The College of Pharmacists of Manitoba (College) partnered with the Institute for Safe Medication Practices Canada (ISMP Canada) to develop Safety Improvement in Quality (Safety IQ). Safety IQ is a standardized continuous quality improvement (CQI) pilot that enables community pharmacies in Manitoba to improve patient safety and ensure better patient health outcomes, while addressing the specific needs and workflow of community pharmacies. Participants in Safety IQ anonymously report medication incidents and near misses to ISMP Canada for analysis. ISMP Canada then shares learnings with pharmacies and makes suggestions for pharmacy practice improvements.
2. What is continuous quality improvement?
Continuous Quality Improvement (CQI) is an ongoing approach to problem-solving and harm-prevention that focuses on identifying the root causes of a problem and introducing ways to eliminate or reduce the problem. Participants in CQI are also continually reassessing to make sure new efforts are effective.
In the healthcare field, CQI means continuous vigilance to potential patient safety issues and on-going improvements in healthcare processes. In the pharmacy field, CQI often focuses on preventing medication incidents and continually looking for ways to improve medication dispensing, therapy management, and counselling for patients. This approach asks ‘what are we doing now and how can we do better?’
3. What is a medication incident?
Medication errors typically come in two varieties: medication incidents and near miss events.
Medication incidents are preventable errors that may result in inappropriate medication use or patient harm. Medication incidents may be related to professional practice, product labelling, dispensing processes or other factors.
A near miss event is an error that could have resulted in inappropriate medication use or patient harm, but was discovered before reaching the patient.
4. What is safety culture?
A safety culture is the shared belief and the practice of healthcare providers that makes safety the first priority in providing patient care. According to the US Institute of Medicine, “the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.” In a safety culture, everyone talks openly about medication incidents and near misses and makes suggestions for improvement. For community pharmacy, a safety culture optimizes learning from medication incidents and near miss events to prevent future errors and improve patient safety.
5. Does safety culture discourage accountability?
Medication errors are rarely caused by a single event or the actions of a single person. Analysis of medication incidents and near misses often reveals a system failure or environmental factors that must be changed to prevent medication incidents.
A safety culture encourages healthcare providers to be open about medication incidents and near misses so they can be reported, analyzed, and changes in practice can be made to prevent recurrences.
Healthcare providers are still held accountable when errors are the result of neglect or incompetence, but these situations are rare. Healthcare providers benefit from understanding why an error occurred and knowing that new safeguards have been put in place to prevent the error from happening again.
6. Aren’t medication incidents already reported by pharmacists?
In Manitoba, the College requires pharmacists to document and investigate medication incidents at the pharmacy level to ensure that:
The patient involved in the error is safe and has any medical attention they need
The patient receives the right medication in a timely fashion
The patient involved has an opportunity to discuss his/her concerns
All pharmacy staff are informed of the error including managers
The medication prescriber is informed of the error
The medication error is investigated to identify the root causes and a plan is put in place so a similar error doesn’t happen in the future
Safety IQ improves the current medication incident reporting requirements by standardizing how medication incidents are reported and analyzed and how learning about ways to prevent these medication incidents is shared among pharmacy professionals at the provincial and national level.
7. Will ISMP Canada investigate medication incidents reported to them?
The information reported to ISMP Canada is analyzed by their team and remains at arm’s length from the College and does not include any information that identifies the person reporting the incident or the patient involved. The purpose of the analysis is to identify possible root causes of a near miss or medication incident and to find any patterns or trends at the pharmacy level that may have been the contributing factors. Individual pharmacies can compare their data with the national aggregate to identify larger-scale patterns, trends, or contributing factors.
8. What should I do if I experience a medication incident?
If you or someone you love is in immediate danger, you should call 911 for emergency medical treatment.
If you experience a medication incident, or if you know of a loved one who has experienced a medication incident, it is important that you tell your pharmacist about your experience and your concerns. Your pharmacist will help make sure you or your loved one are safe and the medication(s) or medical attention needed is provided.
If you or someone you love are not satisfied with the outcome when you report an incident to your pharmacist, they should contact the College of Pharmacists of Manitoba.
9. Where can I find more information about Safety IQ?
You can find more information about Safety IQ on the College of Pharmacists of Manitoba website at www.cphm.ca or by calling the College at 204-233-1411.