmacy-based quality management program.

Purpose is to identify, report, analyze and learn from medication errors and near misses, collectively known as Quality Related events or QREs.

ObjectivesTo provide an open dialogue between retail pharmacies, regulatory bodies, and academic researchers on quality related events;

To disseminate the knowledge needed to enable retail pharmacies to assess and benchmark their own QRE reporting and learning practices in a systematic and validated way;

To provide a standardized, and packaged process that pharmacies can adopt to identify, report, and manage QREs that meets the NSCP standard for an effective continuing, documented quality assurance program;

To identify the major organizational culture and change management issues that may promote or hamper the use of QRE reporting.4Who is involved with SafetyNET-Rx?Dalhousie University College of PharmacyDr. Neil MacKinnonSt. Francis Xavier UniversityDr. Todd Boyle & Dr. Tom MahaffeyInstitute for Safe Medication Practices (ISMP) CanadaCertina HoNova Scotia College of Pharmacists (NSCP)Bev ZwickerFunded by: Nova Scotia Health Research Foundation (NSHRF)Social Sciences & Humanities Research Council5Why is SafetyNET-Rx Important?The Standard of Practice for Quality Assurance Programs in Community Pharmacies was approved and adopted by the Council of the Nova Scotia College of Pharmacists (NSCP) on March 30w.fth 2010.

All pharmacies in Nova Scotia will be assessed against this standard as part of their routine inspection beginning in October, 2010.

Pharmacies participating in the SafetyNETRx project will have the advantage of the support of the project team and resources to establish the necessary policies and processes to achieve the standard.

6Show standards, have in their binder6What is Involved in Participating1. The commitment of at least two pharmacy staff members (ideally one pharmacist and one pharmacy technician) to facilitate implementation of the process at the store level.2. Completion of Medication Safety Self-Assessment (MSSA ) survey at the beginning and end of the project.3. Utilization of the Canadian Pharmacy Incident Reporting program (CPhIR).4. Quarterly staff meetings.5. Completion of SafetyNET-Rx project evaluation surveys at various points throughout the project.

7Advantages of Participation Free access to the MSSA tool for one year, a savings of $325

Free access to the online CPhIR reporting tool for one year, a savings of $325

Access to the SafetyNET-Rx website

Ongoing support from the SafetyNET-Rx research team to address quality-related problems or issues in your pharmacy

8Background Information: The foundation of SafetyNET-Rx9http://media.cop.ufl.edu/camtasia/ms/error/video.html

http://media.cop.ufl.edu/videos/pha6277/abc.html

The Problem Of Pharmacy ErrorMechanical ErrorWrong DrugWrong StrengthWrong DirectionsWrong PatientJudgmental ErrorInaccurate CounselingInaccurate DURFailure to CounselFailure to Conduct DURIndividual CausesLack of KnowledgeLack of SkillLack of CarePersonal DistractionsSystem CausesWorkflowCommunicationStaffingPatient Expectations10Different types of common dispensing errors10The QRE: Clarifying The Use of LanguageError (Backward Looking; Blame-Laying)Incident (Patient Received Medication)Near MissNear Hit (An Almost Error)Sentinel Event (Screams Out Danger)Quality-Related Event (QRE)IncidentsNear HitsSentinel EventsPositive QREs11Facilitator: The Quality Team LeaderDoes not have all of the answers, but does know how to ask the right questions.This person is responsible for Initial training, Implementation of the program, Continuation of the program, and Conduct of Quality Consults.Not a spy for management. This activity is separate from performance evaluation.1212Role of FacilitatorsAs part of SafetyNET-Rx, each store will select at least two in-store facilitators, ideally one pharmacist and one pharmacy technician.

To assist in tailoring the training to the needs of the participants, and to achieve awareness of potential issues impacting QREs prior to the training session, each pharmacy is expected to complete and submit the MSSA one week prior to their training session.

