ROP Handbook en

ROPs
Required
Organizational
Pr actices
2012
Required
Organizational
Practices
Required Organizational Practices

Published by: Accreditation Canada
All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without the proper written permission of the
publisher.
Accreditation Canada, 2012
www.accreditation.ca
contents
Overview.......................................................................................1
About the ROP handbook.............................................................2
Major and minor tests for compliance...........................................3
SAFETY CULTURE
Adverse events disclosure............................................................4

Adverse events reporting..............................................................5
Client safety as a strategic priority................................................6
Client safety quarterly reports.......................................................7
Client safety-related prospective analysis.....................................8
COMMUNICATION
Client and family role in safety......................................................9

Dangerous abbreviations............................................................10
Information transfer.....................................................................11
Medication reconciliation as an organizational priority
For Leadership Standards..................................................... 12
Medication reconciliation at admission
For Ambulatory Care Services and Ambulatory Systemic
Cancer Therapy Services...................................................... 13
For Emergency Department Standards................................. 15
For Acquired Brain Injury Services, Cancer Care and
Oncology Services, Critical Care, Hospice, Paliative, and
End-of-Life Services, Long-Term Care Services, Medicine
Services, Mental Health Services, Obstetrics Services,
Rehabilitation Services, Residential Homes for Seniors,
Substance Abuse and Problem Gambling Services, and
Surgical Care Services.......................................................... 17
For Case Management Services, Community-Based
Mental Health Services and Supports, and Home Care
Services.................................................................................19
Medication Reconciliation at Transfer or Discharge
For teams using Ambulatory Care Services and Ambulatory
Systemic Cancer Therapy Services.......................................21
For teams using Acquired Brain Injury Services, Cancer
Care and Oncology Services, Critical Care Services,
Emergency Departments, Hospice, Palliative, End-of-Life
Care Services, Medicine Services, Mental Health Services,
Obstetrics Services, Rehabilitation Services, Substance
Abuse and Problem Gambling Services, and Surgical
Care Services........................................................................23
For teams using Home Care Services, Case Management
Services, and Community Based Mental Health Services
and Supports.........................................................................26
For teams using Long Term Care Services and Residential
Homes for Seniors.................................................................28
Accreditation Canada, 2012
Safe surgery checklist.................................................................30

Two client identifiers
For Managing Medications Standards................................... 31
For teams using standards other than Managing
Medications............................................................................32
Verification processes for high-risk activities...............................33
MEDICATION USE
Antimicrobial Stewardship.......................................................34
Concentrated electrolytes............................................................36
Heparin safety.............................................................................37
Infusion pumps training...............................................................38
Medication concentrations...........................................................39
Narcotics safety...........................................................................40
WORKLIFE/WORKFORCE
Client safety: education and training...........................................41

Client safety plan.........................................................................42
Client safety: roles and responsibilities.......................................43
Preventive maintenance program...............................................44
Workplace violence prevention...................................................45
INFECTION CONTROL
Hand-hygiene audit.....................................................................47
Hand-hygiene education and training..........................................48
Infection control guidelines..........................................................49
Infection rates..............................................................................50
Influenza vaccine.........................................................................51
Pneumococcal vaccine................................................................52
Sterilization processes................................................................53
RISK ASSESSMENT
Falls prevention strategy.............................................................54

Home safety risk assessment.....................................................55
Pressure ulcer prevention........................................................56
Suicide prevention.......................................................................58
Venous thromboembolism (VTE) prophylaxis.............................59
Chart of Required Organizational Practices................................60
Index . .........................................................................................61
New in 2013
New in 2013 for select acute care standard sets
OVeRVIeW
Accreditation Canada defines a Required Organizational Practice (ROP) as an essential practice that organizations must have
in place to enhance patient/client safety and minimize risk.
In the Qmentum accreditation program, ROPs are vital components of patient safety and quality improvement.
ROPs are reviewed annually and updated as required. New ROPs are developed as recommended by expert advisory committees and field-specific consultation.
ROPs are categorized into six patient safety areas, each with its own goal
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
Accreditation Canada began developing ROPs in 2004 under the leadership of its Patient Safety Advisory Committee. Initial
work includes national and international literature reviews to identify major patient safety risk areas and best practices, analysis
of patient safety-related accreditation on-site survey results and compliance issues, and research into related activities in other
international accrediting bodies. Before being released to the field, each ROP is then subject to extensive testing, consultation,
and feedback from expert advisory committees, client organizations, surveyors, and other stakeholders such as governments
and content experts.
For more information on ROPs, Accreditation Canada, or the Qmentum accreditation program, visit www.accreditation.ca.
1
ABOUt tHe
ROP HAnDBOOK
For convenience and ease of use, all ROPs that appear in the standards have been collected into this handbook.
Most ROPs are applicable to more than one set of standards, and some of them, such as medication reconciliation, are customized for a specific service or field.
Each ROP in this handbook is presented as follows:
The ROP
e.g. 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.
Guidelines
The guidelines provide context and rationale on why the ROP is important to patient safety and risk management, supporting
evidence, and information about meeting the tests for compliance.
Tests for Compliance
The tests for compliance show the specific requirements that are assessed to establish compliance with the ROP. Even one
unmet test for compliance results in an unmet rating for that ROP.
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 requirements.
2
MAJOR AnD MInOR tests

FOR cOMPLIAnce
ROPs are evidence-based practices that mitigate risk and contribute to improving the quality and safety of health services.
These practices address high priority areas that have been identified as central to quality and safety.
Beginning in January 2012, all ROP tests for compliance have been given a designation of major or minor. In order to be rated
compliant for an ROP, organizations must meet all tests for compliance, both major and minor.
Major tests for compliance have an immediate impact on safety. For unmet major tests for compliance, organizations will have
5 months to submit required follow-ups. Minor tests for compliance support safety culture and quality improvement, yet may
require additional time to be fully developed and/or evaluated. For unmet minor tests for compliance, organizations will have
11 months to submit required follow-ups. In some cases, time to submit required follow-ups may vary based on associated
levels of risk, surveyor observations, and an organizations accreditation status.
In the ROP handbook, major/minor designations will be displayed beside each test for compliance as follows:
Major At least one prospective analysis has been completed within the past year.
Minor The organization uses information from the analysis to make improvements.
3
Required
Organizational
Practices
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.
GUIDELINES
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 clients 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.
TESTS FOR COMPLIANCE
Major There is a written policy for disclosure of adverse events to clients and families.
Major The disclosure policy includes support mechanisms for clients, families, staff, and service providers.
Major There is evidence of a process for disclosure of adverse events to clients, families, staff, and services providers.
REFERENCE MATERIAL
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-%20RespectfulManagementofSeriousClinicalAdverseEvents_490ab9fb-d691-43e8-af97-6d39638cedec/
IHIRespectfulManagementofSeriousClinicalAdverseEventsOct11.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.
Institut canadien pour la scurit des patients. (2011). Lignes directrices nationales relatives la divulgation des vnements indsirables: parler
ouvertement aux patients et aux proches. Institut canadien pour la scurit des patients [On-line]. Available:
www.patientsafetyinstitute.ca/French/toolsresources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines%20FR.pdf
Institute for Healthcare Improvement. (2007). Disclosure Toolkit and Disclosure Culture Assessment Tool. Institute for Healthcare Improvement
[On-line]. Available: www.ihi.org/knowledge/Pages/Tools/DisclosureToolkitandDisclosureCultureAssessmentTool.aspx
Kraman, S. S. & Hamm, G. (1999). Risk management: extreme honesty may be the best policy. Ann.Intern.Med., 131, 963-967.
4
Required
Organizational
Practices
SAFETY CULTURE
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.
GUIDELINES
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. Major 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.
Major There is a reporting policy and process to report adverse events, sentinel events, and near misses.
Minor Improvements are made following investigation and follow-up.
REFERENCE MATERIAL
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.
Canadian Patient Safety Institute. (2008). Building a Safer System: The Canadian Adverse Event Reporting and Learning System Consultation
Paper. Canadian Patient Safety Institute [On-line]. Available: http://signup.patientsafetyinstitute.ca/English/toolsResources/ReportingAndLearning/
CanadianAdverseEventsReportingAndLearningSystem/Documents/CAERLS%20Consultation%20Paper.pdf
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-%20IHIGlobalTriggerToolforMeasuringAdverseEvents_df8a18b652cc-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
5
Required
Organizational
Practices
SAFETY CULTURE
CLIENT SAFETY AS A STRATEGIC PRIORITY

The organization adopts client safety as a written, strategic priority or goal.
GUIDELINES
There is an important connection between organization excellence and safety. Ensuring safety in the provision and delivery
of services is among an organizations primary responsibilities to clients, staff and providers. Accordingly, safety should be a
formally written component of the organizations strategic objectives. This may be in the form of the strategic plan, the annual
report, or list of organizational goals.
Major Client safety appears as a written, strategic priority or goal.

