Required Handbook 2014
Handbook 2014 All rights reserved. 2013 Accreditation Canada Accreditation Canada is an independent, not-for-profit organization that accredits health organizations in Canada and around the world. Its comprehensive accreditation program uses evidence-based standards and a rigorous peer review process to foster ongoing quality improvement. Accreditation Canada has been helping organizations improve health care quality and patient safety for more than 55 years. 1150 Cyrville Road, Ottawa, ON K1J 7S9 1-800-814-7769 613-738-3800
About the ROP Handbook...1 Overview...2 Chart of Required...3 ROP development over the years...73 Index...74 ROPs SAFETY CULTURE Accountability for Quality For the Governance Standards...4 Adverse Events Disclosure...6 Adverse Events Reporting...7 Client Safety Quarterly Reports...8 Client Safety-related Prospective Analysis...9 COMMUNICATION Client and Family Role in Safety...10 Dangerous Abbreviations...11 Information Transfer...12 Medication Reconciliation as a Strategic Priority For the following sets of standards: Leadership, Leadership for Small Community-based Organizations...13 Medication Reconciliation at Care Transitions For the following sets of standards: Acquired Brain Injury Services, Cancer Care and Oncology Services, Correctional Service of Canada Health Services, Critical Care Services, Emergency Department, Hospice Palliative and End-of-Life Services, Medicine Services, Mental Health Services, Obstetrics Services, Provincial Correctional Health Services, Rehabilitation Services, and Surgical Care Services...16 For the following sets of standards: Aboriginal Integrated Primary Care Services, Ambulatory Care Services, Ambulatory Systemic Cancer Therapy Services, and Remote/Isolated Health Services...19 For the Emergency Department Standards...22 For the following sets of standards: Case Management Services, Community-Based Mental Health Services and Supports, and Home Care Services...25 For the following sets of standards: Long-term Care Services, and Residential Homes for Seniors...27 For the following sets of standards: Aboriginal Substance Misuse Services, and Substance Abuse and Problem Gambling Services...29 Safe Surgery Checklist...31 Two Client Identifiers...32 MEDICATION USE Antimicrobial Stewardship...33 Concentrated Electrolytes For on-site surveys until December 31 2014 for the Customized Managing Medications Standards...35 For on-site surveys starting January 2014 for the following sets of standards: Medication Management and Medication Management for Remote/Isolated Health Services...36 For on-site surveys starting January 2015 for the Medication Management Standards for Community-Based Organizations...36 Heparin Safety For on-site surveys until December 31 2014 for the Customized Managing Medications Standards...38 For on-site surveys starting January 2014 for the following sets of standards: Medication Management, and Medication Management for Remote/Isolated Health Services...39 For on-site surveys starting January 2015 for the Medication Management Standards for Community-Based Organizations...39 High-alert Medications For on-site surveys starting January 2014 for the following sets of standards: Emergency Medical Services, Medication Management, and Medication Management for Remote/Isolated Health Services...41 For on-site surveys starting January 2015 for the following sets of standards: Independent Medical Surgical Facilities, and Medication Management for Community-Based Organizations...41 Infusion Pumps Training...43 Medication Concentrations For on-site surveys until December 31 2014 for the Independent Medical Surgical Facilities Standards...44
Narcotics Safety For on-site surveys until December 31 2014 for the following sets of standards: Customized Medication Management, and Independent Medical Surgical Facilities...45 For on-site surveys starting January 2014 for the following sets of standards: Emergency Medical Services, Medication Management, and Medication Management for Remote/Isolated Health Services...46 For on-site surveys starting January 2015 the following sets of standards: Independent Medical Surgical Facilities, and Medication Management for Community-Based Organizations...46 WORKLIFE/WORKFORCE Client Flow For the Leadership Standards...48 Client Safety: Education and Training...50 Client Safety Plan...51 Preventive Maintenance Program...52 Workplace Violence Prevention...53 INFECTION CONTROL Hand-hygiene Compliance (formerly called Hand-hygiene Audit)...55 Hand-hygiene Compliance For on-site surveys starting January 2015...56 Hand-hygiene Education and Training...58 Hand-hygiene Education and Training For on-site surveys starting January 2015...59 Infection Rates...60 Infection Rates For on-site surveys starting January 2015...61 Pneumococcal Vaccine...62 Reprocessing (formerly called Sterilization processes)...63 RISK ASSESSMENT Falls Prevention Strategy...64 Home Safety Risk Assessment...65 Pressure Ulcer Prevention...66 Skin and Wound Care For the Home Care Services Standards...68 Suicide Prevention...70 Venous Thromboembolism (VTE) Prophylaxis...71
ABOUT THE ROP HANDBOOK For convenience and ease of use, all ROPs that appear in the Accreditation Canada Qmentum standards sets have been collected into this handbook. Most ROPs apply to more than one sector and therefore appear in multiple sets of standards. In this handbook, the ROPs are presented as follows: The ROP The ROP statement defines the practice that is expected. For example: Adverse Events Disclosure: The organization implements a formal and open policy and process for disclosure of adverse events to clients and families, including support mechanisms for clients, family, staff, and service providers involved in adverse events. If the ROP has been customized for specific sectors or services, the applicable sets of standards are shown in this section. Guidelines The guidelines provide context and rationale on why the ROP is important to patient safety and risk management. They also show supporting evidence and provide information about meeting the