13What Does CQI Look Like?Define the process through which prescriptions are filled.Make a record of quality related events.Discuss how systems can be used to prevent similar events in the future.

14Gathering The TroopsEveryone must participate: Pharmacists, techs, clerks.There are no stupid questions or suggestions.Blaming others is forbidden.15

Setting The ToneThis is a professional meeting to improve outcomes for patients.The focus is on the future, not the past.Everything said is held in confidence.My job is to help you not punish you.

16Promoting an Orderly DiscussionReviewing The FactsFacts about eventsFacts about environmentAddressing The IssuesStaffing issuesWorkflow issuesCommunication IssuesReviewing PoliciesProblem SolvingProblem identificationProblem resolutionOpen time for any commentEncouraging follow throughFollow policiesRemember the team17Reviewing Facts About EventsWas the prescription telephoned to the pharmacy, or was it transmitted in writing (paper, fax, or computer)?Was the prescription a new prescription or a refill prescription?Was the prescription prepared for a person who chose to wait for it, or was it prepared for the will call or delivery area?Was the prescription dispensed to the patient or to another person acting for the patient?Was the pharmacist a relief pharmacist?18Facts About EnvironmentHow many prescriptions were filled on the day the incident occurred?How many pharmacists/techs/clerks were working on that day?It is documented that DUR was done (if needed) with the prescription?Is it documented that the patient was offered (or received) counseling?Was there anything special about the day?19Issues: StaffingAre the supportive staff hours scheduled properly to efficiently handle peaks in prescription volume?

Do the pharmacists schedules provide for sufficient overlap on peak volume days?

Are all personnel properly trained, especially with regard to prescription error prevention procedures?20Issues: WorkflowAre look alike and sound alike drugs separated in their physical location on shelves to reduce confusion?

Is the primary work area/counter organized for accuracy; is it neat and clean?

Are baskets used to separate waiting and will call prescriptions?21Classification of dispensing errorsTypes of error:Selection of wrong medicine (60.3%)Incorrect labelling of the medicine (33.0%)

Causes attributed to:misreading the prescription (24.5%)similarity of drug names (16.8%)selecting the previous drug or dose from the patient's medication record on the pharmacy computer (11.4%)similar medicine packaging (7.6%)

Circumstances associated with errors:Staffing issues (25.9%)Excessive workload and distractions (34.5%)2222Issues: CommunicationAre personnel repeating the patients name and the name of the physician to the person picking up the prescription?

Are pharmacists evaluating all DUR computer prompts before a tech fills a prescription?

Are procedures implemented to assure that all medications going into a bag are for that patient?23Handling a Failure of QualityFirst Duty--Practice Good PharmacyCare for the patient!!!!!!Attitude, Attitude, Attitude!Investigate all complaints in a caring manner.Choose the right languageWrite notes carefullyJust the facts.No scapegoating.The First ResponseWhom to InvolvePharmacist ResponsibilityWhere to goQuiet Place-ConfidentialityCareful ListeningWhat to SayI can see you are upsetThank you for bringing this to our attentionNOT We sure got sloppy, what a terrible error.The Safe ApologyObjective DescriptionWe will learn from this.24Why the reluctance to report?Fear of blame:I would feel more comfortable if the information went to someone other than my line managerI would be far more likely to use an anonymous system because we have still got a residual blame cultureSome managers dont like errors being reportedbecause of that particular manager you tend to keep things to yourself Pressure of work:We are very busy and we dont have the time to start writing all this stuff downLoyalty to colleagues:I told them and we talked about it, but I didnt report it to Head Office252526In seeking to improve safety, one of the most frustrating aspects for patients and professionals alike is the apparent failure of health-care systems to learn from their mistakes.

