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Safety Improvement in Quality (Safety IQ) is a standardized continuous quality improvement (CQI) program. Its elements include reporting, analyzing, documenting, and shared learning from medication incidents and near-miss events to improve patient safety.
Safety IQ is mandatory for community pharmacies in Manitoba.
The following brief video provides an overview of what you can expect from Safety IQ:
Community pharmacy professionals can use the following resources to implement and maintain Safety IQ in their pharmacies.
Medication Incident and Near-Miss Event Practice Direction
The Medication Incident and Near-Miss Event Practice Direction provides standards to pharmacy professionals on implementing and maintaining Safety IQ in community pharmacies.
Guide to Safety IQ
The College of Pharmacists of Manitoba Guide to Safety IQ provides pharmacy professionals with comprehensive information and resources to support full engagement with continuous quality improvement in community pharmacy.
The Guide to Safety IQ is available at the following link: https://cphm.ca/resource/guide-to-safety-iq/
Quick Guides to Safety IQ
Disclosing a Medication Incident
The first action of pharmacy staff following a medication incident is to ensure the immediate safety of the patient. The pharmacy must retrieve/quarantine the wrong medication and provide the correct one as soon as possible to prevent harm or delays in care.
How a pharmacy professional handles and discusses a medication incident with a patient is critical to preventing further distress to the patient, healing the relationship, and renewing trust. Empathy, understanding, transparency and accountability are of utmost importance.
A pharmacist must give the patient a sincere apology and acknowledge the incident and the possible distress it may have caused. Sincerity should be communicated with open and active listening that allows the patient to speak and ask questions before the pharmacy professional makes a judgement or tries to explain what happened.
At first, you may not know all the details of how the incident occurred, but you must still provide an explanation to the patient including the following:
- The pharmacy will conduct an investigation of the incident and analyze the contributing factors;
- Staff will discuss the incident and develop changes in processes to prevent a similar incident from happening in the future;
- The incident will be anonymously reported to a national medication safety database to share learning with other healthcare providers; and
- You will follow-up with the patient to tell them what changes you have made to prevent a recurrence. The Medication Incident and Near-Miss Event Practice Direction requires this step which can restore trust with your patient.
When an incident occurs, patients want the pharmacy staff to:
- Ensure their safety – what effects may occur, what should they do?;
- Apologize in a sincere and open manner – do not assign blame to others, be forthright and genuine; and,
- Take action – investigate the incident and implement changes to prevent a similar occurrence for another individual or family.
Pharmacists have a trusted relationship with their patients. When an incident occurs, communication with the patient or caregiver must be empathetic and transparent. Genuine and open communication of the pharmacy’s actions during and after an incident can help to restore the patient’s trust. For additional information on properly disclosing a medication incident to a patient, please see the Canadian Disclosure Guidelines.
Additional CPhM resources include:
- Conflict and Communication Resolution Tool: additional guidance on constructively and respectfully communicating with patients and caregivers.
- Responding to an Incident Quick Guide: short overview of the disclosure process and requirements.
- Facts for Patients and the Public About Safety IQ: a patient-friendly resource to explain the Safety IQ program including tips about medication safety.
Facts for Patients and the Public about Safety IQ
Pharmacy professionals can use Facts for Patients and the Public about Safety IQ when they disclose medication incidents to help their patients understand what happens to improve quality in the pharmacy and prevent a similar incident from recurring.
This resource is available at the following link: https://cphm.ca/resource/facts-for-patients-and-the-public-about-safety-iq/
Introduction to Safety IQ for Community Pharmacy (training video)
Use the Introduction to Safety IQ for Community Pharmacies training video to learn the basics of the Safety IQ program to support implementation in your pharmacy including:
- Concept of continuous quality improvement within the health care field and pharmacy profession
- Elements and requirements of the College’s continuous quality improvement program Safety IQ for community pharmacies in Manitoba
- Implementation steps pharmacies must take for the launch of Safety IQ on June 1, 2021
- Role of the College, pharmacy managers and pharmacy staff all have in Safety IQ
- Strategies to prepare for future implementation of Safety IQ within your pharmacy both from a pharmacy manager and a pharmacy team perspective
Safety IQ Frequently Asked Questions
The Safety IQ FAQ addresses the most common questions about Safety IQ.
Implementation Toolkit for New Pharmacies
The Safety IQ Implementation Toolkit for New Pharmacies supports pharmacy managers and owners to understand Safety IQ and put the technical requirements of the program in place when opening a new pharmacy.
The Toolkit is available at the following link: https://cphm.ca/resource/siq-new-pharm-toolkit/
Medication Incident Reporting Platform Criteria
The Medication Incident Reporting Platform Criteria outlines the software requirements that reporting platforms must meet to be eligible as service providers for incident reporting in community pharmacies in Manitoba.