tests for compliance. While the guidelines provide insight and information, they are not requirements. In fact, the tests for compliance can be met without following the guidelines. Tests for Compliance (major and minor) The tests for compliance, categorized as major or minor, are the specific expectations that surveyors assess on-site to determine whether the organization complies with the ROP. For the ROP to be assessed as compliant, all of the associated tests for compliance must be rated as met. tests for compliance have an immediate impact on safety, while minor tests for compliance support longer-term safety culture and quality improvement activities and may require additional time to be fully developed and/or evaluated. As a rule, required follow-ups for major unmet tests for compliance must be submitted within five months, while those for minor unmet tests for compliance must be submitted within eleven months. Reference Material This section shows sources of supporting evidence used to develop the ROP, as well as tools and resources to assist organizations in meeting the tests for compliance. The list of reference materials does not appear in the standards. 1
OVERVIEW In the Accreditation Canada Qmentum accreditation program, Required (ROPs) are evidenceinformed practices addressing high-priority areas that are central to quality and safety. Accreditation Canada defines an ROP as an essential practice that organizations must have in place to enhance patient/client safety and minimize risk. Accreditation Canada began developing ROPs in 2004 under the leadership of its Patient Safety Advisory Committee. The first steps in developing a new ROP involve national and international literature reviews to identify major patient safety risk areas and best practices, analysis of patient safety-related on-site survey results and compliance rates, and field-specific research. The ROP is then subject to national consultation, and feedback from expert advisory committees, client organizations, surveyors, and other stakeholders such as governments and content experts before it is released to the field. ROPs are reviewed and updated as required. As some ROPs achieve widespread implementation, they are transitioned into high-priority criteria within the accreditation program. ROPs are categorized into six patient safety areas, each with its own goal, as follows: SAFETY CULTURE: Create a culture of safety within the organization COMMUNICATION: Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum MEDICATION USE: Ensure the safe use of high-risk medications WORKLIFE/WORKFORCE: Create a worklife and physical environment that supports the safe delivery of care and service INFECTION CONTROL: Reduce the risk of health care-associated infections and their impact across the continuum of care/service RISK ASSESSMENT: Identify safety risks inherent in the client population For more information on ROPs, Accreditation Canada, or the Qmentum accreditation program, visit. 2
CHART OF REQUIRED ORGANIZATIONAL PRACTICES SAFETY CULTURE COMMUNICATION MEDICATION USE WORKLIFE/WORKFORCE INFECTION CONTROL RISK ASSESSMENT Accountability for quality Adverse events disclosure Adverse events reporting Client safety quarterly reports Client safety-related prospective analysis Client and family role in safety Dangerous abbreviations Information transfer Medication reconciliation as a strategic priority Medication reconciliation at care transitions Safe surgery checklist Two client identifiers Antimicrobial stewardship Concentrated electrolytes Heparin safety High-alert medications Infusion pumps training Medication concentrations Narcotics safety Client flow Client safety: education and training Client safety plan Preventive maintenance program Workplace violence prevention Hand-hygiene compliance (formerly called Hand-hygiene audit) Hand-hygiene education and training Infection rates Pneumococcal vaccine Reprocessing (formerly called Sterilization processes) Falls prevention strategy Home safety risk assessment Pressure ulcer prevention Skin and wound care Suicide prevention Venous thromboembolism (VTE) prophylaxis New for on-site surveys starting in 2015 Revised for on-site surveys starting in 2015 Revised for on-site surveys starting in 2014 or 2015, depending on the set of standards (see ROP for details). 3
SAFETY CULTURE Create a culture of safety within the organization New For on-site surveys starting January 2015 ACCOUNTABILITY FOR QUALITY For the Governance Standards The governing body demonstrates accountability for the quality of care provided by the organization. Accreditation Canada defines quality in health care using eight dimensions that represent key service elements: accessibility, client-centred, continuity, effectiveness, efficiency, population-focus, safety, and worklife. Governing bodies are accountable for the quality of care provided by their organizations. When governing bodies are engaged in overseeing quality, their organizations have better quality performance (better care, better client outcomes, better worklife, and reduced costs). The members of the governing body need to be aware of key quality and safety principles if they are to effectively understand, monitor, and oversee the quality performance of the organization. Knowledge gaps among the membership can be addressed through targeted recruitment for specific competencies (e.g., quality assurance, risk management, quality improvement, and safety) from health care or other sectors (e.g., education or industry) or by providing education through workshops, modules, retreats, virtual networks, or conferences. The governing body can demonstrate a clear commitment to quality when quality is discussed at every regular meeting. Often the governing body overestimates the quality performance of an organization, so discussions about quality need to be supported with indicators and feedback from clients and families. A small number of easily understood performance indicators that measure quality at the system level (i.e., big-dot indicators) such as number of clients who died or were harmed by preventable errors, quality of worklife, number of complaints, and client experience results will help answer the question is our care getting better?. Quality performance indicators need to be directly linked to strategic goals and objectives and balanced across a number of priority areas. Knowledge gained from the review of quality performance indicators can be used to set the board agenda, inform strategic planning, and develop an integrated quality improvement plan. It can also be used to set quality performance objectives for senior leadership and to determine whether they have met their quality performance objectives. 4