Reference: WHO Draft Guidelines For Adverse Event Reporting And Learning Systems http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf

26MSSA CAP

27MSSA-CAPProactive approach for risk assessment and quality improvement MSSA is simple to complete and results can identify areas of improvement to becoming a safer medication systemIncreased practitioner and staff awareness of safety issues and practices Assesses safety of current medication practicesIdentifies improvement opportunities Supports monitoring of progress in changesCan compare your scores with maximum achievable AND aggregate scores of similar pharmaciesAddresses the Standard of Practice for Quality Assurance Programs in Community Pharmacies (Nova Scotia College of Pharmacists)2828Survey Tool Key Elements: 10 key elements that most significantly influence safe medication use

Core Characteristics: Further broken down into 20 core distinguishing characteristics

Self-Assessment Item: Criteria that help to evaluate the degree to which each key element or core characteristic is met by the facility (89 in MSSA-CAP)2929All MSSAs have the same key elements and core characteristics (different wording specific to setting)differ by self-assessment item (number of items and items themselves)MSSA: 10 Key ElementsPatient informationDrug informationCommunication of drug informationDrug labeling, packaging, nomenclatureDrug storage, stock and standardizationUse of devicesEnvironmental factorsStaff competency and educationPatient EducationQuality processes and risk management

30Self-Assessment Items Per Key ElementKey ElementDescriptionItemsIPatient Information1-6IIDrug Information7-15IIICommunication of Drug Orders and Other Drug Information16-19IVDrug Labeling, Packaging, and Nomenclature 20-24VDrug Standardization, Storage, and Distribution25-31VIUse of Devices32-34VIIEnvironmental Factors35-49VIIIStaff Competence and Education50-55IXPatient Education56-65XQuality Processes and Risk Management66-8931MSSA Process Engage a team from the pharmacyDiscuss each self assessment item with the team consensusEnter data into password protected secure online siteUse online site to review results numeric, graphsScores compared to maximum achievable (items are assigned a weighted score based on impact on patient safety and sustained improvement)Scores compared to aggregate scores of similar pharmaciesRepeat (every 1-3 years) to document progress with improvement efforts32MSSA-CAP TeamThe medication system is complex, and involves the actions of many people - no one person knows everything about how the system is workingMinimally team members should include a pharmacist, pharmacy technician, managerPlan 3 x 1 hour meetings of the team if possible3333Engage a team from the pharmacyMSSA ScoringScoring system reflects RISK inherent in that aspect of the medication systemResponseDescriptionScore (weighted)AApplicable but No Activity to implement1BDiscussed but not implemented2CPartially implemented in some areas3DFully implemented in some areas4EFully implemented in all areas53434Use MedCheck example w/ blister packsScores are weighted not absolute values, relative weightingResults - Example

35

Results - Example363636The results printout can be reviewed. It shows the specific ratings (A to E) and the scores for four of the selected characteristics (questions).Different weighting uses formula, adapted from American version, dropped some self-assessment itemsResults - Example

37Results - Example

38Monitor Improvements Example

3939Repeat every 1-3 years40From a patients perspectiveMedication errors may lead to profound suffering and grief to the patients / family affected:A patient with advanced nasopharyngeal cancer had inadvertently received an infusion of fluorouracil over 4 hours that was intended to be administered over 4 days.Profound mouth sores and reductions in red blood cells, white blood cells and platelets developed.The patient died 22 days after the medication incident occurred. 40Reference: Fluorouracil Incident Root Cause Analysis: Follow-up. ISMP Can Saf Bull 2007;7(4). Available at: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2007-04Fluorouracil.pdfProvide ISMP Bulletin as referenceAsk for audience response (personal or family experience on medication incident)41Preventable medical mistakes cause more deaths per year than car accidents, breast cancer or AIDS

41Reference: The Institute of Medicine: To Err is Human: Building a safer health system, 1999. Additional estimates from the Centres for Disease Control and Prevention, National Vital Statistics Reports, Vol. 47, No. 25

In terms of lives lost, patient safety is as important an issue as worker safety.Each year, over 6,000 Americans die from workplace injuries. Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annually (IOM report) Medication-related errors occur frequently in hospitals and although not all result in actual harm, those that do, are costly.One study found that 2 out of every 100 admissions experienced a preventable adverse drug event.