One of the requirements of Safety IQ outlined in the Medication Incidents and Near-Miss Events Practice Direction is completion of a safety self-assessment (SSA).
An SSA is a quality improvement tool pharmacy teams use to assess the safety of current medication practices, proactively identify areas of potential risk, and support the development of improvement strategies or plans. It is the pharmacy manager’s responsibility to ensure an SSA is sourced and completed, but the SSA should be completed with the involvement of a variety of pharmacy team members. When using an SSA tool, pharmacy staff consider several areas of pharmacy practice from collecting patient information to patient education and rate how well or consistently the pharmacy performs in each area. An SSA helps to increase pharmacy staff awareness of safety issues and practices and sets a baseline for pharmacies to review their progress over time.
For more information about SSAs, please see the SSA FAQ.
The new deadline for your pharmacy to complete an SSA is October 1, 2022, if your pharmacy
- implemented Safety IQ on the June 1, 2021, program launch date; or
- opened between June 1 and September 31, 2021.
If your pharmacy opened after October 1, 2021, then your team must complete an SSA meeting within one year of opening.
All pharmacies must complete an SSA every three years after their initial SSA. An SSA can be conducted more frequently if the pharmacy undertakes a significant change such as a manager change or several staff changes or implementation of new services like opioid agonist therapy, for example.
Your chosen medication incident reporting platform may or may not offer an SSA as part of its service. Two medication incident reporting platform providers offer an SSA as a stand-alone product:
- ISMP Canada’s Medication Safety Self-Assessment for Community/Ambulatory Pharmacy; and
- Pharmapod’s Pharmacy Safety Self-Assessment.
If your reporting platform does not offer an SSA, please visit ISMP Canada and Pharmapod for information on their SSA tools and subscribe to the one that meets your needs. If your pharmacy wants to use an SSA product not listed here, please contact the Safety IQ team at firstname.lastname@example.org
Community Pharmacy Safety Culture Toolkit
The Community Pharmacy Safety Culture Toolkit provides pharmacy professionals with an overview of the principles and practices they can use to promote patient safety culture.
Shared Learning from Safety IQ
Continuous quality improvement (CQI) to reduce the chances of patient harm from medication incidents is an ongoing process that requires a preoccupation with safety. Your pharmacy can use the resources below to stimulate staff discussion about medication incidents and near-miss events, examine your pharmacy’s practices through an improvement lens, or strengthen your knowledge of CQI.
Shared learning is a cornerstone of Safety IQ and the resources below are a representation of community pharmacy’s commitment to CQI in Manitoba. Your reports and CQI stories are contributing to shared learning across Canada.
If your pharmacy has experienced an incident or near-miss event that would be a good learning opportunity for other pharmacies, please forward your story to the Safety IQ team at email@example.com. Your story will be shared with the profession through College publications and any identifying information about the pharmacy or staff will be kept anonymous.
For some examples of shared learning contributions of pharmacy professionals on medication incidents, please see the latest edition of Directions, the Saskatchewan College of Pharmacy Professionals’ (SCPP) Newsletter specific to the SCPP COMPASS CQI program and medication and patient safety.
Quality Improvement Case Studies: Near-Miss Events
A near-miss event is an discrepancy that could have resulted in inappropriate medication use or patient harm but is discovered by a pharmacy professional before the prescription reaches the patient. Pharmacy professionals excel at this type of ‘good catch.’ Near-miss event reporting and analysis is an opportunity to proactively address gaps in existing pharmacy systems or procedures to prevent a near-miss event from becoming a medication incident in the future.
Not all near-miss events are valuable from an improvement or learning perspective. Every pharmacy should have official protocol on near-miss reporting, but staff should always consider the following when deciding to report a near-miss event:
- The potential impact on the patient: Would the patient be harmed if they used the incorrect medication?
- The recurring nature of the near-miss event: Does the same-near miss happen repeatedly? If yes, there are potential areas of risk or weakness within the pharmacy process or system that pharmacy staff should review and change.
- The potential shared learning for others: Could learning from a near-miss event benefit colleagues and patients in other pharmacies?
The following scenarios from Manitoba pharmacies demonstrate the benefit of near-miss reporting and what near-miss events your team should be reporting. Reporting and sharing learning from near-miss events or good catches is beneficial for patients as well as your colleagues.
Pharmacy managers and staff should consider what near-miss events to report and then discuss how to change or enhance pharmacy processes to reduce the risk of patient harm.
The College would like to acknowledge the pharmacy professionals who shared their experience for the benefit of their colleagues. The College also thanks the Ontario College of Pharmacists for permission to adapt their Pharmacy Connection Spring 2019 article, AIMs Program: Exercise Professional Judgement When Deciding to Record a Near Miss.