ACCOUNTABILITY FOR QUALITY The membership of the governing body has knowledge of key quality and safety principles, by recruiting members who have this knowledge or providing access to education. The governing body includes quality as a standing agenda item at all regular meetings. The governing body identifies the key system-level indicators it will use to monitor the quality performance of the organization. At least quarterly, the governing body monitors and evaluates the quality performance of the organization against agreed-upon goals and objectives. The governing body uses information about the quality performance of the organization to make resource allocation decisions and set priorities and expectations. As part of their performance evaluation, senior leaders who report to the governing body (e.g., the CEO, Chief of Staff) are held accountable for the quality performance of the organization. S: 5 Million Lives Campaign. (2008) Getting Started Kit: Governance Leadership Boards on Board How-to Guide. Institute for Healthcare Improvement; Cambridge, MA. [On-line] Available: www.ihi.org/knowledge/pages/tools/howtoguidegovernanceleadership.aspx Baker, G.R., Denis, J., Pomey, M., MacIntosh-Murray, A. (2010) Designing effective Governance for quality and safety in Canadian healthcare. Healthc.Q. 13(1);38-46. Governance for Quality and Patient Safety Steering Committee (2010). Effective Governance for Quality and Patient Safety: a toolkit for healthcare board members and senior leaders. Canadian Patient Safety Institute. Edmonton, AB. [On-line]. Available: www.patientsafetyinstitute.ca/english/toolsresources/governancepatientsafety/ The Health Foundation. (2013) Quality improvement made simple: what every board should know about healthcare quality improvement. The Health Foundation. London, UK. [On-line]. Available: www.health.org.uk/publications/quality-improvement-made-simple/ Jha, A., Epstein,A. (2010) Hospital governance and the quality of care. Health.Affairs. 29(1);182-187. Jiang, H.J., Lockee, C., Fraser, I. (2012). Enhancing board oversight on quality of hospital care: an agency theory perspective. Health. Care.Manage.Rev. 37(2), 144-53. Martin, L.A., Nelson, E.C., Lloyd, R.C., Nolan, T.W. (2007) Whole System Measures. IHI Innovation Series white paper. Institute for Healthcare Improvement; Cambridge, MA. [On-line] Available: www.ihi.org Roberts, J., Durbin, S. (2007) The Board s Role in Quality and Safety: 7 Key Governance Questions. Providence Health Care. Seattle, WA. [On-line] Available: www.patientsafetyinstitute.ca/english/toolsresources/governancepatientsafety/ CreatingExecutingPatientSafetyPlan/Pages/Tools.aspx 5
SAFETY CULTURE Create a culture of safety within the organization ADVERSE EVENTS DISCLOSURE The organization implements a formal and open policy and process for disclosure of adverse events to clients and families, including support mechanisms for clients, family, staff, and service providers involved in adverse events. Research shows a positive relationship between client satisfaction with how an adverse event is handled by an organization and formal open disclosure. Disclosing adverse events in an open and timely manner may maintain the client s relationship with the health service organization, staff and service providers, and reduce the risk of litigation. Core elements of disclosure include discussing the event with the client, family, and relevant staff or service providers; acknowledging or apologizing for the event; reviewing the actions taken to mitigate the circumstances surrounding the event; discussing corrective action to prevent further similar adverse events; responding to client, family and staff or service provider questions; and offering counselling to staff, service providers, and clients involved. The Canadian Disclosure Guidelines, published by the Canadian Patient Safety Institute (CPSI) is a resource intended to encourage and support healthcare providers, interdisciplinary teams, organizations and regulators in developing and implementing disclosure policies, practices and training methods. They can be accessed on the CPSI website. The disclosure policy and process is in compliance with any applicable legislation and within any protection afforded by legislation. There is a written policy for disclosure of adverse events to clients and families. The disclosure policy includes support mechanisms for clients, families, staff, and service providers. There is evidence of a process for disclosure of adverse events to clients, families, staff, and services providers. Chafe, R., Levinson, W., & Sullivan, T. (2009). Disclosing errors that affect multiple patients. CMAJ., 180, 1125-1127. Conway J, Federico F, Stewart K, & Campbell MJ (2011). Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper [On-line]. Available: www.ihi.org/knowledge/knowledge%20center%20assets/ihiwhitepapers%20-%20respectfulmanagementofseriousclinicaladverseev ents_490ab9fb-d691-43e8-af97-6d39638cedec/ihirespectfulmanagementofseriousclinicaladverseeventsoct11.pdf Disclosure Working Group (2011). Canadian disclosure guidelines: being open and honest with patients and families. Edmonton,AB. Canadian Patient Safety Institute. [On-line]. Available: www.patientsafetyinstitute.ca/english/toolsresources/disclosure/documents/cpsi%20canadian%20disclosure%20guidelines.pdf Iedema, R., Sorensen, R., Manias, E., Tuckett, A., Piper, D., Mallock, N. et al. (2008). Patients and family members experiences of open disclosure following adverse events. Int.J.Qual.Health Care, 20, 421-432. Iedema, R., Jorm, C., Wakefield, J., Ryan, C., & Sorensen, R. (2009). A New Structure of Attention? Open Disclosure of Adverse Events to Patients and Their Families. Journal of Language and Social Psychology, 28, 139-157. Institute for Healthcare Improvement (2011). Disclosure Toolkit and Disclosure Culture Assessment Tool. Institute for Healthcare Improvement [On-line]. Available: www.ihi.org/knowledge/pages/tools/disclosuretoolkitanddisclosurecultureassessmenttool.aspx 6