The IOM report designated a third category of defect called MISUSEWhat they mean here is error, or mistakes. The right or wrong plan was selected but it was incorrectly executed and placed the patient at risk. The patient in essence is harmed by the care, instead of by the disease, and the rates here are very disturbing.According to the IOM report, as many as 44,000 98,000 people die in U.S. hospitals each year as a result of medical errors. They are killed by their care instead of by their disease.We have very strong evidence that 3 to 4 of every 100 patients in hospitals (even in the best of hospitals) are seriously harmed by their care instead of by their disease.About 7 in 100 patients in a hospital are subjected to a serious or potentially serious medication error which either harms them or could have harmed them. The errors are not always obvious, but the point is the treatment itself is toxic.Extrapolations from dataCalculated how many errors and deaths per year based on the number of hospital admissions. Lots of exposures to harm with relatively high lethality earns the right to be called a public health burdenBecause there are millions and millions of admissions to hospitals, with rates of injury in the parts per 100 or parts per 1000 earns you the right to be a public health burden. Thats why the committee fast tracked the issue of patient safety.

In Nov 1999 committee issued its first report:A safe system was the first job of the system - published to Err is Human - was a bomb shell - reached the front pages of every newspaper in the U.S. and alll TV stations. Became the Cause Celebre in the quality issues.Reached 3 conclusions : 1. there is problem - a rate of injury that is surprisingly high. this is not obvious to the average American, the average American thinks they get good care 2. It isnt the workers - they are doing as well as any workforce in fact they are very careful 3. The cause of injury is the way we have designed the work.Quality is a property of the system. The second report received far less publicity but may be a more important report Crossing the quality Chasm. 2001. This report is a charter document of where we have to go.

42The person approach

The systems approachReactions to medication errors

4243The Person ApproachBlame and ShameThe person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness.J. Reason, March 18, 2000, BMJ

Focus is on blame & shameFocus on individual performances and not system issues

43Focus on blame & shame.Focus on individual performances and not system issues.

Front line staff not involved in the review of an adverse event.

Parial or incomplete "solutions" that do not fully resolve the underlying cause and leave the oganization vulnerable to recurrence of the event.

What message does this send? Is reporting and discussion within a quality improvement environment encouraged?

44 The Person Approach: FlawsAll staff, even the most experienced and dedicated professionals can be involved in preventable adverse events.

Accidents result from a sequence of events and tend to fall in recurrent patterns regardless of the personnel involved.

Fear of reprisals drives important information underground.

4445 The Systems ApproachThe systems approach is not about changing the human condition but rather the conditions under which humans work.J.T. Reason, 20014546 Recognizes that:Humans are incapable of perfect performance.

Accidents are caused by flaws in the working environment (system) and that human errors are an expected part of any working environment.

Accidents can be prevented by building a system that is resilient to expected human errors.The Systems Approach4647Need to move away from blame & shameWho did it?

Punishment

Errors are rare

Add more layers

What allowed it?

Thank you for reporting!

Errors are everywhere

Simplify/standardize

4775-minute mark48CPhIRThe Community Pharmacy Incident Reporting (CPhIR) program was designed by ISMP Canada specifically for incident reporting in the community pharmacy setting CPhIR contributes to the Canadian Medication Incident Reporting and Prevention System (CMIRPS)Benefits of CPhIR:Encourages assessment of contributing factors in medication incidentsPromotes development of system-based strategies for quality improvement and prevent potential errors from occurring again in the future Pharmacies can view aggregate data from CPhIRs incident database to determine if other pharmacies have had similar incidentsSubscription to CPhIR includes ISMP Canada Safety Bulletins and ISMP US Medication Safety Alert Bulletin (Community/Ambulatory Care Edition)48Based on an OMID study, it was found that there are very few incidents reported voluntary from the community pharmacy setting (relative to hospitals, LTC, and other institutions)49Data Sharing AgreementThe user must sign a Data Sharing Agreement before gaining access to CPhIR