Minor Resources are allocated to support the organizations implementation of the client safety strategic priority or goal.
REFERENCE MATERIAL
Baldrige Performance Excellence Program. (2012). Health Care Criteria for Performance Excellence. National Institute of Standards and
Technology [On-line]. Available: www.nist.gov/baldrige/publications/upload/2011_2012_Health_Care_Criteria.pdf
Canadian Patient Safety Institute. (2012). Effective Governance for Quality and Patient Safety. Canadian Patient Safety Institute [On-line].
Available: www.patientsafetyinstitute.ca/English/toolsResources/GovernancePatientSafety/Pages/default.aspx
Thomas R.Krause, John Hidley, & Diane C.Pinakiewicz (Foreword by) (2008). Taking the Lead in Patient Safety: How Healthcare Leaders
Influence Behaviour and Create Culture. Wiley.
6
Required
Organizational
Practices
SAFETY CULTURE
CLIENT SAFETY QUARTERLY REPORTS

The organizations 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.
GUIDELINES
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.
Major
Minor
Minor
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 bodys involvement in supporting the activities and accomplishments, and
acting on the recommendations in the quarterly reports.
REFERENCE MATERIAL
Institute for Healthcare Improvement. (2008). Getting Started Kit: Governance Leadership Boards on Board How-to Guide. www.ihi.org [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
7
Required
Organizational
Practices
SAFETY CULTURE
CLIENT SAFETY-RELATED PROSPECTIVE ANALYSIS

The organization carries out at least one client safety-related prospective analysis and implements
appropriate improvements.
GUIDELINES
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 Reasons Errors of Omissions model.
Major
Minor
At least one prospective analysis has been completed within the past year.
The organization uses information from the analysis to make improvements.
REFERENCE MATERIAL
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 Canadas 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.
8
Required
Organizational
Practices
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 familys role in
promoting safety.
GUIDELINES
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 Safetys Its Safe to Ask, and the Ontario Hospital Associations Your Healthcare Be Involved.
Major
Major
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.
REFERENCE MATERIAL
Alberta Health Services. (2012). Patient Engagement. Alberta Health Services [On-line]. Available:
www.albertahealthservices.ca/patientengagement.asp
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). Its 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.
9
Required
Organizational
Practices
COMMUNICATION
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.
GUIDELINES
Medication errors are the largest identified source of preventable hospital medical error. From 2004-2006, a total of 643,151
medication errors were reported to the United States Pharmacopeia (USP) MEDMARX program, with a total annual cost of
$3.5 billion. 5% 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.
Major
Major
Major
Major
Minor
Minor
Minor
The list is inclusive of the abbreviations, symbols, and dose designations, as identified of the Institute of Safe
Medication Practices (ISMP) Canadas Do Not Use List, available at
http://www.ismp-canada.org/dangerousabbreviations.htm.
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 organizations 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 organizations processes.
The organization audits compliance with the Do Not Use List and implements process changes based on
identified issues.
REFERENCE MATERIAL
Medication safety issue brief. Eliminating dangerous abbreviations, acronyms and symbols (2005). Hosp.Health Netw., 79, 41-42.
Institute for Safe Medication Practices Canada. (2006). Eliminate Use of Dangerous Abbreviations, Symbols, and Dose Designations. ISMP
Canada Safety Bulletin [On-line]. Available: ismp-canada.org/download/safetyBulletins/ISMPCSB2006-04Abbr.pdf
Institute for Safe Medication Practices Canada. (2012). Do Not Use: List of Dangerous Abbreviations, Symbols, and Dose Designations. Institute
for Safe Medication Practices 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.
10
Required
Organizational
Practices
COMMUNICATION
INFORMATION TRANSFER
The team transfers information effectively among service providers at transition points.
GUIDELINES
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.
Major
Major
The team has established mechanisms for timely and accurate transfer of information at transition points.
The team uses the established mechanisms to transfer information.
REFERENCE MATERIAL
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 [On-line].
Available: www.health.gov.on.ca/en/public/publications/ministry_reports/baker_2011/baker_2011.pdf
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
11
Required
Organizational
Practices
COMMUNICATION
MEDICATION RECONCILIATION AS AN ORGANIZATIONAL

PRIORITY
For Leadership Standards
The organization reconciles clients medications at admission, and transfer or discharge.

GUIDELINES
Medication reconciliation is a structured process in which healthcare professionals partner with clients, families and caregivers
for accurate and complete transfer of medication information at transitions of care. Medication reconciliation is complex and
requires support from all levels of an organization, and many disciplines within the system.
Medication reconciliation is widely recognized as an important safety initiative. Research suggests that over 50% of patients
have at least one medication discrepancy upon admission to hospital, with many discrepancies carrying the potential to cause
adverse health effects. Evidence shows that medication reconciliation reduces the potential for medication discrepancies such
as omissions, duplications, and dosing errors, while cost-effectiveness analyses have also demonstrated that medication
reconciliation is an extremely cost-effective strategy for preventing medication errors. Additional research highlights that
successful medication reconciliation can also reduce workload and rework associated with patient medication management.
In Canada, Safer Healthcare Now! identifies medication reconciliation as a 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.
Major Medication reconciliation is implemented in one client service area at admission.

Major Medication reconciliation is implemented in one client service area at transfer or discharge.
Major There is a documented plan to implement medication reconciliation throughout the organization.
Major The plan includes locations and timelines for implementing medication reconciliation throughout the organization.
REFERENCE MATERIAL
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/public/publications/ministry_reports/baker_2011/baker_2011.pdf
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, 477-485.
Institute for Safe Medication Practices Canada. (2011). Optimizing Medication Safety at Care Transitions - Creating a National Challenge.
Institute for Safe Medication Practices - Canada [On-line]. Available:
www.ismp-canada.org/download/MedRec/MedRec_National_summitreport_Feb_2011_EN.pdf
Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation (MedRec). Institute for Safe Medication Practices - Canada
[On-line]. Available: www.ismp-canada.org/medrec/
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.
12
Required
Organizational
Practices
COMMUNICATION
MEDICATION RECONCILIATION AT ADMISSION