SAFETY CULTURE Create a culture of safety within the organization ADVERSE EVENTS REPORTING The organization establishes a reporting system for adverse events, sentinel events, and near misses, including appropriate follow-up. The reporting system is in compliance with any applicable legislation, and within any protection afforded by legislation. An adverse event is an unexpected and undesirable incident directly associated with the care or services provided to the client. The incident occurs during the process of receiving health services. The adverse event is an adverse outcome, injury or complication for the client. A sentinel event is an adverse event that leads to death or major and enduring loss of function for a recipient of healthcare services. and enduring loss of function refers to sensory, motor, physiological, or psychological impairment not present at the time services were sought or began, i.e. a client dies or is seriously harmed by a medication error. A near miss is an event or situation that could have resulted in an accident, injury or illness to a client but did not, either by chance or through timely intervention. The reporting system for adverse events, sentinel events and near misses may be part of a larger incident reporting system. The goal of the reporting system for adverse events, sentinel events and near misses is to learn from the event, prevent recurrences, and strengthen the culture of safety. There is a reporting policy and process to report adverse events, sentinel events, and near misses. Improvements are made following investigation and follow-up. Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J. et al. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ., 170, 1678-1686. Griffin FA & Resar RK (2009). IHI Global Trigger Tool for Measuring Adverse Events (2nd Edition). Institute for Healthcare Improvement [On-line]. Available: www.ihi.org/knowledge/knowledge%20center%20assets/tools%20-%20 IHIGlobalTriggerToolforMeasuringAdverseEvents_df8a18b6-52cc-4674-8258-030941832115/IHIGlobalTriggerToolWhitePaper2009.pdf World Alliance for Patient Safety (2005). WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. World Health Organization [On-line]. Available: www.who.int/patientsafety/events/05/reporting_guidelines.pdf World Health Organization (2009). Conceptual Framework for the International Classification for Patient Safety (Version 1.1). World Health Organization [On-line]. Available: www.who.int/patientsafety/implementation/taxonomy/icps_technical_report_en.pdf 7
SAFETY CULTURE Create a culture of safety within the organization CLIENT SAFETY QUARTERLY REPORTS The organization s leaders provide the governing body with quarterly reports on client safety, and include recommendations arising out of adverse incident investigation and follow-up, and improvements made. The board or governing body for each organization is ultimately accountable for the quality and safety of health services. Literature supports the important role of a governing body to enable an organizational culture that enhances client safety. An organization is more likely to make safety and quality improvement a central feature of health services if the governing body is aware of client safety issues and adverse events, and leads in the quality improvement efforts of the organization. In addition, the governing body needs to be informed about and have input into follow-up actions or improvement initiatives resulting from adverse events. Evidence is emerging that organizations with active board engagement in client safety are able to achieve improved outcomes and processes of care. Quarterly client safety reports have been provided to the governing body. The reports outline specific organizational activities and accomplishments in support of client safety goals and objectives. There is evidence of the governing body s involvement in supporting the activities and accomplishments, and acting on the recommendations in the quarterly reports. Institute for Healthcare Improvement (2008). Getting Started Kit: Governance Leadership "Boards on Board" How-to Guide. [On-line]. Available: www.ihi.org/knowledge/pages/tools/howtoguidegovernanceleadership.aspx Jiang, H. J., Lockee, C., Bass, K., & Fraser, I. (2009). Board oversight of quality: any differences in process of care and mortality? J.Healthc.Manag., 54, 15-29. Reinertsen JL, Bisognano M, & Pugh MD (2008). Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). IHI Innovation Series white paper [On-line]. Available: www.ihi.org/knowledge/pages/ihiwhitepapers/ SevenLeadershipLeveragePointsWhitePaper.aspx 8