ISMP Canada is committed to privacy and confidentiality

ISMP Canada complies with privacy legislation and best practices: Personal Health Information Protection Act (PHIRA), Ontario 2004 and Personal Information Protection and Electronic documents Act (PIPEDA), Canada 2000 only de-identified and non-identifying information is collected Data is used only for the purposes of analysis, shared learning, and incident prevention strategy formulation Access to CPhIR allows the user to view individual and aggregate data from the incident database, this information is confidential and cannot be published without written permission from ISMP Canada

Upon receiving the signed Data Sharing Agreement, ISMP Canada will assign a username and password49Once the pharmacy has agreed to the data sharing agreement, then ISMP Canada will assign a username and password50

Login PageTo access CPhIR, go to:www.cphir.ca

ISMP Canada will provide each individual pharmacy with a unique username and password

If you forget your password or have any other questions, click Contact ISMP Canada to send an e-mail E.g. Microsoft Outlook will launch in a new window50Web-based program, can be accessed anywhere there is internetUsername and password will be assigned by ISMP Canada and e-mailed out to the respective contact person after signed agreementPasswords can be changed (show how later)Passwords can be reset if forgotten (must e-mail ISMP Canada)51

HomeTo navigate CPhIR, there are five tabs at the top of the page

Open incidents are displayed on the home pageAn open incident is an incident that has been entered into the system and can still be edited within 90 days of the initial entry dateOpen incidents are sorted by the date first entered (also numerically by incident number)51Once logged in, five tabs will always be present to navigateAn open Incident is an incident that has started to be entered, it may be missing information or must be reviewed before being closedOpen Incidents are listed on the home page as a reminder to complete them once you log in, the incident number, drug involved, incident date, incident type, outcome and days left to edit the incident are displayed52

Report an IncidentThe Print Blank Form option allows you to print a blank copy and enter data manually

Mandatory fields are in red, optional fields are in gray52View of incident reporting form, very straight forward form with a mix of drop boxes, checkboxes, and textboxesRed- Mandatory fieldsGray- Optional fields (added based on feedback from NS pharmacists)Can be printed to fill in form manually (more time consuming)53Report an IncidentThe following fields are listed in the incident reporting form:Date Incident Occurred Time Incident OccurredType of Incident Incident Discovered ByMedication System Stages Involved in this IncidentMedicationsPatients GenderPatients AgeDegree of Harm to Patient due to IncidentIncident Description/How Incident was DiscoveredOther Incident InformationContributing Factors of this IncidentActions at Store LevelShared Learning for ISMP to DisseminateSubmit Report to ISMP Canada

53When reporting an incident, the following information is listed in the form:Red- Mandatory fieldsblue- Optional fieldsSeems like a lot of information, but the form is very easy to fill in and will not take much time

54Report an IncidentMedications

By default, the incident is checked as a medication-related incidentIf unchecked, the medication fields will disappear

Medication name(s) may be entered in 3 ways:Enter complete medication name and DIN freeformEnter the first few letters of the medication name and a black auto-finish box will appear for a few secondsTo view options, roll the cursor anywhere within the box and it will remain open until a selection is chosenSelect the most appropriate option from the auto-finish list (Health Canadas Drug Product Database)Brand Names (i.e. Lopressor, Apo-Metoprolol, etc.)Generic Name (i.e. Metoprolol)The DIN field will automatically be populatedEnter the DIN and choose from the auto-finish box, the medication will automatically be entered

Multiple medications can be entered, as more medications are entered, more fields will appear