For Ambulatory Care Services and Ambulatory Systemic Cancer Therapy Services
The team reconciles the clients medications with the involvement of the client, family, or caregiver at the
beginning of service when medication therapy is a significant component of care. Reconciliation should be
repeated periodically as appropriate for the client or population receiving services.
GUIDELINES
Medication reconciliation is a structured process in which health care professionals partner with clients, families and caregivers
for accurate and complete transfer of medication information at transitions of care.
The medication reconciliation process involves generating a comprehensive list of all medications the client has been taking
prior to a visit the Best Possible Medication History (BPMH). The BPMH is compiled using a number of different sources,
and includes information about prescription medications, non-prescription medications, vitamins, and supplements, along with
detailed documentation of drug name, dose, frequency, and route of administration. Any discrepancies identified between what
the client is prescribed, and what they are actually taking, will be resolved at the clinic or referred to their provider of care (e.g.
family physician).
Medication reconciliation is widely recognized as an important safety initiative. Evidence shows medication reconciliation
reduces potential for medication discrepancies such as omissions, duplications, and dosing errors. In Canada, Safer
Healthcare Now! identifies medication reconciliation as a 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.
Medication reconciliation is a shared responsibility which must involve the client or family. Liaison with the primary care
provider and community pharmacist may be required.
Due to the wide range of service offerings and client populations receiving care in ambulatory clinics, teams are encouraged
to establish appropriate target populations to receive formal medication reconciliation. Medication reconciliation should focus
on clients for whom medication therapy is a significant component of care. A screening or risk assessment approach may be
adopted, and should consider: i) the clients needs, ii) the type of clinic, and iii) the service offerings of the clinic.
NOTE: Documented rationale for the selection of target clients or populations, as well as the appropriate interval of
reconciliation for these clients or populations, must be provided.
(Contd on next page...)
13
Required
Organizational
Practices
COMMUNICATION
Medication reconciliation at admission (contd)

Major The team provides documented rationale for the selection of target clients or populations to receive formal
medication reconciliation.
Major There is a demonstrated, formal process to reconcile client medications at the beginning of service, and
periodically as appropriate for the client or population receiving services.
Major The team generates or updates a comprehensive list of medications the client has been taking prior to the
beginning of services (Best Possible Medication History (BPMH)).
Major The team documents any changes to the medications list (i.e. medications that have been discontinued, altered, or
prescribed).
Minor The team provides clients and their providers of care (e.g. family physician) with a copy of the BPMH and clear
information about the changes.
Major An up-to-date medications list is retained in the client record.
Minor The process is a shared responsibility involving the client and one or more health care practitioner(s), such as
nursing staff, medical staff, pharmacists, and pharmacy technicians, as appropriate.
REFERENCE MATERIAL
American Medical Association. (2007). The physicians role in medication reconciliation. American Medical Association
[On-line]. Available: www.ama-assn.org/resources/doc/cqi/med-rec-monograph.pdf
Institute for Healthcare Improvement. (2012). How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation). Institute for Healthcare
Improvement [On-line]. Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx
Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation (MedRec). Institute for Safe Medication Practices Canada [Online]. Available: www.ismp-canada.org/medrec/
Institute for Safe Medication Practices Canada. (2012). Cross Country Med Rec Check-Up. Institute for Safe Medication Practices Canada [Online]. Available: www.ismp-canada.org/medrec/map/
Safer Healthcare Now!. (2012). Medication Reconciliation: Getting Started Kits. Safer Healthcare Now! [On-line]. Available:
www.saferhealthcarenow.ca/EN/Interventions/medrec/Pages/default.aspx
World Health Organization. (2009). Assuring Medication Accuracy at Transitions in Care: Medication Reconciliation. High 5s: Action on Patient
Safety Getting Started Kit [On-line]. Available: www.high5s.org/pub/Manual/TrainingMaterials/MR_Getting_Started_Kit.pdf
14
Required
Organizational
Practices
COMMUNICATION

For Emergency Department Standards
The team reconciles medications for clients with a decision to admit, with the involvement of the client, family
or caregiver.
GUIDELINES
prior to admission the Best Possible Medication History (BPMH). The BPMH is compiled using a number of different
sources, and includes information about prescription medications, non-prescription medications, vitamins, and supplements,
along with detailed documentation of drug name, dose, frequency, and route of administration.
Medication reconciliation at admission generally fits into two models - the proactive process, the retroactive process, or a
combination of the two:
In the proactive process, the prescriber uses the BPMH to create admission medication orders. This process includes
verification that every medication in the BPMH has been assessed by the prescriber.
In the retroactive process, the BPMH is generated after the admission medication orders are written. This process
requires a timely comparison of the BPMH against the admission medication orders, with any discrepancies identified
and resolved with the prescriber.
safety.
15
Required
Organizational
Practices
COMMUNICATION

Major There is a demonstrated, formal process to reconcile client medications for clients with a decision to admit.
Major The team generates a Best Possible Medication History (BPMH) for clients with a decision to admit.
Major Depending on the model, the prescriber uses the BPMH to create admission medication orders (proactive), OR, the
team makes a timely comparison of the BPMH against the admission medication orders (retroactive).
Major The team documents that the BPMH and admission medication orders have been reconciled; and appropriate
modifications to medications have been made where necessary.
REFERENCE MATERIAL
Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation (MedRec). Institute for Safe Medication Practices Canada. [Online]. Available: www.ismp-canada.org/medrec/
16
Required
Organizational
Practices
COMMUNICATION

For Acquired Brain Injury Services, Cancer Care and Oncology Services, Critical Care, Hospice, Paliative, and
End-of-Life Services, Long-Term Care Services, Medicine Services, Mental Health Services, Obstetrics Services,
Rehabilitation Services, Residential Homes for Seniors, Substance Abuse and Problem Gambling Services, and Surgical
Care Services.
The team reconciles the clients medications upon admission to the organization, with the involvement of the
client, family or caregiver.
GUIDELINES
prior to admission the Best Possible Medication History (BPMH). The BPMH is compiled using a number of different sources,
and includes information about prescription medications, non-prescription medications, vitamins, and supplements, along with
detailed documentation of drug name, dose, frequency, and route of administration.
Medication reconciliation at admission generally fits into two models - the proactive process, the retroactive process, or a
combination of the two:
In the proactive process, the prescriber uses the BPMH to create admission medication orders. This process includes
verification that every medication in the BPMH has been assessed by the prescriber.
In the retroactive process, the BPMH is generated after the admission medication orders are written. This process
requires a timely comparison of the BPMH against the admission medication orders, with any discrepancies identified
and resolved with the prescriber.
safety.
17
Required
Organizational
Practices
COMMUNICATION

Major There is a demonstrated, formal process to reconcile client medications upon admission.
Major The team generates a Best Possible Medication History (BPMH) for the client upon admission.
Major Depending on the model, the prescriber uses the BPMH to create admission medication orders (proactive), OR, the
team makes a timely comparison of the BPMH against the admission medication orders (retroactive).
Major The team documents that the BPMH and admission medication orders have been reconciled; and appropriate
modifications to medications have been made where necessary.
REFERENCE MATERIAL
Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation (MedRec). Institute for Safe Medication Practices Canada. [Online]. Available: www.ismp-canada.org/medrec/
18
Required
Organizational
Practices
COMMUNICATION

For Case Management Services, Community-Based Mental Health Services and Supports, and Home Care Services
The team reconciles the clients medication at the beginning of service with the involvement of the client and
family or caregiver when medication management is a component of care.
GUIDELINES
prior to the beginning of service the Best Possible Medication History (BPMH). The BPMH is compiled using a number
of different sources, and includes information about prescription medications, non-prescription medications, vitamins, and
supplements, along with detailed documentation of drug name, dose, frequency, and route of administration.
safety.
Major There is a demonstrated, formal process to reconcile client medications at each visit if medications have been
discontinued, altered or changed.
Major The team generates a Best Possible Medication History (BPMH) at the beginning of service when medication
management is a component of care.
Major The team conducts a timely comparison of the BPMH with medications prescribed, ordered, dispensed, or
administered during service.
Major The team communicates the BPMH and discrepancies requiring resolution to the appropriate health care provider,
and documents actions taken in the client record.
19
Required
Organizational
Practices
COMMUNICATION

REFERENCE MATERIAL
Improvement [On-line]. Available:
www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx
Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation (MedRec). Institute for Safe Medication Practices Canada [Online]. Available: www.ismp-canada.org/medrec/
Safer Healthcare Now!. (2012). Medication Reconciliation: Getting Started Kits. Safer Healthcare Now! [On-line]. Available: www.
saferhealthcarenow.ca/EN/Interventions/medrec/Pages/default.aspx
Safety Getting Started Kit [On-line]. Available:
www.high5s.org/pub/Manual/TrainingMaterials/MR_Getting_Started_Kit.pdf
20
Required
Organizational
Practices
COMMUNICATION
MEDICATION RECONCILIATION AT TRANSFER OR DISCHARGE