Potential to Harm the Patient: Pediatric allergy intercepted at Rx pick-up
The pharmacy receives a faxed prescription for an antibiotic suspension for a new patient. The patient’s parents are called to collect general information (address, PHIN, etc.) and to confirm that the prescription was to be filled. The pharmacy professional did not assess the patient’s medical history or allergies during the phone conversation.
The prescription for the antibiotic suspension is prepared and during patient counselling the pharmacy professional asked the patient’s parents to confirm the patient has no allergies. At that point, it was determined that the patient is, in fact, allergic to the antibiotic prescribed. A pharmacy professional contacts the prescriber and the prescription is changed to an appropriate antibiotic.
Decision to Report
The near-miss event in this case could have harmed the patient. A standard process for gathering patient information is in place when the pharmacy receives a prescription in-person, but in the case of prescriptions delivered to the pharmacy by phone or fax, the process is not consistent.
The pharmacy team determined that all patient information including medication history, allergies, etc. must be obtained before filling all new prescriptions whether received in-person, by fax or phone. If information is missing, then the prescription must be highlighted to alert pharmacy staff to verify the missing information before they release the prescription to the patient
Repeated Occurrence: Similar patient names leads to process change
Pharmacy receives a prescription for a steroid cream for a patient who has the same first and last name as another family member who lives at the same address.
A relief pharmacy staff member was unaware that there were two patients with the same name. During patient counselling, the pharmacist confirmed the patient’s birthdate and discovered the prescription was mistakenly filled for the son instead of the father. The parent advised the pharmacist this has happened before and was only discovered after they left the pharmacy.
Decision to Report
Due to the similarity of names, this error has happened repeatedly and obtaining a second patient identifier such as an address is not helpful in this situation.
The pharmacy team reviewed the near-miss event and determined that for each new prescription, the date of birth of the patient should be confirmed when the prescription is dropped off. The pharmacy software can bold patient names, so the pharmacy bolds any patients with similar names to highlight the potential error for staff.
Potential Harm and Shared Learning Opportunity
Pharmacy staff prepared a compliance package for a new patient who was starting on methotrexate 5mg weekly on Wednesdays.
When the pharmacist reviewed the medications with the patient, they noted that methotrexate was entered into the computer as weekly, but the compliance packaging contained daily doses.
Decision to Report
Methotrexate taken daily can lead to serious and life-threatening consequences. Sharing of this near-miss event is beneficial for all staff to consider changes to prevent a similar occurrence.
Pharmacy staff reviewed the near-miss event and identified some process changes including:
- Count out medications before filling compliance packaging to try to eliminate the addition of extra doses.
- For all methotrexate prescriptions, limit dispensed quantities of oral methotrexate to a one-month supply whenever possible.
- Include explicit dosing instructions for methotrexate, such as day of the week, on the prescription label and medication administration record.
- Before sealing a compliance package that includes methotrexate, perform an independent double-check to confirm only a weekly dose is included.
- During patient counselling, double-check methotrexate discharge prescriptions for accurate dose and directions.
Quality Improvement Case Studies: Medication Incidents
A medication incident is a preventable occurrence or circumstance that may cause or lead to inappropriate medication use or patient harm. Medication incidents may be caused by several simultaneous contributing issues including human factors, environmental factors, procedures, and systems. Medication incidents can happen at any stage in the prescription process including prescribing, order communication, product labelling/packaging/ nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. Medication incidents are complex events that can involve any member of a healthcare team regardless of experience or diligence.
Medication incident reporting in community pharmacies is mandatory in Manitoba.
The following scenarios from Manitoba pharmacies demonstrate the benefits of medication incident reporting and some suggestions on analysis and system improvement measures.
The College would like to acknowledge the pharmacy professionals who shared their experience for the benefit of their colleagues.
Missing or Extra Doses in Compliance Packaging
Compliance pack preparation can be a high-risk process especially when compared with traditional prescription preparation. The high number of prescriptions being dispensed in the same packaging introduces additional steps and increases the mental work that pharmacy professionals need to do. This can lead to an increased risk of a medication incident like the Manitoba-based case study below.
The pharmacy prepares a monthly compliance package for a patient who is on multiple prescriptions. The patient advised the pharmacy that they were leaving on holiday the next day and needed their medications as soon as possible.
That evening the only pharmacist on duty prepared and checked the patient’s compliance packages. After picking up the compliance package, the patient informed the pharmacy that a metformin dose was missing from the morning slot in one set of blisters.
The pharmacy picked up and re-packaged the card with the missing metformin and confirmed the remaining cards were all correct.