54Medication-related checked by default (ex. Glucometers/crutch rentals/breast pumps not medication related)Medications entered completely freeform or use of auto-finish HC DPDAll generic brands available (Apo, Novo, Pms, Gen/Mylan, Ratio, Ran, etc.) since it is based on Health Canadas databaseBrand or generic depending on individual pharmacy preferenceIf chosen from list, DIN will auto-populate; if not, enter DIN manually55Report an IncidentDegree of Harm to Patient due to IncidentSelect ONE degree of harm

55Near Misses = Free lessonsDegree of Harm: How serious was it? Ex. No Error (caught by pharmacist on double check) Near Miss/Good Catch/Free LessonsEx. No Harm (Synthroid dispensed, but patient did not taken due to different color)Ex. Mild Harm (Short term symptoms such as drowsiness)Ex. Death (anaphylactic reaction to drug)

56Report an IncidentIncident Description/How Incident was Discovered

Please do not supply identifying information (e.g., patient name or date of birth, pharmacy name, or healthcare provider names).

Freeform textbox enter description of incident

56Incident Description: only mandatory freeform text boxImportant to not identify patient Can be short or long ex. Counted too many tablets, or more details (relief pharmacist, patient with same last name, printer malfunction)

57Report an Incident

Expanded View of Other Incident Info and Contributing Factors57Expanded ViewLooks like a lot of text, but very easy to complete, just check appropriate boxesOther Incident Info:Rx is from: Hospital (list of many discharge medications, can be confusing)Rx is presented as a: Hand-written Rx (illegible) Computer generated (confusing)Type of Rx: Refill (copied previous sig, may be incorrect) vs. New (Order Entry)Contributing Factors:Critical patient information missing: Weight of child missingDrug name: sound-alike names ex. bisacodyl vs. bisoprolol (both are small pink tablets)Staffing: not enough staff on Monday morning58Report an IncidentA checkbox at the end of the form gives the option of closing the report

If left unchecked (Open) Default:Can be edited for up to 90 days (after which it automatically closes)Will be displayed on the home pageWill not be displayed during a search

If checked (Closed):Cannot be editedWill not be displayed on home pageWill be displayed during a search

58Before submitting report, option to leave as open or closedUnchecked by default (open) similar to save button-leave open for review or editing, not enough time

59SearchThe search function allows you to find an individual or a series of medication incidents based on certain criteria

Search criteria are based on the mandatory fields and contributing factors

Open incidents will not be displayed during the search

Search results can be:PrintedExported to PDF for record keepingExported to Excel for customized analysis

59Search criteria includes all mandatory fields and contributing factors (review report an incident to see fields)60SearchExample: Search all incidents between Jan. 1, 2009 to Dec. 31, 2009 that involved an incorrect drugSelect dates from calendar End Date cannot be before Start DateSelect Incorrect Drug from Type of IncidentLeave all other fields blankScroll to the bottom of the form and click Submit SearchTo clear the form, click Reset

60Ex. Display all incidents in 2009All search fields are grey, so they are optional (vs. red in report an incident)61SearchExport Data OptionsTo view export options, scroll down under the search results at the bottom of the page

PDFExports all search results into a PDF file in a new windowAll results are exported, 1 incident per page (unless it is a very detailed incident, may be more pages)Presents all entered data from each incident in a table formatCheck options to be included in PDF

ExcelExports all search results into Excel file in a new windowAllows for customized analysis based on Excel functions (ex. Charts)

61Scroll to bottom of form for data exporting optionsPDFExports all search results ie. all 25 results will be printed, 1/page, total 25 pages62Search

PDF

Excel62PDFExample of 1 incident of 25 search results, all entered fields will appear; if not entered, will be left blankExcelAll incidents inserted into table sorted under categories63SearchAlthough ISMP Canada does not collect identifying information, we recognize certain pharmacies would like to have this informationThe search function allows the user to print each medication incident with the following additional fields: (ISMP Canada will not have access to this information)