For teams using Ambulatory Care Services and Ambulatory Systemic Cancer Therapy Services
The team reconciles the clients medications with the involvement of the client, family, or caregiver at
interfaces of care where the client is a risk of medication discrepancies (transfer, discharge), when medication
therapy is a significant component of care. Reconciliation should be repeated periodically as appropriate for
the client or population receiving services.
GUIDELINES
for accurate and complete transfer of medication information at transitions of care. The Medication Reconciliation at Transfer
or Discharge ROP is designed to complement Accreditation Canadas Medication Reconciliation at Admission ROPs.
prior to the beginning of services the Best Possible Medication History (BPMH). The BPMH is compiled using a number of
different sources, and includes information about prescription medications, non-prescription medications, vitamins, herbal
remedies, and supplements, along with detailed documentation of drug name, dose, frequency, and route of administration.
Throughout a clients health care journey, the BPMH serves as an important reference for reconciling medications at interfaces
of care. In instances where a client has been receiving services for an extended period and did not receive a BPMH at
the beginning of services, the up-to-date, complete medication list may be used as a BPMH (the period of time should be
determined by organizational policy). In these instances, every effort should be made to account for medications the patient
may have been taking prior to the beginning of services that may not be included on the up-to-date medication list.
tRAnsFeR and DIscHARGe
Transfer and discharge in ambulatory care settings are defined as critical interfaces of care where clients are at risk of
medication discrepancies as they transition from one clinic service to another, or when a clients services with a clinic come
to an end. Examples of transfer and discharge may include a client who is transferred between renal program sites (transfer),
external transfer from a renal program to a long term care facility (discharge), or external transfer of a client no longer in need
of chemotherapy to palliative care (discharge).
Due to the wide range of service offerings and client populations receiving care in ambulatory clinics, teams are encouraged
to establish appropriate target populations to receive formal medication reconciliation. Medication reconciliation should focus
on clients for whom medication therapy is a significant component of care. A screening or risk assessment approach may be
adopted, and should consider: i) the clients needs, ii) the type of clinic, and iii) the service offerings of the clinic. Regarding
transfer and discharge, teams are also encouraged to identify the risk points during service delivery where medication
reconciliation is appropriate, and establish reconciliation processes at these junctures to mitigate the risk of medication errors.
NOTE: Documented rationale for the selection of target clients or populations, the appropriate interval of reconciliation for
these clients or populations, and the risk points where reconciliation will be conducted must be provided.
21
Required
Organizational
Practices
COMMUNICATION
Medication Reconciliation at Transfer or Discharge (contd)

Medication reconciliation is widely recognized as an important safety initiative. In Canada, Safer Healthcare Now! identifies
medication reconciliation as a safety priority. The Institute for Safe Medication Practices Canada has developed a Standard
Operating Protocol for medication reconciliation which has been endorsed by the World Health Organization as one of its
interventions designed to enhance patient safety.
Major The team provides documented rationale for the selection of target clients or populations to receive formal
medication reconciliation, and the risk points during service delivery where reconciliation will be conducted.
Major There is a demonstrated, formal process to reconcile client medications at interfaces of care where the client
is at risk of medication discrepancies (transfer, discharge), and periodically as appropriate for the client or
population receiving services.
Major The team documents any changes to the medications list (i.e. medications that have been discontinued, altered,
or prescribed).
Major Upon transfer or discharge, the team provides clients and their providers of care (e.g. family physician, next
provider of care) with a copy of the up-to-date medications list and clear information about the changes.
Minor The process is a shared responsibility involving the client or family, and one or more health care practitioner(s),
such as nursing staff, medical staff, and pharmacy staff, as appropriate.
REFERENCE MATERIAL
American Medical Association. (2007). The physicians role in medication reconciliation. American Medical Association [On-line]. Available:
www.ama-assn.org/resources/doc/cqi/med-rec-monograph.pdf
Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation (MedRec). Institute for Safe Medication Practices Canada
Institute for Safe Medication Practices Canada. (2012). Cross Country Med Rec Check-Up. Institute for Safe Medication Practices Canada
[On-line]. Available: www.ismp-canada.org/medrec/map/
22
Required
Organizational
Practices
COMMUNICATION

For teams using Acquired Brain Injury Services, Cancer Care and Oncology Services, Critical Care Services, Emergency
Departments, Hospice, Palliative, End-of-Life Care Services, Medicine Services, Mental Health Services, Obstetrics
Services, Rehabilitation Services, Substance Abuse and Problem Gambling Services, and Surgical Care Services
The team reconciles the clients medications with the involvement of the client, family or caregiver at transition
points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge).
GUIDELINES
and includes information about prescription medications, non-prescription medications, vitamins, herbal remedies, and
Throughout a clients health care journey, the BPMH serves as an important reference for reconciling medications at
transitions of care. In instances where a client has been in a service environment for an extended period and did not receive
a BPMH upon admission, the up-to-date, complete medication list may be used as a BPMH (the period of time should be
may have been taking prior to admission that may not be included on the up-to-date medication list.
InteRnAL tRAnsFeR
Internal transfer is defined as an interface of care within a facility where medication orders are changed or rewritten. Internal
transfers where medication reconciliation should occur include a change in responsible medical service, a change in level of
care, post-operatively, and/or transfer between units when one of the previous three conditions is present. Bed relocation or
transitions of care where the responsible health care provider does not change should not be considered an internal transfer
for the purpose of medication reconciliation.
The goal of medication reconciliation at internal transfer is to consider not only what the patient was receiving on the
transferring/sending unit, but also medications they were taking at home that may be appropriate to continue, restart,
discontinue, or modify.
DIscHARGe
Discharge is defined as a critical interface of care where clients are at risk of medication discrepancies as they transition out
of a facility. Discharge includes external transfers to another service environment or community-based service provider, or the
end of service. Examples may include but are not limited to acute care to long term care, acute care to home care, acute care
to rehab, and acute care to self-care.
The goal of discharge medication reconciliation is to reconcile the medications the patient was taking prior to admission, and
those initiated in hospital, with the medications they should be taking post-discharge. (Contd on next page...)
23
Required
Organizational
Practices
COMMUNICATION

Medication reconciliation at internal transfer and discharge generally fits into two models the proactive process or the
retroactive process.
In the proactive process, the prescriber uses the BPMH and the active medication orders to generate transfer or
discharge medication orders. This process includes verification that every medication in the BPMH has been assessed
by the prescriber.
In the retroactive process, the team makes a timely comparison of the BPMH, the active medication orders, and the
transfer or discharge medication orders to identify discrepancies and resolve with the prescriber.
At discharge, this information should be used to generate a Best Possible Medication Discharge Plan (BPMDP). The BPMDP
includes all detailed medication information outlined in the BPMH description above, and should be communicated to the client
and/or caregiver, community-based physician or service, community pharmacy, and alternative care facility or service, as
appropriate.
NOTE: For emergency departments, medication reconciliation at internal transfer or discharge is only expected for patients
who have been admitted.
Major There is a demonstrated, formal process to reconcile client medications at transition points where medication
orders are changed or rewritten (i.e. internal transfer, and/or discharge).
Major Depending on the model, the prescriber uses the Best Possible Medication History (BPMH) and the active
medication orders to generate transfer or discharge medication orders (proactive), OR, the team makes a
timely comparison of the BPMH, the active medication orders, and the transfer or discharge medication orders
(retroactive).
Major The team documents that the BPMH, the active medication orders, and the transfer or discharge medication
orders have been reconciled; and appropriate modifications to medications have been made where necessary.
Major Depending on the transition point, an up-to-date medication list is retained in the client record (internal transfer),
OR, the team generates a Best Possible Medication Discharge Plan (BPMDP) that is communicated to the
client, community-based physician or service provider, and community pharmacy, as appropriate (discharge).
24
Required
Organizational
Practices
COMMUNICATION

