CQI IN COMMUNITY PRACTICE
Learning objectives
- To report, analyze, and share medication incident learning according to the continuous quality improvement, or CQI, process in community pharmacy practice;
- To document CQI activities, such as incident analysis and action plans, using standardized CQI programs; and
To be aware of the Canadian jurisdictions that have implemented mandatory standardized CQI and medication safety programs, in an effort to populate a larger database for aggregate analysis and learning.
First, let’s look at the CQI process in community pharmacy practice.—Given the complexity of the pharmacy workflow, medication incidents are an inevitable part of practice. Reporting, analyzing, and sharing learning from medication incidents are key components of a CQI program that aims to reduce the risk of future recurrences. CQI involves an ongoing and systematic examination of an organization’s work processes, both proactively and retrospectively, to identify and address the factors contributing to safety and quality issues and implement corresponding changes.
CQI in pharmacy practices must be built in a culture of safety –defined by ISMP Canada as the underlying beliefs and values of an organization as they relate to safety as a priority. Therefore, for CQI to be successful, organizations and practitioners must foster a culture of shared learning dedicated to patient and medication safety in community pharmacy practice, where members of the team feel comfortable reporting and discussing medication errors, without fear of negative consequences.
CQI Process in Community Pharmacy Using CQI Tools
The CQI process in community pharmacy practice include 4 key actions –Report, Analyze, Share, and Document, and they’re not necessarily completed in this order every time. I’ll go into more detail for each, but at a high level, we’d want to have a reporting platform to receive medication incidents in a manner that users can search and retrieve them for subsequent discussion and analysis of potential contributing factors and solution development.
Currently, CPhIR and PharmaPod are two such platforms currently used in certain provinces, which we’ll demo today, and there are others available as well, including Sobey’s Patient Safety Company and Rexall’s in–house platform.
Report
- Date Incident Occurred
- Time Incident Occurred
- Type of Incident
- Incident Discovered By
- Medication System Stages Involved in this Incident
- Medications
- Patient’s Gender
- Patient’s Age
- Degree of Harm to Patient due to Incident
- Incident Description/How Incident was Discovered
- Other Incident Information
- Contributing Factors of this Incident
- Actions at Store Level
- Shared Learning for ISMP Canada to Disseminate
Benefits and Limitations of Reporting
Benefits
- As medication incident reporting programs continue to accumulate data over time, particularly from multiple pharmacies, and ideally, multiple jurisdictions, any trends and changes in medication incident patterns can be identified.
- Medication incident analysis can provide guidance to reporting community pharmacies, and on a larger scale, can help identify new areas of focus to enhance medication safety in pharmacy practice throughout the country.
Limitations
- Of course, there are limitations and potential barriers to reporting as well. Since it’s mostly done on a voluntary basis, there is under–reporting and we cannot know the denominator –how many medication incidents are actually happening – only those that are reported.
- As I mentioned, CPhIR has made an effort to minimize the time barrier by incorporating as many pull–down menus and check boxes as possible, but it is still time out of a user’s busy day.
- And lastly, some jurisdictions and even individual pharmacies may have different thresholds for reporting –some may say that all incidents, including near misses that didn’t reach the patient, need to be reported, while others may recommend that only incidents that reached the patient, or those causing harm, should be reported. This variation in the reporting threshold may limit certain reports.
Analyze
Analyze the reported medication incident to determine potential contributing factors and develop solutions to prevent recurrence.—You’ve seen this summary before, from the Canadian Incident Analysis Framework. With medication incident data, we can do quantitative analysis and qualitative analysis. And within the qualitative analysis, an individual incident can be analyzed in detail, or a number of incidents can be analyzed together in an aggregate, multi–incident analysis. Quantitative analyses summarize medication incident data using descriptive statistics such as graphs and tables, while qualitative analyses focus on the medication incident narratives.
Quantitative analysis can be used to address the “what” question –it provides an overview of the data and monitoring of trends, and can quickly identify areas for improvement. A key limitation of quantitative analysis, however, is that case–specific contributing factors cannot be identified; additionally, with voluntary reporting, we cannot ensure the reliability of the results.
Qualitative analysis can be used to address the “why” question –it provides an in–depth analysis of the incident narrative to identify detailed, case–specific contributing factors. This in–depth analysis can be time–consuming, however, and incident rates cannot be determined.—We’ll take a look atan example of quantitative analysis in CPhIR.
Quantitative Analysis – Stats
Medication incidents can be sorted by:
- No. of Incidents by Day of the Week
- No. of Incidents by Month
- No. of Incidents by Year
- No. of Incidents by Type
- No. of Incidents by Discoverer
- No. of Incidents by Medication System Stages
- No. of Incidents by Degree of Harm to Patient
- No. of Incidents by Contributing Factors
- Top 10 DINs
- Top 10 Active Ingredients
Qualitative Analysis – Quality Improvement
Documentation of CQI activities.
Internal Documentation
a) Medication Incident Discussion
- Step 1 is to describe the medication incident. If you import the incident, that information will already be at the top of the form.
- Step 2 is to gather all relevant information –consider the 10 Key Elements in the MSSA to get you thinking about what additional information may be useful. For example, in terms of patient and drug information, you will likely want to pull up the patient profile in the pharmacy system. In terms of labelling and packagingand drug storage, you should identify the two products and note their placement on the shelves.
- Step 3 is to identify all possible contributing factors –the MSSA items can help with this process as they uncover potential safety gaps in the system.