SAFETY CULTURE Create a culture of safety within the organization CLIENT SAFETY-RELATED PROSPECTIVE ANALYSIS The organization carries out at least one client safety-related prospective analysis and implements appropriate improvements. Evidence shows that conducting systematic prospective analyses of potential adverse events is an effective method to prevent or reduce errors. The principle behind the reduction of such events is the elimination of unsafe actions and conditions that can lead to potentially serious events. A study by Nickerson applied Failure Modes and Effects Analysis (FMEA) to two high-risk situations, transcription of medication errors for inpatients, and overcrowding in the emergency department. Results showed a significant improvement. There are numerous tools and techniques available to conduct a prospective analysis. One tool is FMEA, a team-based, systematic, and proactive approach that identifies the ways a process or design might fail, why it might fail, the effects of that failure, and how it can be made safer. Other methods to proactively analyze key processes include fault tree analysis, hazard analysis, simulations, and Reason s Errors of Omissions model. At least one prospective analysis has been completed within the past year. The organization uses information from the analysis to make improvements. Chiozza, M. L. & Ponzetti, C. (2009). FMEA: a model for reducing medical errors. Clin.Chim.Acta, 404, 75-78. Grout, J. (2007). Mistake-Proofing the Design of Healthcare Processes. www.ahrq.gov [On-line]. Available: www.ahrq.gov/qual/ mistakeproof/mistakeproofing.pdf Nickerson, T., Jenkins, M., & Greenall, J. (2008). Using ISMP Canada s framework for failure mode and effects analysis: a tale of two FMEAs. Healthc.Q., 11, 40-46. Spath, P. L. (2003). Using failure mode and effects analysis to improve patient safety. AORN J., 78, 16-37. Tezak, B., Anderson, C., Down, A., Gibson, H., Lynn, B., McKinney, S. et al. (2009). Looking ahead: the use of prospective analysis to improve the quality and safety of care. Healthc.Q., 12 Spec No Patient, 80-84. 9
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum CLIENT AND FAMILY ROLE IN SAFETY The team informs and educates clients and families in writing and verbally about the client and family s role in promoting safety. Clients and families play an important role in preventing adverse events. Their questions and comments are often a good source of information about potential risks, errors, or safety issues. Clients and families are able to fulfill this role when they are included and actively involved in the process of care. Many organizations have developed materials that relate to client safety-related issues and provide guidance and direction for questions and topics to address during care. Examples of client safety educational materials include the Manitoba Institute of Patient Safety s It s Safe to Ask, and the Ontario Hospital Association s Your Healthcare Be Involved. The team develops written and verbal information for clients and families about their role in promoting safety. The team provides written and verbal information to clients and families about their role in promoting safety. Alberta Health Services (2012). Patient Engagement. Alberta Health Services [On-line]. Available: www.albertahealthservices.ca/ patientengagement.asp Canadian Medication Incident Reporting System (CMIRPS) Consumer focused website. (2012) Available: www.safemedicationuse.ca Center for Advancing Health (2010). A New Definition of Patient Engagement: What is Engagement and Why is it Important? Center for Advancing Health [On-line]. Available: www.cfah.org/pdfs/cfah_engagement_behavior_framework_current.pdf Entwistle, V. A., Mello, M. M., & Brennan, T. A. (2005). Advising patients about patient safety: current initiatives risk shifting responsibility. Jt.Comm J.Qual.Patient.Saf, 31, 483-494. Manitoba Institute for Patient Safety (2012). It s Safe to Ask. Manitoba Institute for Patient Safety [On-line]. Available: www.safetoask.ca Ontario Hospital Association (2012). Your Health Care - Be Involved. Ontario Hospital Association [On-line]. Available: www.oha.com/knowledgecentre/library/patientsafety/pages/yourhealthcarebeinvolved.aspx Weingart, S. N., Zhu, J., Chiappetta, L., Stuver, S. O., Schneider, E. C., Epstein, A. M. et al. (2011). Hospitalized patients participation and its impact on quality of care and patient safety. Int.J.Qual.Health Care, 23, 269-277. 10
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum DANGEROUS ABBREVIATIONS The organization has identified and implemented a list of abbreviations, symbols, and dose designations that are not to be used in the organization. Medication errors are the largest identified source of preventable hospital medical error. From 2004-2006, more than 600,000 medication errors were reported to the United States Pharmacopeia (USP) MEDMARX program, with a total annual cost of $3.5 billion. Five percent of those errors were attributed to abbreviation use. Misinterpreted abbreviations can result in omission errors, extra or improper doses, administering the wrong drug, or giving a drug in the wrong manner. In return this can lead to an increase in the length of stay, more diagnostic tests and changes in drug treatment. The list is inclusive of the abbreviations, symbols, and dose designations, as identified on the Institute of Safe Medication (ISMP) Canada s Do Not Use List. The organization implements the Do Not Use List and applies this to all medication-related documentation when hand written or entered as free text into a computer. The organization s preprinted forms, related to medication use do not include any abbreviations, symbols, and dose designations identified on the Do Not Use List. The dangerous abbreviations, symbols, and dose designations are not used on any pharmacy-generated labels and forms. The organization educates staff about the list at orientation and when changes are made to the list. The organization updates the list and implements necessary changes to the organization s processes. The organization audits compliance with the Do Not Use List and implements process changes based on identified issues. Medication safety issue brief. Eliminating dangerous abbreviations, acronyms and symbols (2005). Hosp.Health Netw., 79, 41-42. Institute for Safe Medication - Canada (2006). Eliminate Use of Dangerous Abbreviations, Symbols, and Dose Designations. ISMP Canada Safety Bulletin [On-line]. Available: www.ismp-canada.org/download/safetybulletins/ismpcsb2006-04abbr.pdf Institute for Safe Medication - Canada (2012). Do Not Use: List of Dangerous Abbreviations, Symbols, and Dose Designations. Institute for Safe Medication - Canada [On-line]. Available: www.ismp-canada.org/dangerousabbreviations.htm Koczmara, C., Jelincic, V., & Dueck, C. (2005). Dangerous abbreviations: U can make a difference! Dynamics., 16, 11-15. 11