Patient NamePatient AgePatient AddressPatient TelephonePatient contacted byPatient contacted at [date/time]Prescriber NamePrescriber TelephonePrescriber contacted byPrescriber contacted at [date/time]Prescribers CommentsDate Submitted to Central OfficeDate of DispensingPrescription NumberTransaction NumberDispensing Pharmacist of PrescriptionSignature of Dispensing PharmacistDispensing Pharmacy Technician of PrescriptionSignature of Dispensing TechnicianPharmacy Staff Member (who discovered this incident)Signature of Pharmacy Staff Member (who discovered this incident)

63Some pharmacies require all medication incidents be reported for legal reasons, instead of duplicating work, use CPhIR and print out form and fax to head office64Search

64Red box-new tabs in window-additional identifying fieldsPharmacies that must report incidents to head offices may find this function usefulAdditional info for follow up inform patient of medication error, apologise, and offer solution65StatsThe Stats function allows you to view the number of medication incidents for your pharmacy and all other pharmacies who use CPhIR (aggregate data)

Medication incidents can be sorted by:No. of Incidents by Day (i.e. Mon, Tue, Wed, Thu, Fri, Sat, Sun) No. of Incidents by Month No. of Incidents by Year No. of Incidents by Type No. of Incidents by Discoverer No. of Incidents by Medication System Stages Involved No. of Incidents by Degree of Harm to Patient No. of Incidents by Contributing Factors Top 10 DINs Top 10 Active Ingredients

Stats are presented in data tables and graphs

6566Stats

Individual data and aggregate data can be viewed in a graph and in a frequency / percentage table67

Your AccountChange passwordMust be 8 characters longInclude letters, numbers, and punctuationCase-sensitive (check caps lock)

Displays number of incidents reportedOpen incidents highlighted in blueClicking on the open incidents will bring you back to the home page672 things to point out: password and account activityOpen incidents in blue as a reminder to close incident, clicking on the incident number will bring user back home pageWhat can we do with the medication incidents?Analysis of Medication Incidents69Analysis of Medication IncidentsUltimately, it is the action we take in response to reporting not reporting itself that leads to change.

Reference: WHO Draft Guidelines For Adverse Event Reporting And Learning Systems http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf70Dissemination of Information

Sample ISMP Medication Safety Alert! Newsletter And ISMP Canada Safety Bulletin70Note to SafetyNET-Rx Team: Subscription to CPhIR includes ISMP Canada Safety Bulletins and ISMP US Medication Safety Alert Bulletin (Community/Ambulatory Care Edition) - An example of how ISMPC may use the CPhIR medication incident data to inform pharmacists regarding medication safety practices or disseminate shared learning from analysis of medication incidents.Results: SafetyNET Phase I Data72Results13 community pharmacies6 independent3 grocery2 chain2 mass merchandisingAugust 2008 to January 20101532 medication incidents analysed1544 medication incidents voluntarily reported12 duplicate or test entries73Reported Medication Incidents Classified by Outcome

74Reported Medication Incidents Classified by Stages

75Top 10 Reported MedicationsRankMedicationReported FrequencyReported Frequency (%)1Metoprolol311.722Hydrochlorothiazide291.613Lorazepam281.564Amoxicillin271.504Rosuvastatin271.506Salbutamol241.336Venlafaxine241.338Levothyroxine231.288Metformin231.2810Hydromorphone211.1710Ranitidine211.1775All medications except hydromorphone and ranitidine appear on the Top 100 dispensed products in 2008 and 2009 (Pharmacy Practice)1799 drugs reported76Main ThemesProduct Mix-UpsIncorrect InstructionsWrong PatientCompliance AidsChanges in TreatmentDrug Therapy Problem76Criteria for Main Theme:Potential for Patient HarmFrequency of OccurrenceQuestions?

