Drug error management
We want to help you put preventative measures into place in your pharmacy before problems arise. Together with the Institute for Safe Medication Practices Canada (ISMP), we are pleased to provide The Systems Approach to Quality Assurance.
You can use this approach to quality assurance to:
- determine risk reduction strategies that include improvements to your organization and systems,
- identify the root and contributory factors of critical incidents,
- develop action plans and measurement strategies to evaluate the effectiveness of the plans, and
- prevent errors from occurring.
This presentation provides an introduction to Failure Mode and Effects Analysis (FMEA).
Module 2 - The Systems Approach for Quality Assurance for Pharmacy Practice: A Framework for Mitigating Risk
Upon completing this learning module, you will be able to:
- Identify and reduce risks in your practice setting using FMEA
- Enhance patient safety and prevent harm from reaching your patients.
- Identify processes in pharmacy practice settings that are suitable for analysis using FMEA
- Participate as a team member in an FMEA, and with experience, be able to lead a team yourself
Part I: Leading Up to Systems Analysis of Drug Incidents
This presentation outlines the differences between drug incidents, adverse drug events and drug errors; and the organizational process for managing critical incidents.
Part II: The Systems Approach to Investigating Drug Incidents
This presentation takes you through an example of a drug incident to illustrate how to apply the principles of systems analysis.
Part III: Application of Systems Analysis Beyond Drug Incidents
Workflow and burglary prevention case examples demonstrate the utility of systems analysis beyond drug incidents.
Quality Assurance for Community Pharmacies – The Systems Approach: A Patient Safety Primer (PDF)
This document provides additional background on how to use the Quick Reference Guide. Your Pharmacy Practice Consultant will review both the Quick Reference Guide and the Patient Safety Primer with you at a future visit to help you implement an effective incident analysis process.
The Systems Approach to Quality Assurance for Pharmacy Practice: A Framework for Mitigating Risk (PDF, 67 pages)
Failure Mode and Effects Analysis (FMEA) is a technique used to identify process and product problems before they occur.
In this document, you will learn how to use FMEA to help your pharmacy team meet the quality assurance objectives of the Standards for the Operation of Licensed Pharmacies.
The Systems Approach to Quality Assurance for Community Pharmacies (PDF, 52 pages)
This document will help you better understand systems analysis. It includes:
- an introduction to systems analysis,
- detailed steps of the incident analysis process,
- factors to consider when performing an analysis, and
- all the tools you will need to conduct an effective investigation and to document your findings and action plans including the following items available as tear outs:
Newly revised Drug Incident – Patient Safety Report with sample completed version
Use this report to document a drug incident the next time one occurs in your pharmacy, and keep it handy so that your Pharmacy Practice Consultant can discuss it with your team on their next visit.
New Drug Incident – Quarterly Review Report with sample completed version
Use the quarterly review report to review drug incidents that occur in each quarter, and document any significant findings and additional measures taken to prevent future recurrence. Have this report available so that your Pharmacy Practice Consultant can review it with your team on their next visit.
Incident Analysis Process Summary and Quick Reference Guide (PDF, 30 pages)
Reasons why incidents occur are not often straightforward. Use this tool to help your pharmacy team navigate the often murky waters of incidents and identify contributory and underlying causes of events.
Drug incident - patient safety report (PDF)
Drug incident - quarterly review report (PDF)
High-level process diagram template (PDF)
Sub-process diagram template (PDF)
Failure mode diagram template (PDF)
FMEA team charter template (PDF, editable)
FMEA spreadsheet (Word, editable)
FMEA action and measurement summary (Word, editable)