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum INFORMATION TRANSFER The team transfers information effectively among service providers at transition points. Effective communication has been identified as a critical element in improving client safety, particularly with regard to transition points such as shift changes, end of service, and client movement to other health services or community-based providers. Effective communication includes transfer of information within the organization, between staff and service providers, with the client and family, and to other services outside the organization, such as primary care providers. Examples of mechanisms to ensure accurate transfer of information may include transfer forms and checklists. The team has established mechanisms for timely and accurate transfer of information at transition points. The team uses the established mechanisms to transfer information. Alvarado, K., Lee, R., Christoffersen, E., Fram, N., Boblin, S., Poole, N. et al. (2006). Transfer of accountability: transforming shift handover to enhance patient safety. Healthc.Q., 9 Spec No, 75-79. Avoidable Hospitalization Advisory Panel (2011). Enhancing the Continuum of Care. Ontario Ministry of Health and Long-Term Care [Online]. Available: www.health.gov.on.ca/en/common/ministry/publications/reports/baker_2011/baker_2011.pdf Canadian Medical Protective Association (CMPA). (2013) Patient Handovers. CMPA Risk Fact Sheet. CMPA. Ottawa, ON. [On-line]. Available: www.cmpa.org/cmpa-risk-fact-sheets Kripalani, S., Jackson, A. T., Schnipper, J. L., & Coleman, E. A. (2007). Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J.Hosp.Med., 2, 314-323. Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA, 297, 831-841. Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The care span: The importance of transitional care in achieving health reform. Health Aff.(Millwood.), 30, 746-754. Patterson, E. S. & Wears, R. L. (2009). Beyond communication failure. Ann.Emerg.Med., 53, 711-712. Trachtenberg, M. & Ryvicker, M. (2011). Research on transitional care: from hospital to home. Home.Healthc.Nurse, 29, 645-651. World Health Organization (2009). Human Factors in Patient Safety Review of Topics and Tools. World Health Organization [On-line]. Available: www.who.int/patientsafety/research/methods_measures/human_factors/human_factors_review.pdf 12
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum MEDICATION RECONCILIATION AS A STRATEGIC PRIORITY For the following sets of standards: Leadership, Leadership for Small Community-based Organizations The organization has a strategy to partner with clients to collect accurate and complete information about client medications and utilize this information during transitions of care. NOTE: Accreditation Canada will move towards full implementation of medication reconciliation in two phases. For on-site surveys between 2014 and 2017, medication reconciliation should be implemented in ONE service (or program) that uses a Qmentum standard containing the Medication Reconciliation at Care Transitions ROP. Medication reconciliation should be implemented as per the tests for compliance for each ROP. For on-site surveys in 2018 and beyond, medication reconciliation should be implemented in ALL services (or programs) that use Qmentum standards containing the Medication Reconciliation at Care Transitions ROP. Medication reconciliation should be implemented as per the tests for compliance for each ROP. Medication reconciliation is widely recognized as an important safety initiative. In Canada, Safer Healthcare Now! identifies medication reconciliation as a patient safety priority. The World Health Organization (WHO) has also developed a Standard Operating Protocol for medication reconciliation as one of its interventions designed to enhance patient safety. Properly conducted medication reconciliation reduces the possibility that medications will be inadvertently omitted, duplicated, or incorrectly ordered at transitions of care. Medication reconciliation can be a cost-effective way to reduce medication errors and can reduce the re-work that can be associated with managing client medications. Safer Healthcare Now! offers a Getting Started Kit for various sectors (including acute care, long-term care, and home-care) at www.saferhealthcarenow.ca. Medication reconciliation is a structured, shared process whereby which health care professionals: 1. Work with the client, family, and caregivers (as appropriate), and at least one other source of information, to generate a Best Possible Medication History (BPMH). A BPMH is a list of all medications (including prescription, non-prescription, traditional, holistic, herbal, vitamins, and supplements). 2. Identify and resolve differences (discrepancies) between the BPMH and medications ordered at transition points. 3. Document and communicate up-to-date information about client medications to the client (and their next service provider, as appropriate). Success at medication reconciliation requires clear commitment and direction from organization leaders. An organization policy signals commitment to medication reconciliation and provides guiding principles (e.g., an overview of the process, roles and responsibilities, transitions where medication reconciliation is required, exemptions, etc). Organization commitment to medication reconciliation also requires investment, with resources allocated towards staffing, education, tools, information technology, etc. Implementing and sustaining medication reconciliation throughout an organization will be more successful when led by an interdisciplinary coordination team. Depending on the organization, the coordination team could include senior leaders (including clinical leaders representing medicine, nursing, and pharmacy staff), front-line staff who are directly involved in 13
