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Annual Topic of Current Interest
Medication Incidents
2001/2002 Annual Report:
Hospital Pharmacy in Canada
Survey

Medication Incident Reporting
System and Review

Medication Incident Reduction
Strategies
Medication Safety Plan

Establish a
multidisciplinary
medication safety
committee

Implement “ Best
Practices” and
measure outcomes:
medication incident
reduction strategies

Adopt a safety
culture:
Encourage
reporting and
disclosure of
medication
incidents

Inform health care
professionals and
patients of the
outcomes of your
medication safety
initiatives
Caldwell et al. Medication Safety and Cost Recovery
A four-Step Approach for Executives
Medication Incident Reporting
Systems

Medication incident reporting system is in
use: 92%



Reporting of “near-misses” :




Written hospital policy: 88 %
Clear definition of an error: 76% ( Qc: 50%)
Prescribing errors detected in Rx: 21%
In pharmacy detected in Rx: 27%
Before medication is administered: 96%
Hospital reporting data to:


Provincial group: 8 % (Atlantic region)
Other organizations (i.e: ISMP): 6 %
Medication Incident Reporting
Systems

Medication incident report is part of the
permanent patient / health record: 29%

Individual medication incident report can be
subpoenaed for legal proceedings: 44%?

Review undertaken by the committee could
be subpoenaed for legal proceedings:
71% ?
Adopt a Safety Culture:
Encourage Reporting

Non punitive medication incident reporting





Name of the person reporting the incident is on
the form: 94%
Name of the person involved in the incident is on
the form 40%
Medication incidents are reported and
openly discussed by staff without fear of
reprisal : 72% ( 61% / 11%)
Medication incident reports can be used
during performance appraisals: 33 %
Strategies to increase medication incident
reporting: 68%
Adopt a Safety Culture:
Encourage Disclosure

Medication incidents are disclosed to
patients and/or families

Most of the time (90%..): 18%

Some of the time (90%): 67%
Mutidisciplinary Safety Committee:
Medication Incident Review

Designated committee responsible for
medication incident review: 69%

Membership of the committee:



Mandate of the committee


Patient representative
Information services
Promote a culture of safety (1)
Position dedicated to safety initiatives: 21%
Pharmacist FTEs: 0.05-0.10
Communicate information :
Outcomes of Safety Initiatives
Routinely provide to staff information
regarding:

Internal medication incidents: 54%

Published medication incidents: 46%

Subscribe to ISMP newsletter: 63%
Implement « Best Practices »:
Medication Incident Reduction
Strategies
Concentrated potassium chloride:
Availability on nursing units



8% (10/123) : not available
31% (38/123) : less than 10%
54% (67/123) : greater than 10%
Implement « Best Practices »:
Medication Incident Reduction
Strategies

There is a designated list of
dangerous abbreviations that
are not accepted
23% (28/123)
Implement « Best Practices »:
Medication Incident Reduction
Strategies
Orders for chemotherapy include the
total doses as well as mg/kg or
mg/m2
Adults
76% (71/93)

Pediatrics
79% (41/52)

Bed Size
Hospitals (n=)
Teaching
Status
All
(123)
100200
(29)
201500
(66)
>500
Yes
No
(28)
(52)
(71)
17
1
8
8
8
9
9
3
3
3
9
0
Computerized
physician order
entry (CPOE)
Approved plan to
implement
Operational
Implement « Best Practices »:
Medication Incident Reduction
Strategies
Patient allergy status is known
prior to dispensing a
medication

Most of the time
59%

Some of the time
34%
Implement « Best Practices »:
Medication Incident Reduction
Strategies
 Single standard infusion
concentrations are used in at
least 90% cases for insulin
46% (56/123)
Implement « Best Practices »:
Medication Incident Reduction
Strategies
 Vincristine is prepared and
dispensed in an intravenous
minibag or infusion bag (NOT
a syringe)
31% (28/89)
Implement « Best Practices »:
Medication Incident Reduction
Strategies

Bar coding is used in the
medication use system
11% (13/123)
100
75
Per Cent of
50
All Hospitals
25
0
Maximum
Dose Alerts
Drug Lab
Values
Therapeutic
Duplicates
Drug Drug
Interactions
Allergies
Pharmacy Computer System is Used to
Check
Why this special interest
topic?
•Provoke further review of
medication use systems in
Canadian hospitals
•Decrease the probability
that a patient or health care
worker will be harmed by a
medication incident