REFERENCE MATERIAL
25
Required
Organizational
Practices
COMMUNICATION

For teams using Home Care Services, Case Management Services, and Community Based Mental Health Services and
Supports.
The team reconciles the clients medications at interfaces of care where the client is at risk for medication
discrepancies (circle of care, discharge) with the involvement of the client and family or caregiver when
medication management is a component of care, or as deemed appropriate through clinician assessment.
GUIDELINES
prior to the beginning of services the Best Possible Medication History (BPMH). The BPMH is compiled using a number of
different sources, and includes information about prescription medications, non-prescription medications, vitamins, herbal
remedies, and supplements, along with detailed documentation of drug name, dose, frequency, and route of administration.
Throughout a clients health care journey, the BPMH serves as an important reference for reconciling medications at interfaces
of care. In instances where a client has been receiving services for an extended period and did not receive a BPMH at
the beginning of services, the up-to-date, complete medication list may be used as a BPMH (the period of time should be
may have been taking prior to the beginning of services that may not be included on the up-to-date medication list.
cIRcLe OF cARe
The circle of care is defined as a group of individuals including the client and family who are involved in the clients care within
the health care setting. This includes health care providers, as well as formal and informal caregivers. Specifically, those who
are involved with the clients care within the community care setting. Examples of risk points for medication discrepancies
within a clients circle of care may include but are not limited to physician, nurse practitioner, or clinic appointments, a change
in client status, or transfers to an alternate level of care within the organization.
The goal of medication reconciliation within a clients circle of care is to maintain and communicate an up-to-date, complete,
and accurate medication list. The community care clinician should update the clients medication list following each
consultation or visit to a health care practitioner in the clients circle of care.
DIscHARGe
Discharge is defined as the discontinuation of service by the community care organization, and includes external transfers to
another service environment. Discharge is an interface of care where clients are at risk of medication discrepancies. Examples
may include but are not limited to discharge to acute care, long term care, palliative care, self-care, or the end of services.
26
Required
Organizational
Practices
COMMUNICATION

The goal of medication reconciliation at discharge is to communicate an up-to-date, complete, and accurate medication
list to the next provider of care. If the client is being discharged to another health care setting, the community care clinician
should update and communicate the clients current reconciled medication list to the next provider of care. If the client is being
discharged into self-care, the community care clinician should verify that the client or family understands any changes to their
medication regimen.
As care in the community is intermittent, the community care organization may not always be immediately aware that a client
has been transferred or discharged. Keeping the reconciled medication list up-to-date and accurate is the best way to be
prepared for transfer and discharge at any time.
Depending on a clients circumstances, community care providers may use a variety of methods to communicate the
medication list to the clients circle of care or next provider of care. Methods may include using the client or family as a carrier,
or face-to-face discussion, a telephone call, or facsimile between health care providers.
Major There is a demonstrated, formal process to reconcile client medications at interfaces of care where the client is at
risk of medication discrepancies (circle of care, discharge).
Major The team updates the clients medication list following each clinician consultation or visit to a health care
practitioner within the clients circle of care.
Minor The team provides the client with a copy of the up-to-date medication list, clear information about the changes, and
educates the client to share the list when encountering providers in the clients circle of care.
Major Upon notification that a client has been transferred or discharged, the community care organization communicates
the most recent medication list to the next provider of care.
REFERENCE MATERIAL
American Medical Association. (2007). The physicians role in medication reconciliation. American Medical Association. [On-line]. Available:
27
Required
Organizational
Practices
COMMUNICATION

For teams using Long Term Care Services and Residential Homes for Seniors.
The team reconciles the clients medications with the involvement of the client, family or caregiver at transition
points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge).
GUIDELINES
and includes information about prescription medications, non-prescription medications, vitamins, herbal remedies, and
Throughout a clients health care journey, the BPMH serves as an important reference for reconciling medications at
transitions of care. For clients that have been in a service environment for an extended period of time, the up-to-date, complete
medication list will become the BPMH.
InteRnAL tRAnsFeR
Internal transfer is defined as an interface of care within a facility where medication orders are changed or rewritten. Internal
transfers where medication reconciliation should occur include a change in responsible medical service, a change in level of
care, and/or transfer between units when one of the previous two conditions is present. Bed relocation or transitions of care
where the responsible health care provider does not change should not be considered an internal transfer for the purpose of
medication reconciliation.
The goal of medication reconciliation at internal transfer is to ensure that all medication orders are completely and accurately
transferred with the client, and that any discrepancies with the medication list are intentional. The process should involve a
comparison of: i) the most current medication list; and ii) the new transfer orders, to identify and resolve discrepancies.
DIscHARGe
Discharge is defined as a critical interface of care where clients are at risk of medication discrepancies as they transition out
of a facility. Discharge includes external transfers to another service environment or community-based service provider, or
the end of service. Examples may include but are not limited to long term care to acute care, long term care to self-care, and
between long term care facilities.
The goal of medication reconciliation at discharge is to communicate a complete list of medications to the next provider of
care. The process should involve a comparison of: i) the BPMH/most current medication list; and ii) recent changes including
newly initiated medications, adjusted doses, and discontinued medications.
In long term care settings, medication reconciliation at internal transfer and discharge provides an opportunity to review the
treatment goal and expected duration of therapy for medications to ensure that continued use is appropriate.
28
Required
Organizational
Practices
COMMUNICATION

Major There is a demonstrated, formal process to reconcile client medications at transition points where medication
orders are changed or rewritten (i.e. internal transfer, and/or discharge).
Major The team makes a timely comparison of the up-to-date, complete medication list, and new medication orders or
recent changes.
Major The team documents that the up-to-date, complete medication list and new medication orders or recent changes
have been reconciled; and appropriate modifications to medications have been made where necessary.
Major Depending on the transition point, an up-to-date medication list is retained in the client record (internal transfer),
OR, the up-to-date medication list is communicated to the next provider of care (discharge).
REFERENCE MATERIAL
29
Required
Organizational
Practices
COMMUNICATION
SAFE SURGERY CHECKLIST

The team uses a safe surgery checklist to confirm safety steps are completed for a surgical procedure.
GUIDELINES
Surgical checklists play an important role in the provision of effective and safe surgery. Evidence demonstrates the use of
surgical checklists reduces likelihood of complications following surgery, and may improve surgical outcomes.
The purpose of a surgical checklist is to initiate, guide, and formalize communication among the team members conducting a
surgical procedure and to integrate these steps into surgical workflow.
Surgical procedures are increasingly complex aspects of health services, and represent significant risk of potentially avoidable
harm. Data show substantial cost savings if surgical checklists are widely used. Semel et al estimate savings in the USA of
15-25 billion.
Surgical checklists have been developed by and are available from Canadian (Canadian Patient Safety Institute) and
international (World Health Organization) sources. Each checklist has three-phases:
i. Briefing before the induction of anesthesia
ii. Time out before skin incision
iii. Debriefing before the patient leaves the operating room
Major
Major
Major
Minor
Minor
The team has agreed on a three-phase checklist to be used in the operating room.
The team uses the checklist for every surgical procedure in the operating room.
The team has developed a process for ongoing monitoring of compliance with the checklist.
The team evaluates the use of the checklist and shares results with staff and service providers.
The team uses results of the evaluation to improve the implementation of and expand the use of the checklist.
REFERENCE MATERIAL
Canadian Patient Safety Institute. (2012). Surgical Safety Checklist - Canadian Version . Canadian Patient Safety Institute [On-line]. Available:
http://signup.patientsafetyinstitute.ca/English/toolsResources/sssl/Pages/SurgicalSafetyChecklist.aspx
Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H., Dellinger, E. P. et al. (2009). A surgical safety checklist to reduce morbidity
and mortality in a global population. N.Engl.J.Med., 360, 491-499.
Panesar, S. S., Cleary, K., Sheikh, A., & Donaldson, L. (2009). The WHO checklist: a global tool to prevent errors in surgery. Patient Saf Surg., 3, 9.
Semel, M. E., Resch, S., Haynes, A. B., Funk, L. M., Bader, A., Berry, W. R. et al. (2010). Adopting a surgical safety checklist could save money
and improve the quality of care in U.S. hospitals. Health Aff.(Millwood.), 29, 1593-1599.
World Alliance for Patient Safety. (2008). Implementation Manual: Surgical Safety Checklist. World Health Organization [On-line]. Available:
www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Manual_finalJun08.pdf
30
Required
Organizational
Practices
COMMUNICATION
TWO CLIENT IDENTIFIERS