77

Chart198000434584229716516

Deaths per Year

Sheet1Preventable Medical Mistakes98,000Car Accidents43,458Breast Cancer42,297AIDS16,516

Sheet10000

Deaths per Year

Sheet2

Sheet3

Quantitative DataOutcomesANo Error1281BNo Harm (Patient received the medication but did not ingest it)160CNo Harm (Patient received and ingested the medication, but did not cause patient harm)90EHarm11532Stages123456PrescribingOrder Entry/TranscriptionDispensing/DeliveryAdministrationMonitoringNot Applicable6284448410192388882-16236146411221111-4-797958581014181668Type of IncidentIncorrect DoseIncorrect DurationIncorrect Strength/ConcentrationIncorrect DrugIncorrect PatientOther277213204153110-2-1-2-2-1-4-12275212202151109PharmacyNumber of incidents submitted129235341491-5522-161287108664-49129-1101641134121141371-1Total1532-12Monthly Report for NS SafetyNET - Number of QRE ReportsWeb IDAug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10TOTALNSCP010000200010008000000029NSCP0210070100000350000000035NSCP03003122263643150210041NSCP040151243371034210000000091NSCP050001102321210000000022NSCP0604717209121365012410000128NSCP07001002511000000000010NSCP08012502553424546432649582125495832300664NSCP090115730701098006000000129NSCP10091012209101413232154551300164NSCP11245129630200000000034NSCP1272013113161025677333340114NSCP13002012159076200000000071TOTAL19118143160135123991168884878241425864393401532

Outcome1281160901

Reported Medication Incidents Classified by Outcome

Stages9795858101418

Stages InvolvedFrequencyQuality Related Events Classified by Stages

Pharmacy2935419122128106641291643411471

Number of incidents submittedPharmacyNumber of Incidents SubmittedNumber of Incidents Submitted by Pharmacy in SafetyNET-Rx Phase I Pilot

Incident Type275212202151109

Type of IncidentFrequencyCommon Incident Types

Frequency of Reporting191181431601351239911688848782414258643934

TimeFrequency of ReportingFrequency of Incidient Reporting During SafetyNET-Rx Phase I Pilot Study

Sheet2

Sheet3

Quantitative DataOutcomesANo Error1281BNo Harm (Patient received the medication but did not ingest it)160CNo Harm (Patient received and ingested the medication, but did not cause patient harm)90EHarm11532Stages123456PrescribingOrder Entry/TranscriptionDispensing/DeliveryAdministrationMonitoringNot Applicable6284448410192388882-16236146411221111-4-797958581014181668Type of IncidentIncorrect DoseIncorrect DurationIncorrect Strength/ConcentrationIncorrect DrugIncorrect PatientOther277213204153110-2-1-2-2-1-4-12275212202151109PharmacyNumber of incidents submitted129235341491-5522-161287108664-49129-1101641134121141371-1Total1532-12Monthly Report for NS SafetyNET - Number of QRE ReportsWeb IDAug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10TOTALNSCP010000200010008000000029NSCP0210070100000350000000035NSCP03003122263643150210041NSCP040151243371034210000000091NSCP050001102321210000000022NSCP0604717209121365012410000128NSCP07001002511000000000010NSCP08012502553424546432649582125495832300664NSCP090115730701098006000000129NSCP10091012209101413232154551300164NSCP11245129630200000000034NSCP1272013113161025677333340114NSCP13002012159076200000000071TOTAL19118143160135123991168884878241425864393401532

Outcome1281160901

Reported Medication Incidents Classified by Outcome

Stages9795858101418

Stages InvolvedFrequencyReported Medication Incidents Classified by Stages

Pharmacy2935419122128106641291643411471

Number of incidents submittedPharmacyNumber of Incidents SubmittedNumber of Incidents Submitted by Pharmacy in SafetyNET-Rx Phase I Pilot

Incident Type275212202151109

Type of IncidentFrequencyCommon Incident Types

Frequency of Reporting191181431601351239911688848782414258643934

TimeFrequency of ReportingFrequency of Incidient Reporting During SafetyNET-Rx Phase I Pilot Study

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