- Step 4 is to develop a causal statement based on identified possible contributing factors. Here’s an example with the structure highlighted for clarity. The look–alike/sound–alike drug names of bisoprolol and bisacodyl increased the likelihood that the incorrect drug would be selected and entered, leading to an incorrect drug being prepared and filled.
- Step 5 is to discuss and identify possible solutions to mitigate the contributing factors. Consider the hierarchy of effectiveness and aim for higher leverage strategies, where feasible.
- One option is a medium leverage independent double check strategy. Engage in dialogue with the patient and/or caregiver as a way to detect potential errors. For example, as an additional check before entering a prescription, ask the patient to state the reason why the medication was prescribed.
- Another option is a low leverage education strategy. Educate pharmacy staff on look–alike/sound–alike drug names and products.
- Yet another option could be a high leverage, longer–term strategy. Incorporate a bar code scanner in the dispensing process to minimize the risk of selection errors reaching the patient. Of the solutions discussed in the CQI meeting, rate the relative effectiveness and feasibility of each to determine which one should be implemented.
- Step 6 is to consider the solution ratings according to effectiveness and feasibility and rank them according to the needs of your pharmacy.
- Step 7 is to develop a SMART action plan for implementation of the selected solution, ensuring that it’s specific, measurable, attainable, relevant, and time–based.
Once the discussion and decisions for those 7 analytical steps are complete, you can decide to finalize the submission, or leave it open to complete during another meeting. Either way, be sure to ‘Save’ your team’s CQI work. CQI staff meetings need not only be used to discuss new medication incidents but also to update a previously unresolved medication incident. This brings us to our second documentation topic in CQI meetings –the MSSA improvement initiative.
b) MSSA Improvement Initiative
Pharmacists can use the MSSA tool to assess the safety of medication practices in their pharmacy, identify opportunities for improvement, and monitor progress in making those improvements via the online interface. We encourage pharmacy staff members to implement this self–assessment program as part of the pharmacy’s CQI process as it can help evaluate the pharmacy’s uptake of various medication safety strategies over time.Within the ‘Quality Improvement’ tab, users can document and update a previous MSSA improvement initiative or add a new one.
c) Staff education
And the third documentation topic for the CQI meeting is staff education. Continuous professional development initiatives educate staff to enable them to embrace and support a culture of medication safety in the pharmacy. This is an important part of the CQI process because
Mandatory CQI programs in Canada.
Key Components & Tools of a Standardized CQI Program
- Completion of a medication safety self–assessment on a regular basis, perhaps annually, to proactively identify areas of improvement and monitor progress of the resulting enhancement or action plans at regular CQI or staff meetings at the pharmacy. An example of this resource is the ISMP Canada Medication Safety Self–Assessment® for Community/ Ambulatory Pharmacy™.
- Anonymous reporting of medication incidents to an independent third–party organization that has the relevant expertise in medication incident analyses and commitment to sharing learning that is derived from trends and patterns of medication incidents reported by pharmacy professionals. An example of this resource is the ISMP Canada Community Pharmacy Incident Reporting (CPhIR) program. Incidents reported to CPhIR populate the National Incident Data Repository for Community Pharmacy, or NIDR, which is a Canadian database for community pharmacy medication incidents.
- An open discussion on medication incidents and their associated contributing factors among pharmacy team members, followed by formal documentation of quality improvements made as a result of regular incident reviews and proactive medication safety self–assessment during CQI or staff meetings at the pharmacy. An example of this is the ‘Quality Improvement’ module within CPhIR.—
Canadian Jurisdictions with Mandatory Reporting Programs
- In October 2010, Nova Scotia started a research project called SafetyNET–Rx as a mandatory standardized CQI program, which was the first of its kind in Canada. No longer called SafetyNet–Rx, Nova Scotia continues to require reporting as part of continuous quality assurance programs in community pharmacies. Years later.
- In December 2017, Saskatchewan’s COMPASS mandatory standardized CQI program began.
- In 2019, both New Brunswick’s MMIR and Ontario’s AIMS began their respective reporting and medication safety programs.—And although delayed due to the pandemic, Manitoba’s SafetyIQ program will be rolled out in 2021.
This slide summarizes the jurisdictional programs we just discussed, alongside the key components of a CQI program –to be proactive, retrospective, and enable documentation. Most of the jurisdictions require the medication incident data to populate a pan–Canadian database –the National Incident Data Repository for Community Pharmacies, or NIDR, is part of the Canadian Medication Incident Reporting and Prevention System, or CMIRPS. Additionally, some jurisdictions specify a particular reporting platform for the incident reporting –CPhIR in Saskatchewan and PharmaPod in Ontario. This chart is likely to grow in the coming years as more and more jurisdictions recognize the value and importance of CQI in community pharmacy practice. In the following slides, I’ll go over a few key outputs of the CQI programs in each of these jurisdictions to further demonstrate the significance of reporting, sharing and learning, particularly at an aggregate level. Firstly, let’s look at some of the analysis and learning from Nova Scotia’s CQA program.—A retrospective descriptive analysis was conducted by the CPhIR team on quality–related events reported to CPhIR from 301 community pharmacies in Nova Scotia between October 1st, 2010 and June 30th, 2017. Quality–related events are defined as medication errors that reach the patient (for example, incorrect drug or dose), in addition to medication errors that are intercepted before dispensing, also known as near misses.