For Managing Medications Standards
The team uses at least two client identifiers before administering medications.
GUIDELINES
Failure to correctly identify clients may result in a range of adverse events such as medication errors, transfusion errors,
testing errors, wrong person procedures, and the discharge of infants to the wrong families. Client misidentification was
identified in more than 100 individual root cause analyses by the US Department of Veterans Affairs National Center for
Patient Safety from January 2000 to March 2003. The UK National Patient Safety Agency reported 236 incidents and near
misses related to missing wristbands or wristbands with incorrect information between 2003 and 2005. Evidence has shown
decreases in client identification errors when using revised client identification systems.
The team uses means of identification that are appropriate to the type of services provided and population served. The
information obtained needs to be specific to the client, and examples include person-specific identification number (e.g.
registration number), client identification cards (e.g. health card with name, address, date of birth), client barcodes, double
witnessing, or a client wristband. Two client identifiers may be taken from a single source, such as client wristband. The clients
room number is not to be used as a client identifier.
TEST FOR COMPLIANCE
Major The team uses at least two client identifiers before administering medications.
REFERENCE MATERIAL
Australian Commission on Safety and Quality in Health Care. (2008). Technology Solutions to Patient Misidentification: Report of Review.
Australian Commission on Safety and Quality in Health Care [On-line]. Available:
www.health.gov.au/internet/safety/publishing.nsf/Content/CE1F60BEAF285FF7CA2574E400219A9F/$File/19794-TechnologyReview.PDF
Jensen, N. J. & Crosson, J. T. (1996). An automated system for bedside verification of the match between patient identification and blood unit
identification. Transfusion, 36, 216-221.
Parisi, L. L. (2003). Patient identification: the foundation for a culture of patient safety. J.Nurs.Care Qual., 18, 73-79.
Sandler, S. G., Langeberg, A., & Dohnalek, L. (2005). Bar code technology improves positive patient identification and transfusion safety.
Dev.Biol.(Basel), 120, 19-24.
World health Organization. (2007). Patient Identification. Patient Safety Solutions [On-line]. Available:
www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution2.pdf
31
Required
Organizational
Practices
COMMUNICATION
TWO CLIENT IDENTIFIERS

For teams using standards other than Managing Medications
The team uses at least two client identifiers before providing any service or procedure.
GUIDELINES
Failure to correctly identify clients may result in a range of adverse events such as medication errors, transfusion errors,
testing errors, wrong person procedures, and the discharge of infants to the wrong families. Client misidentification was
identified in more than 100 individual root cause analyses by the US Department of Veterans Affairs National Center for
Patient Safety from January 2000 to March 2003. The UK National Patient Safety Agency reported 236 incidents and near
misses related to missing wristbands or wristbands with incorrect information between 2003 and 2005. Evidence has shown
decreases in client identification errors when revised client identification systems are used.
The team uses means of identification that are appropriate to the type of services provided and population served. The
information obtained needs to be specific to the client, and examples include person-specific identification number such as
a registration number; client identification cards such as the health card with name, address, date of birth; client barcodes;
double witnessing; or a client wristband. Two client identifiers may be taken from a single source, such as the client wristband.
The clients room number is not to be used as a client identifier.
TEST FOR COMPLIANCE
Major The team uses at least two client identifiers before providing any service or procedure.
REFERENCE MATERIAL
Australian Commission on Safety and Quality in Health Care. (2008). Technology Solutions to Patient Misidentification: Report of Review.
Australian Commission on Safety and Quality in Health Care [On-line]. Available:
www.health.gov.au/internet/safety/publishing.nsf/Content/CE1F60BEAF285FF7CA2574E400219A9F/$File/19794-TechnologyReview.PDF
Jensen, N. J. & Crosson, J. T. (1996). An automated system for bedside verification of the match between patient identification and blood unit
identification. Transfusion, 36, 216-221.
Parisi, L. L. (2003). Patient identification: the foundation for a culture of patient safety. J.Nurs.Care Qual., 18, 73-79.
Sandler, S. G., Langeberg, A., & Dohnalek, L. (2005). Bar code technology improves positive patient identification and transfusion safety.
Dev.Biol.(Basel), 120, 19-24.
World health Organization. (2007). Patient Identification. Patient Safety Solutions [On-line]. Available:
32
Required
Organizational
Practices
COMMUNICATION
VERIFICATION PROCESSES FOR HIGH-RISK ACTIVITIES

The team implements verification processes and other checking systems for high-risk activities.
GUIDELINES
Processes and checking systems for high-risk care or service activities are important to client safety. To identify high-risk
activities the team reviews their services and uses this information to develop and implement checking systems to prevent and
reduce risk of harm to clients.
Across the care continuum, systems will vary depending on services. Examples may include but are not limited to:
Repeat back or read back processes for diagnostics or verbal orders
Checking systems for water temperature for client bathing
Standardized tracking sheets for clients with complex medication management needs
Automated alert systems for communication of critical test results
Computer-generated reminders for follow-up testing in high-risk patients
Two person verification process for blood transfusions
Critical interventions related to drug orders
Independent double checks for the dispensing/administration of high-risk medications
Medication bar coding systems for drug dispensing, labeling, and administration
Decision support software for order entry and/or drug interaction checking
Safety monitoring systems for service providers in community-based organizations, or for clients in high-risk
environments
Standardized protocols for the monitoring of fetal heart rate during medical induction/augmentation of labour, or in
high-risk deliveries
System for monitoring of vaccine fridge temperatures
Standardized protocols for the use of restraints
Standardized screening processes for allergies to contrast media
Major The team identifies high-risk activities.

Major The team develops and implements verification processes for high-risk activities.
Minor The team evaluates the verification processes and uses information to make improvements.
REFERENCE MATERIAL
Battles, J. B. & Lilford, R. J. (2003). Organizing patient safety research to identify risks and hazards. Qual.Saf Health Care, 12 Suppl 2, ii2-ii7.
Battles, J. B., Dixon, N. M., Borotkanics, R. J., Rabin-Fastmen, B., & Kaplan, H. S. (2006). Sensemaking of patient safety risks and hazards.
Health Serv.Res., 41, 1555-1575.
Easty, E., Moser, J., Trip, K., Hyland, S., Savage, P., Cafazzo, J. et al. (2008). Checking It Twice: Developing and Implementing an Effective
Method for Independent-Double Checking of High-Risk Clinical Procedures. Canadian Patient Safety Institute [On-line]. Available:
www.patientsafetyinstitute.ca/English/research/cpsiResearchCompetitions/2005/Documents/Easty/Reports/Easty%20Full%20Report.pdf
The Lewin Group (2008). Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Agency for Healthcare Research
and Quality [On-line]. Available: www.ahrq.gov/qual/hroadvice/hroadvice.pdf
33
Required
Organizational
Practices
MEDICATION USE
Ensure the safe use of high-risk medications
ANTIMICROBIAL STEWARDSHIP
The organization has a program for antimicrobial stewardship to optimize antimicrobial use.
note: This ROP only applies to organizations that provide acute care services.
GUIDELINES
Use of antimicrobial agents is an important health intervention, yet may result in unintended consequences including toxicity,
the selection of pathogenic organisms, and the development of organisms resistant to antimicrobial agents. Antibiotic resistant
organisms may have a substantial impact on the health and safety of clients, and the resources of health care system.
Antimicrobial stewardship is an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy.
The primary focus of an antimicrobial stewardship program is to optimize the use of antimicrobials to achieve the best patient
outcomes, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and promote patient safety.
Effective antimicrobial stewardship in combination with a comprehensive infection control program has been shown to limit the
emergence and transmission of antimicrobial-resistant bacteria. Studies also indicate that antimicrobial stewardship programs
are cost effective, and provide savings through reduced drug costs and avoidance of microbial resistance.
A comprehensive, evidence-based antimicrobial stewardship program may include a number of interventions based on local
antimicrobial use and available resources. Possible interventions include:
Prospective audit and feedback
Formulary of targeted antimicrobials and approved indications
Education
Guidelines and clinical pathways
Antimicrobial order forms
Streamlining or de-escalation of therapy
Dose optimization
Parenteral to oral conversion
Organizations are encouraged to tailor an approach to antimicrobial stewardship consistent with their size, service environment,
and patient population, and to establish processes for ongoing monitoring and improvement of the program over time.
A successful antimicrobial stewardship program requires an inter-disciplinary approach, with collaboration between
the antimicrobial stewardship team, pharmacy, and hospital infection control. The involvement and support of hospital
administrators, medical staff leadership, and health care providers is essential.
New in 2013
34
Required
Organizational
Practices
MEDICATION USE
Antimicrobial Stewardship (contd)

Major The organization implements an antimicrobial stewardship program.

Major The program includes lines of accountability for implementation.
Major The program is inter-disciplinary involving pharmacists, infectious diseases physicians, infection control specialists,
physicians, microbiology staff, nursing staff, hospital administrators, and information system specialists, as available
and appropriate.
Major The program includes interventions to optimize antimicrobial use that may include audit and feedback, a formulary
of targeted antimicrobials and approved indications, education, antimicrobial order forms, guidelines and clinical
pathways for antimicrobial utilization, strategies for streamlining or de-escalation of therapy, dose optimization, and
parenteral to oral conversion of antimicrobials (where appropriate).
Minor The organization establishes mechanisms to evaluate the program on an ongoing basis, and shares results with
stakeholders in the organization.
REFERENCE MATERIAL
Canadian Antibiotic Awareness Partnership (2012). Antibiotic Awareness - Health Care Providers. Canadian Antibiotic Awareness Partnership
[On-line]. Available: http://antibioticawareness.ca/?page_id=58
Centers for Disease Control and Prevention (2010). Get Smart for Healthcare - Evidence to Support Stewardship. Centers for Disease Control
and Prevention [On-line]. Available: http://www.cdc.gov/getsmart/healthcare/support-efforts/index.html
Coenen, S., Ferech, M., Haaijer-Ruskamp, F. M., Butler, C. C., Vander Stichele, R. H., Verheij, T. J. et al. (2007). European Surveillance of
Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe. Qual.Saf Health Care, 16, 440-445.
Dellit, T. H., Owens, R. C., McGowan, J. E., Jr., Gerding, D. N., Weinstein, R. A., Burke, J. P. et al. (2007). Infectious Diseases Society of America
and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.
Clin.Infect.Dis., 44, 159-177.
Joint Commission Resources (2009). What Every Health Care Executive Should Know - The Cost of Antibiotic Resistance. Joint Commission
Resources [On-line]. Available: http://www.jcrinc.com/MDRO-Toolkit/
Public Health Ontario (2012). Public Health Ontario - Antimicrobial Stewardship Program. Public Health Ontario [On-line]. Available:
http://www.oahpp.ca/services/antimicrobial-stewardship-program.html
New in 2013
35
Required
Organizational
Practices
MEDICATION USE
CONCENTRATED ELECTROLYTES
The organization removes concentrated electrolytes (including, but not limited to, potassium chloride,
potassium phosphate, sodium chloride >0.9%) from client service areas.
GUIDELINES
Concentrated electrolytes are high-risk medications and should not be stored in client service areas. Removal of concentrated
electrolyte solutions from client care units reduces risk of death or disabling injury associated with these agents.
Concentrated potassium chloride in particular has been identified as a high-risk medication. In Canada, 23 incidents involving
potassium chloride mis-administration occurred between 1993 and 1996. There are also reports of accidental death from the
inadvertent administration of concentrated saline solution.
The organization identifies concentrated electrolytes to be removed from client care areas, and ensures the policy is followed.
TEST FOR COMPLIANCE
Major There are no concentrated electrolytes stored in client service areas.

REFERENCE MATERIAL
Hyland, S. & U, D. (2002). Medication Safety Alerts. Institute for Safe Medication Practices Canada [On-line]. Available:
www.ismp-canada.org/download/cjhp/cjhp0209.pdf
Institute for Safe Medication Practices - Canada (2001). Reported Error With Sodium Chloride 3% Reminds Us Of The Need For Added System
Safeguards With This Product. ISMP Canada Safety Bulletin [On-line]. Available:
www.ismp-canada.org/download/safetyBulletins/ISMPCSB2001-11NaCl.pdf
Institute for Safe Medication Practices Canada. (2003). More on Potassium Chloride. ISMP Canada Safety Bulletin [On-line]. Available:
www.ismp-canada.org/download/safetyBulletins/ISMPCSB2003-11KCl.pdf
Institute for Safe Medication Practices Canada. (2004). Concentrated Potassium Chloride - A Recurring Danger. ISMP Canada Safety Bulletin
[On-line]. Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2004-03.pdf
Institute for Safe Medication Practices - Canada. (2006). Safety Strategies for Potassium Phosphates Injection. ISMP Canada Safety Bulletin [Online]. Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2006-02PotassiumPhosphates.pdf
World Health Organization. (2007). Control of Concentrated Electrolyte Solutions. World Health Organization [On-line]. Available:
36
Required
Organizational
Practices
MEDICATION USE
HEPARIN SAFETY
The organization evaluates and limits the availability of heparin products and has removed high-dose formats.
GUIDELINES
Heparin is identified as a high alert medication that is an area of focus for safety. More than 17,000 heparin-related medication
errors were reported to the U.S. Pharmacopoeia (USP) MEDMARX from 2003 to 2007; 556 of these resulted in harm to
clients, including seven deaths.
Implementation of safety recommendations and other measures can help to improve safety and heparin therapy.
Major The organization has completed an audit of unfractionated and low molecular weight heparin storage in the
pharmacy and in all patient care areas.
Major The audit includes a review of products and quantities stored; assessment of the intended use for each heparin
product stored (alignment with evidence-based guidelines); and identification of unnecessary products to be
removed.
Major The organization has removed high-dose formats of unfractionated heparin products (50,000 unit total drug
quantity) from patient care areas, ie. 10,000 units/mL in 5 mL vials and 25,000 units/mL in 2 mL vials.
Major The organization has reviewed and reduced, where possible, availability of the following unfractionated heparin
products in patient care areas, ie. 10,000 units/mL in 1 mL vials and 1,000 units/mL in 10 mL vials.
REFERENCE MATERIAL
Harder, K. A., Bloomfield, J. R., Sendelbach, S. E., Shepherd, M. F., Rush, P. S., Sinclair, J. S. et al. (2005). Improving the Safety of Heparin
Administration by Implementing a Human Factors Process Analysis.
Institute for Safe Medication Practices - Canada (2004). A Need to Flush Out High Concentration Heparin Products. ISMP Canada Safety
Bulletin [On-line]. Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2004-10.pdf
Institute for Safe Medication Practices - Canada (2005). Heparin Induced Thrombocytopenia - Effective Communication Can Prevent a Tragedy.
ISMP Canada Safety Bulletin [On-line]. Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005-03HIT.pdf
Institute for Safe Medication Practices Canada. (2008). Enhancing Safety with Unfractionated Heparin: A National and International Area of
Focus. ISMP Canada Safety Bulletin [On-line]. Available:
www.ismp-canada.org/download/safetyBulletins/ISMPCSB2008-05UnfractionatedHeparin.pdf
MacKinnon, N., Koczmara, C., & U, D. (2008). Medication Incidents Involving Heparin in Canada: Flushing Out the Problem. Institute for Safe
Medication Practices - Canada [On-line]. Available: www.ismp-canada.org/download/cjhp/cjhp0810.pdf
Schneider, P. (2008). Improving Heparin Safety. CareFusion Center for Safety and Clinical Excellence [On-line]. Available:
www.carefusion.com/pdf/Center_for_Safety/InvitedConferences/Improving%20Heparin%20Safety%20Proceedings.pdf
37
Required
Organizational
Practices
MEDICATION USE
INFUSION PUMPS TRAINING

The organization provides ongoing, effective training for service providers on all infusion pumps.
GUIDELINES
The more types of infusion pumps there are within an organization, the more chance there is for serious error. To minimize
risk staff and service providers receive ongoing, effective training on infusion pumps, covering client clinical needs, staff
competency, staff continuity, infusion pump technology, and the location of the pumps (e.g. hospital, community, home). This
training is particularly important given that many service providers often work at more than one health service organization,
meaning they need to be competent in using many different types of infusion pumps.
Organizations are also encouraged to standardize infusion pumps to the greatest possible extent.
TEST FOR COMPLIANCE
Major There is documented evidence of ongoing, effective training on infusion pumps.

