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​​1.    Conduct a Medication Safety Self-Assessment

The ISMP Canada Medication Safety Self-Assessment for hospitals can be used to raise awareness of the many characteristics of a safe medication use system (ISMP Canada, 2016).

Examples of recommendations for preventing medication-related errors include:

  • Prompts in electronic order entry systems (e.g. allergy and drug interaction warnings).
  • Availability and accessibility to drug information resources.
  • Inclusion of the indication for the medication within the prescription; avoidance of dangerous abbreviations or dose designations.
  • Communication of relevant patient information.
  • Use of decision support software.
  • Use of automated identification (e.g. barcoding).

2.    Implement Medication Reconciliation

(Safer Healthcare Now! Medication Reconciliation Getting Started Kit, 2011)

  • Create a complete and accurate Best Possible Medication History (BPMH) of the patient's medications including name, dosage, route and frequency. This includes:
    • A systematic process of interviewing the patient/family.
    • A review of at least one other reliable source of information.
  • Reconcile Medications: Use the BPMH to create admission orders or compare the BPMH against admission, transfer or discharge medication orders; identify and resolve all differences or discrepancies.
  • Document and Communicate any resulting changes in medication orders to the patient, family/caregiver and to the next provider of care.

Ultimately, the goal is to develop a process which provides an accurate list that can be used for medication orders by all healthcare providers as patients are admitted, transferred through the institution, and eventually discharged and reduce the potential for ADEs.

3.    Implement High Alert Medication Safety Processes

(IHI, 2012)

  1. Methods to prevent harm include:
  • Develop order sets, preprinted order forms, and clinical pathways or protocols to establish a standardized approach to treating patients with similar problems, disease states, or needs.
  • Minimize variability by standardizing concentrations and dose strengths to the minimum needed to provide safe care.
  • Include reminders and information about appropriate monitoring parameters in the order sets, protocols, and flow sheets.
  • Consider protocols for vulnerable populations such as elderly, pediatric, and obese patients.
  • Adopt TALL man lettering for pharmacy produced labels to differentiate drug names with potential for mix-up.

2.    Methods to identify errors and harm include:

  • Include reminders and information about appropriate monitoring parameters in the order sets, protocols, and flow sheets.
  • Ensure that critical lab information is available to those who need the information and can take action.
  • Implement independent double-checks where appropriate.
  • Instruct patients on symptoms that indicate side effects and when to contact a health care provider for assistance.

3.    Methods to mitigate harm include:

  • Develop protocols allowing for the administration of reversal agents without having to contact the physician.
  • Ensure that antidotes and reversal agents are readily available.
  • Have rescue protocols available.

For details on changes to improve management of specific categories of medications (i.e. Anticoagulants, Narcotics, Insulin, and Sedatives) refer to the How- to Guide: Prevent Harm from High-Alert Medications, 2012.

4.    Improve Core Processes for Ordering Medications

(IHI, 2016)

Several practices have been shown to improve the overall safety of ordering processes. IHI has a listing for several changes for improvement. Read more.

5.    Improve Core Processes for Dispensing Medications

(IHI, 2016)

Several practices have been shown to improve the overall safety of dispensing processes. IHI has a listing for several changes for improvement. Read more.

6.    Improve Core Processes for Administering Medications

(IHI, 2016)

Several practices have been shown to improve the overall safety of administration processes. IHI has a listing for several changes for improvement. Read more.

7.     Conduct Clinical and System Reviews

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  • Measure and monitor the types and frequency of these occurrences.
  • Use appropriate analytical methods to understand the contributing factors.
  • Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
  • Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in the section Resources for Conducting Incident and/or Prospective Analyses.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews: