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© 2011 Institute for Safe Medication Practices Canada
Why is Critical Incident Reporting and Shared Learning Important for Patient Safety?
Reporting on Critical Incidents Related to Medication / IV Fluid
Ontario Hospital Association Video and Webcast
Toronto, Ontario
August 24, 2011
Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
Overview
1. Introduction to ISMP Canada
2. Examples of Ontario Leadership
3. Value of Reporting
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© 2011 Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
ISMP Canada Board
Barry McLellan, MD President and CEO, Sunnybrook Health Sciences Centre
Beverley Orser, MD, FRCPC, PhD Associate Professor of Anesthesia and Physiology, University of Toronto
Eleanor Morton, CCHRA(C), Hons BAS, Risk Management, previously Healthcare Insurance Reciprocal of Canada
Emily Lap Sum Musing, RPh, BScPhm, MHSc, ACPR, FCSHP, CHE Executive Director of Pharmacy, Patient Safety Officer, Director of Clinical Risk and Quality, University Health Network
John Senders, PhD Scientific Consultant to ISMP, Professor Emeritus, University of Toronto
Michael Cohen, MS, RPh President, ISMP US
Ruth Wilson, MD, CCFP Department of Family Medicine, Queen's University
Tom Paton, PharmD, Director of Pharmacy, Sunnybrook & Women's Health Sciences Centre
W. Morley Lemon, FCA, CPA Professor Emeritus, University of Waterloo
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© 2011 Institute for Safe Medication Practices Canada
Medication Incident Analysis
1. Shared learning from medication incidents helps identify system improvement opportunities
2. Solution development involves consultation and collaboration
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© 2011 Institute for Safe Medication Practices Canada
Globe & Mail – June 12, 2002
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© 2011 Institute for Safe Medication Practices Canada
Initiative to eliminate concentrated potassium chloride from patient care areas was supported by MOHLTC
Similar packaging and storage
contributed to fatal errors
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© 2011 Institute for Safe Medication Practices Canada
Provincial Advisory Committee
• Ontario Ministry of Health and Long-Term Care
• Ontario Hospital Association
• Registered Nurses Association of Ontario
• Registered Practical Nurses of Ontario
• Ontario Medical Association
• Ontario Pharmacists’ Association
• Quality Health Network
• College of Nurses of Ontario
• Canadian Society of Hospital Pharmacists – Ontario Branch
• College of Physicians and Surgeons of Ontario
• Ontario College of Pharmacists
• Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
Province-wide effort
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© 2011 Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
Strategic Partners
• Accreditation Canada
• Canadian Patient Safety Institute
• Canadian Institute for Health Information
• Health Canada
• Healthcare Insurance Reciprocal of Canada
• Healthcare Professional associations
• Healthcare Professional colleges
• Provincial Ministries
• Provincial Quality Councils
• International Medication Safety Network
• World Health Organization
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© 2011 Institute for Safe Medication Practices Canada
Results
A 2004 independent national survey reported 96% of Ontario
hospital respondents had removed KCl concentrate from patient care areas.
“Ontario most successful province in this safety initiative”1
Work informed Accreditation Canada standards development.
1 McKerrow R, Johnson N, Hall KW, Roberts N, Salsman B, Bussieres JF, Macgregor P, Lefebvre P, Harding J. (Eds.).
2004. “2003/2004 Annual Report, Hospital Pharmacy in Canada: Medication Safety” [15tth Hospital Pharmacy in Canada
Survey]. Eli Lilly Canada. P;. 55-57. Retrieved March 9, 2007.
<http://www.lillyhospitalsurvey.ca/hpc2/content/rep_2004_toc.asp
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© 2011 Institute for Safe Medication Practices Canada
Report: Transdermal Fentanyl Patch Not Visible after Application
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© 2011 Institute for Safe Medication Practices Canada
Result: Product Change Implemented
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© 2011 Institute for Safe Medication Practices Canada
Report: Dose Calculation Difficulty
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© 2011 Institute for Safe Medication Practices Canada
Result: Label Change Implemented
• Concentration now expressed in g per total volume, and mg per mL
• Manufacturer logo removed to give prominence to critical information
• CEO called to express appreciation for improvement recommendation
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© 2011 Institute for Safe Medication Practices Canada
Reports involving Neuromuscular Blocking Agents
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© 2011 Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
Result: Package and Label Changes
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© 2011 Institute for Safe Medication Practices Canada
Moving Forward
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© 2011 Institute for Safe Medication Practices Canada
All manufacturer’s now include a warning:
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© 2011 Institute for Safe Medication Practices Canada
Branding
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© 2011 Institute for Safe Medication Practices Canada
Global Impact
Original Carton Label
Canadian Initiated Over-label (April ’04)
New Global Carton Label
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© 2011 Institute for Safe Medication Practices Canada
Knowledge Transfer
Work has informed Health Canada’s Draft Guidance
Document - Labelling of Pharmaceutical Drugs for Human Use
• Designed to facilitate compliance with regulated labelling requirements.
• Supports safe and effective use of drugs
Available from: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/guide-ld/index-eng.php
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© 2011 Institute for Safe Medication Practices Canada
To download the bulletin: http://www.ismp-canada.org/download/ISMPCSB2008-03HIVPEP.pdf
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© 2011 Institute for Safe Medication Practices Canada
Available from: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005-03HIT.pdf
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© 2011 Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
Pharmaceutical Bar Coding Project
Major Objectives:
• To develop a pan-Canadian strategy for bar coding of commercial pharmaceutical products.
• To select a common product database for standardized product data
• To facilitate clinical information systems development which utilizes automated identification and data capture at each point of the medication chain
• To create a national environment for automated identification implementation within each identified healthcare sector.
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© 2011 Institute for Safe Medication Practices Canada
Endorsements
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© 2011 Institute for Safe Medication Practices Canada
Canadian Adverse Events Study
"Efforts to make patient care safer will require leadership to encourage the reporting of AEs, continued monitoring of the incidence of these events, the judicious application of new technologies and improved communication and coordination among caregivers."
Baker GR, Norton PG, Flintoft V, et al. CMAJ. 2004;170(1):1686. Available online at www.cmaj.ca
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© 2011 Institute for Safe Medication Practices Canada
Distinction between Adverse Drug Reactions and Medication Incidents
Adverse Drug Reaction Reporting Medication Incident Reporting
Adverse Drug Reaction Reports (Canada Vigilance) inform the risk:benefit ratio inherent with drug use (properties of the medication).
Medication incidents are preventable and inform medication system improvement.
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© 2011 Institute for Safe Medication Practices Canada
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© 2011 Institute for Safe Medication Practices Canada
Core Principles of Reporting
• Reporting must be safe - individuals who report incidents must not be punished or suffer other ill-effects from reporting. Reporting is only of value if it leads to a constructive response.
• The most important function of a reporting system is to use the results of data analysis and investigation to formulate and disseminate recommendations for system improvements.
• A reporting system must produce a visible, useful response to stimulate improvement and continued reporting.
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© 2011 Institute for Safe Medication Practices Canada
Why is Reporting Important?
• Learning from experience can prevent harmful mistakes from recurring. Safety is enhanced by learning from failures.
• Meaningful analysis, learning, and system improvement requires collaboration at all levels.
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© 2011 Institute for Safe Medication Practices Canada
Discussion
• ? Questions
• ? Feedback
• ? Opportunities
Sylvia Hyland, VP and COO
Institute for Safe Medication Practices Canada
416-733-3131 ext. 222