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum MEDICATION RECONCILIATION AS A STRATEGIC PRIORITY the process, information technology staff, representatives from quality, risk, and safety committees, and clients and families. For organizations that are just starting, it can be helpful to develop the necessary forms and tools and implement them in one service area to gain expertise. As monitoring indicates implementation is successful, a plan can be developed to implement medication reconciliation throughout the organization, continuing to monitor and make improvements as required. As medication reconciliation is successfully implemented, organizations need to consider the sustainability of the process, continuing to monitor and make improvements as required. Physician and staff education about medication reconciliation should include the rationale for and steps involved in medication reconciliation. The Agency for Healthcare Research and Quality s MATCH toolkit provides more information about medication reconciliation training (www.ahrq.gov). Evidence of education can include orientation checklists, a list of education sessions offered, attendance lists, competency evaluation forms, sign-off sheets for having read policies/procedures, etc. It is important to monitor, in consultation with the coordination team and front-line staff, the extent to which the medication reconciliation policy and process are being followed. Monitoring should assess compliance with the overall medication reconciliation process (e.g., the quality of the collection of the BPMH, whether the BPMH is documented, and whether medication discrepancies are identified and resolved). The Safer Healthcare Now! Getting Started Kit also has useful resources to monitor implementation. ISMP Canada and the Canadian Patient Safety Institute (CPSI) have developed an audit tool that can be used to help assess the quality of an established medication reconciliation process. The organization has a medication reconciliation policy and process to collect and utilize accurate and complete information about client medication at transitions of care. The organization defines roles and responsibilities for completing medication reconciliation. The organization has a plan to implement and sustain medication reconciliation that specifies services/programs, locations and timelines. The organizational plan is led and sustained by an interdisciplinary coordination team. There is documented evidence that the organization educates staff and physicians responsible for medication reconciliation. The organization monitors compliance with the medication reconciliation process, and makes improvements when required. 14
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum MEDICATION RECONCILIATION AS A STRATEGIC PRIORITY Accreditation Canada, the Canadian Institute for Health Information, the Canadian Patient Safety Institute, and the Institute for Safe Medication Canada. (2012). Medication Reconciliation in Canada: Raising The Bar Progress to date and the course ahead. Ottawa, ON: Accreditation Canada. [On-line] Available: www./med_rec_report.aspx Avoidable Hospitalization Advisory Panel (2011). Enhancing the Continuum of Care. Ontario Ministry of Health and Long-Term Care [On-line]. Available: www.health.gov.on.ca/en/common/ministry/publications/reports/baker_2011/baker_2011.pdf Canadian Medical Protective Association (CMPA) (2013). Medication Reconciliation. CMPA Risk Fact Sheet. CMPA. [On-line]. Available: www.cmpa.org/cmpa-risk-fact-sheets Feldman, L.S., Costa, L.L., Feroli, E.R., Nelson, T., Poe, S.S., Frick, et al. (2012) Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J.Hosp.Med., 7(5), 396-401. Greenwald, J. L., Halasyamani, L., Greene, J., LaCivita, C., Stucky, E., Benjamin, B. et al. (2010). Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J.Hosp.Med., 5(8), 477-485. Institute for Safe Medication Canada (2013). Quality Medication Reconciliation Processes Are Critical. Ontario Critical Incident Learning. Issue 3. [On-line]. Available: www.ismp-canada.org/ocil/ Institute for Safe Medication - Canada (2011). Optimizing Medication Safety at Care Transitions - Creating a National Challenge. Institute for Safe Medication - Canada [On-line]. Available: www.ismp-canada.org/download/medrec/medrec_national_summitreport_feb_2011_en.pdf Institute for Safe Medication - Canada (2012). Medication Reconciliation (MedRec). Institute for Safe Medication - Canada [On-line]. Available: www.ismp-canada.org/medrec/ Institute for Safe Medication Canada and Canadian Patient Safety Institute (2012). National Medication Reconciliation Strategy: Identifying practice leaders for medication reconciliation in Canada. Canadian Patient Safety Institute. [On-line]. Available: www.saferhealthcarenow.ca/en/interventions/medrec/pages/resources.aspx Karapinar-Carkit, F., Borgsteede, S. D., Zoer, J., Egberts, T. C., van den Bemt, P. M., & van, T. M. (2012). Effect of medication reconciliation on medication costs after hospital discharge in relation to hospital pharmacy labor costs. Ann.Pharmacother., 46, 329-338. Karnon, J., Campbell, F., & Czoski-Murray, C. (2009). Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation). J.Eval.Clin Pract., 15, 299-306. 15
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum This ROP has been revised for the Emergency Department Standards for on-site surveys starting January 2015. See page 22. MEDICATION RECONCILIATION AT CARE TRANSITIONS Acute Care Services For the following sets of standards: Acquired Brain Injury Services, Cancer Care and Oncology Services, Correctional Service of Canada Health Services, Critical Care Services, Emergency Department, Hospice Palliative and End-of-Life Services, Medicine Services, Mental Health Services, Obstetrics Services, Provincial Correctional Health Services, Rehabilitation Services, and Surgical Care Services. With the involvement of the client, family, or caregiver (as appropriate), the team generates a Best Possible Medication History (BPMH) and uses it to reconcile client medications at transitions of care. Research suggests that more than 50 percent of clients have at least one discrepancy between the medications they take at home with those ordered upon admission to the hospital. Many of these have the potential to cause adverse drug events a recognized patient safety