Possible Contributing Factors
- The patient was on multiple prescriptions making the compliance package more complex and difficult to package and check than usual
- No independent double-check was performed by another pharmacy staff person
- Pharmacy staff may have been stressed due to the urgency of the request and minimal staff present
- The pharmacist was likely distracted by other duties during filling and checking steps
- Develop a system for checking compliance packages such as
- using a current and accurate blister card;
- counting out medications before preparing the compliance package to ensure the correct quantity; and
- physically counting the number of pills in each slot.
- Minimize distractions for the staff person preparing compliance packaging to reduce chance of omission or duplication of medications.
- Perform an independent double-check whenever possible. Have one staff member prepare and another check compliance packaging to mitigate confirmation bias.
- If an independent check is not possible, then separate the preparation process from the checking of the packaging to a later time or the next day to reduce confirmation bias.
Hospital Discharge Prescription and Compounded Prednisone for Pediatric Patient
Hospital discharge prescriptions can be complex because they often include information related to discontinued or changed medications as well new prescriptions. This type of prescription can be especially risky for pediatric patients who need a compounded product that could lead to a dosing error causing significant or fatal harm. This could have been the outcome in the following real-life Manitoba case study.
A pharmacy receives a hospital discharge prescription for a pediatric patient who has had prescriptions from the pharmacy in the past. The hospital discharge includes several pages and pharmacy staff generally leave these types of prescription orders for the pharmacist to review and enter since they are often complicated and confusing.
The discharge includes a prescription for a compounded predniSONE 5mg/ml suspension and the pharmacist misreads the prescription and enters and fills the commercial predniSOLONE 1mg/ml product instead. When reviewing the medication with the pharmacist, the patient’s parent notes that the dose amount is different from what they discussed with the hospital pharmacist before the patient was discharged. The pharmacist did not follow-up on the information provided by the patient’s parent at this time.
When they arrived home, the patient’s parent compares the prescription label with the hospital discharge summary and discovers that predniSOLONE is on the label rather than predniSONE and contacts the pharmacy. Fortunately, the patient does not consume a dose of the prednisolone.
The pharmacy picked up the prednisolone medication and ordered the compounded prednisone from a compounding pharmacy.
- The hospital discharge summary is complex increasing the mental workload of the pharmacist which increases the risk of a medication incident.
- Look-alike/sound-alike medications are involved.
- Staffing deficiency or lack of training as staff are uncomfortable entering hospital discharge prescriptions.
- Lack of independent double-check with the pharmacist completing both order entry and prescription check leading to confirmation bias.
- Lack of follow-up when the caregiver notes the difference in doses.
- Train a variety of pharmacy staff to enter and fill hospital discharge prescriptions. This will support independent double-checks to overcome confirmation bias.
- Raise awareness among the pharmacy team about the hazards of look-alike/sound-alike drug names and put an action plan in place that targets this hazard. For instance, discuss and/or implement ISMP Canada’s recommendations in Preventable Medication Errors: Look-alike/Sound-alike Drug Names and post ISMP’s (US) look-alike/sound alike drug list.
- Pharmacist reviews discharge prescriptions and highlights the medications that need to be filled.
- Use open-ended questions when counselling about the health condition, medication, and dosing information to confirm patient’s understanding and act as a double-check. Any discrepancies or conflicting information obtained during patient counselling should be immediately investigated.
- Recognize that patients and caregivers have the privileged perspective of experiencing the entire continuum of the care they receive. They are vital members of a care team, and their concerns should be taken seriously and followed-up on.
- Conduct patient counselling when medications are dispensed even when patients or care givers may have received pharmacist counselling at discharge from hospital.
- Review the medication profile for a full picture of patient history to determine appropriateness of therapy and dosing.
National Incident Data Repository Safety Briefs
Your pharmacy’s de-identified medication incident and near-miss event reports are sent to the National Incident Data Repository (NIDR) for Community Pharmacies hosted by ISMP Canada. Medication safety experts at ISMP Canada analyze the aggregate data from across the country to share learning and recommendations with pharmacy professionals and other health care providers via Safety Bulletins and other communications.
In the spirit of knowledge dissemination and shared learning, the NIDR communicates Safety Briefs that include:
- Number of incidents received by the NIDR;
- Top five types of incidents reported; and
- Level of harm from reported incidents.
In addition, the report shares medication safety recommendations for you to consider. Please review the Safety Briefs below and share widely with your pharmacy team.
National Incident Data Repository Safety Brief - October 1, 2021
The autumn 2021 NIDR Safety Brief is available at the following link:
eQuipped is the official Safety IQ e-newsletter. Each issue will help your pharmacy prepare for the program. Get notable statistics, continuous quality improvement tips and tricks, and resources and information to stay updated on all things Safety IQ.
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