Safety IQ Academy

While mistakes in medication dispensing are rare in community pharmacies, they do occasionally happen. Pharmacy practice regulation in Manitoba alreadyrequires that

• patients are safe and have any medical attention they need;
• patients receive the right medication in a timely fashion;
• patients have an opportunity to discuss their concerns;
• pharmacy staff and managers are informed of the error;
• medication prescribers are informed of the error; and
• medication errors are investigated to find the root causes and a plan is put in place so similar errors won’t happen in the future.

Safety IQ improves the current system by ensuring that pharmacy professionals across the country share lessons about medication incidents using a standardized continuous quality improvement program.

Safety IQ enables community pharmacies to

• anonymously report medication incidents and near-miss events to a national database;
• enhance patient safety using standardized tools and practices;
• learn from medication incidents and near-miss events in other pharmacies;
• contribute to analysis that will identify causes of medication incidents in Canada and potential system safeguards; and
• promote a culture of safety in which all pharmacy staff feel comfortable reporting and talking about medication incidents.

The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program designed to reduce and prevent harmful medication incidents in Canada. The National Incident Data Repository (NIDR) for Community Pharmacies is a component of CMIRPS hosted by the Institute for Safe Medication Practices Canada (ISMP Canada).

Information from the NIDR along with data from individual practitioners, consumers, hospitals, and long-term care reporting programs of CMIRPS is analyzed, and targeted recommendations are developed and shared with all healthcare professionals. The NIDR helps to create a cohesive information-sharing system that facilitates the understanding of medication incidents and the development of robust strategies to prevent patient harm.

The medication incident and near-miss event data sent to the NIDR is de-identified (anonymous) of both patients' and healthcare professionals’ personal information. The NIDR accepts reporting data from multiple reporting platforms using a common set of standards. Contributions to the NIDR populates national aggregate data for analysis of contributing factors and trends which can be communicated across healthcare professions.

Continuous Quality Improvement (CQI) is an ongoing approach to problem-solving and harm prevention. It focuses on identifying the root cause 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.

A safety culture is the shared belief and the practice of healthcare providers that make patient safety the first priority. 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.”

Medication incidents are rarely caused by a single event or the actions of a single person. Analysis of medication incidents and near-miss events often reveal a system failure that must be changed to prevent medication incidents. A safety culture encourages healthcare providers to be open about medication incidents and near-miss events so they can be reported, analyzed, and changes in practice can be made.

Healthcare providers are still accountable when medication incidents are the result of neglect or incompetence, but these situations are rare. Healthcare providers and patients benefit from understanding why a medication incident occurred and knowing that new safeguards have been put in place to prevent the medication incident from happening again.

A medication incident reporting platform is a software program that pharmacy teams use to record data on medication incidents and near-miss events. The reporting platform stores data at the store level and exports anonymous data to the National Incident Data Repository (NIDR). The software program must meet the data standards and requirements of the Medication Incident Reporting Platform Criteria.

A safety self-assessment (SSA) is a tool for pharmacy staff to examine various areas within the pharmacy to identify gaps in pharmacy practice that could put patients at risk. The goal of an SSA is to proactively identify processes or systems in the pharmacy that have the potential to cause medication incidents. Once risky practices are identified, the pharmacy has an opportunity to change the process or system to prevent medication incidents.