issue. Conducting medication reconciliation reduces the possibility that medications will be omitted, duplicated, or ordered incorrectly at transitions of care. Medication reconciliation can be a cost-effective way to reduce medication errors and the re-work that can be associated with managing client medications. Medication reconciliation is a structured process to communicate accurate and complete information about client medications at transitions of care. This is a shared responsibility that requires discussion with the client, family, or caregiver (as appropriate) and often requires liaison with community service providers (such as primary care providers, home care, and community pharmacists). Safer Healthcare Now! offers a Getting Started Toolkit for medication reconciliation in the acute care setting (www.saferhealthcarenow.ca). Medication reconciliation begins with generating a Best Possible Medication History (BPMH) for each client. The BPMH is a complete list of the client s current medications, including prescription, non-prescription, traditional, holistic, herbal, vitamins, and supplements). For each medication, the name, dose, frequency, and route of administration is listed. Creating the BPMH involves interviewing the client, family, or caregivers (as appropriate), and consulting at least one other source of information such as the client s previous health record, the community pharmacist, or a provincial database. Once it has been generated, the BPMH follows the client through their health care journey and is an important reference tool for reconciling medications at each transition of care. When a client has been receiving care in a service environment for an extended period of time and is being transferred to another health care organization or service, the current medication list may be used as a BPMH. The extended period of time must be specified in organizational policy. Safer Healthcare Now! s Medication Reconciliation Community of Practice provides a number of BPMH tools and forms, at http://tools.patientsafetyinstitute.ca. Medication reconciliation at admission can be achieved using one of two models. In the proactive model, the prescriber uses the BPMH list to generate admission medication orders. In the retroactive model, the team generates the BPMH after admission medication orders have been written and makes a timely comparison of the BPMH to the admission medication orders. Regardless of the model used, it is important to identify, resolve, and document medication discrepancies. 16
COMMUNICATION Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum MEDICATION RECONCILIATION AT CARE TRANSITIONS This process needs to be repeated at any transition of care when medications are changed or re-ordered, including internal transfers involving a change in the level of care (e.g. from critical care to a medicine unit, or from one facility to another within an organization). Medication reconciliation is not required for bed relocation. Similar to admission, the goal of medication reconciliation at internal transfer is to compare the medications the client was receiving on the transferring/sending unit with those that were being taken at home to determine if any medications need to be continued, restarted, discontinued, or modified. At all times a current medication list (often called a medication administration record or MAR) is retained in the client record. When discrepancies are resolved, the current medications list is reconciled and updated in the client record. End of service is a critical transition of care that puts clients at risk of potential adverse drug events. End of service includes discharge home, and external transfer to another service environment or community-based service provider. Examples include a move from acute care to long-term care or hospice, from rehabilitation to home care, or from acute care to home/self-care. The goal of medication reconciliation at end of service is to reconcile the medications the client was taking prior to admission with those initiated in hospital and with those that should be taken at end of service. The result of medication reconciliation at end of service is a complete list of medications the client should be taking, including information about medications that need to be stopped. A systematic process needs to be followed to ensure this information is documented and shared with the client, family, and subsequent care providers (e.g., primary care provider, community pharmacy, long-term care provider, home care provider, as appropriate). Ideally, information about client medications is part of a Best Possible Medication Discharge Plan (BPMDP) that also includes a medication information transfer letter to the next care provider, a structured discharge prescription to the next care provider or community pharmacist, and clear information for the client about the medications the client should be taking (in plain language that the client can understand). Note: For emergency departments, medication reconciliation is only expected for clients for whom the decision to admit has been made. For clients with a decision to admit, medication reconciliation may begin in the emergency department and be completed following admission to the inpatient unit. Upon or prior to admission, the team generates and documents a Best Possible Medication History (BPMH), with the involvement of the client, family, or caregiver (and others, as appropriate). The team uses the BPMH to generate admission medication orders OR compares the Best Possible Medication History (BPMH) with current medication orders and identifies, resolves, and documents any medication discrepancies. A current medication list is retained in the client record. The prescriber uses the Best Possible Medication History (BPMH) and the current medication orders to generate transfer or discharge medication orders. The team provides the client, community-based health care provider, and community pharmacy (as appropriate) with a complete list of medications the client should be taking following discharge. 17