REFERENCE MATERIAL
Bjorn, B., Garde, K., & Pedersen, B. L. (2007). [Infusion pumps and patient safety]. Ugeskr.Laeger, 169, 315-318.
Health Canada (2004). Health risks associated with use of INFUSION PUMPS - Notice to Hospitals. Health Canada [On-line]. Available:
www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2004/infusion_pumps_nth-ah-eng.php
Institute for Safe Medication Practices Canada. (2003). Infusion Pumps Opportunities for Improvement. ISMP Canada Safety Bulletin
[On-line]. Available: http://ismp-canada.org/download/safetyBulletins/ISMPCSB2003-07InfusionPumps.pdf
Institute for Safe Medication Practices Canada. (2004). Infusion Pump Project: Survey Results and Time for Action. ISMP Canada Safety
Bulletin [On-line]. Available: http://ismp-canada.org/download/safetyBulletins/ISMPCSB2004-01InfusionPump.pdf
Institute for Safe Medication Practices Canada. (2006). ALERT: Potential for Key Bounce with Infusion Pumps. ISMP Canada Safety Bulletin
[On-line]. Available: http://ismp-canada.org/download/safetyBulletins/ISMPCSB2006-06KeyBounce.pdf
Institute for Safe Medication Practices. (2009). Proceedings from the ISMP summit on the use of smart infusion pumps: guidelines for safe
implementation and use. Institute for Safe Medication Practices [On-line]. Available: www.ismp.org/tools/guidelines/smartpumps/printerversion.pdf
Lamsdale, A., Chisolm, S., Gagnon, R., Davies, J., & Caird, J. (2005). A Usability Evaluation of an Infusion Pump by Nurses Using a Patient
Simulator. Proceedings of the Human Factors and Ergonomics Society Annual Meeting [On-line]. Available:
https://fp.ucalgary.ca/cerl/files/cerl/Lamsdale%20et%20al.%20HFES%20.pdf
Scroggs, J. (2008). Improving patient safety using clinical needs assessments in IV therapy. Br.J.Nurs., 17, S22-S28.
38
Required
Organizational
Practices
MEDICATION USE
MEDICATION CONCENTRATIONS
The organization standardizes and limits the number of medication concentrations available.
GUIDELINES
Having multiple concentrations or strengths of the same medication available increases the risk that clinicians will select,
dispense, or administer the wrong concentration. Standardizing medication concentrations across the organization and limiting
strengths to as few as possible reduces chances for error.
TEST FOR COMPLIANCE
Major Medication concentrations are standardized and limited across the organization.
REFERENCE MATERIAL
Hennessy, S. C. (2007). Developing standard concentrations in the neonatal intensive care unit. Am.J.Health Syst.Pharm., 64, 28-30.
Institute for Safe Medication Practices. (2011). Standard Concentrations of Neonatal Drug Infusions. Institute for Safe Medication Practices [Online]. Available: www.ismp.org/tools/PediatricConcentrations.pdf
Institute for Safe Medication Practices Canada. (2012). Drug Shortages and Medication Safety Concerns. ISMP Canada Safety Bulletin [Online]. Available: http://ismp-canada.org/download/safetyBulletins/2012/ISMPCSB2012-03_Drug_Shortages.pdf
Irwin, D., Vaillancourt, R., Dalgleish, D., Thomas, M., Grenier, S., Wong, E. et al. (2008). Standard concentrations of high-alert drug infusions
across paediatric acute care. Paediatr.Child Health, 13, 371-376.
Larsen, G. Y., Parker, H. B., Cash, J., OConnell, M., & Grant, M. C. (2005). Standard drug concentrations and smart-pump technology reduce
continuous-medication-infusion errors in pediatric patients. Pediatrics, 116, e21-e25.
39
Required
Organizational
Practices
MEDICATION USE
NARCOTICS SAFETY
The organization evaluates and limits the availability of narcotic (opioid) products and removes high-dose,
high-potency formats from patient care areas.
GUIDELINES
Narcotics are identified as high alert medications that are an area of focus for safety. In 2002 and 2003, 416 medication
incidents involving narcotics were reported to ISMP Canada by hospitals that participated in a research project.
Limiting opiates and narcotics available in floor stock, as well as staff education and training about the potential confusion
between hydromorphone and morphine can reduce medication errors.
Major The organization has completed an audit of narcotic (opioid) storage areas. The audit includes a review of products
and quantities stored; and identification and removal of unnecessary products.
Major The organization has removed the following products (exceptions include palliative care): hydromorphone ampoules
or vials with concentration greater than 2 mg/ml; and morphine ampoules or vials with concentration greater than
15 mg/ml.
Major The organization standardizes and limits the number of parenteral narcotic (opioid) concentrations available.
REFERENCE MATERIAL
Canadian Association of Paediatric Health Centres. (2012). Paediatric Opioid Safety Resource Kit. Canadian Association of Paediatric Health
Centres [On-line]. Available: http://ken.caphc.org/xwiki/bin/view/PaediatricOpioidSafetyResourceKit/References+and+Recommended+Reading
Colquhoun, M., Koczmara, C., & Greenall, J. (2006). Implementing system safeguards to prevent error-induced injury with opioids (narcotics): an
ISMP Canada collaborative. Healthc.Q., 9 Spec No, 36-42.
Institute for Safe Medication Practices Canada. (2002). Narcotic Safeguards The Challenge Continues. ISMP Canada Safety Bulletin [On-line].
Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2002-02Narcotics.pdf
Institute for Safe Medication Practices Canada. (2003). Safeguard Against Errors with Long-Acting Oral Narcotics. ISMP Canada Safety Bulletin
[On-line]. Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2003-09Narcotics.pdf
Institute for Safe Medication Practices Canada. (2005). Narcotic (Opioid) Medication Safety Initiative. Institute for Safe Medication Practices Canada [On-line]. Available: www.ismp-canada.org/NarcInit.htm
Institute for Safe Medication Practices - Canada (2012). A National Collaborative: Advancing Medication Safety in Paediatrics. Institute for Safe
Medication Practices - Canada [On-line]. Available: www.ismp-canada.org/CurrentProjects/Paediatrics/
40
Required
Organizational
Practices
WORKLIFE/WORKFORCE
Create a worklife and physical environment that
supports the safe delivery of care and service
CLIENT SAFETY: EDUCATION AND TRAINING

The organization delivers client safety training and education at least annually to the organizations leaders,
staff, service providers, and volunteers, including education targeted to specific client safety focus areas.
GUIDELINES
Annual education on client safety is made available to the organizations leaders, staff, service providers, and volunteers, and
organizations identify specific client safety focus areas such as safe medication use, using the reporting system for adverse
events, human factors training, techniques for effective communication, equipment and facility sterilization, handwashing and
hand hygiene, and infection prevention and control.
TEST FOR COMPLIANCE
Major There is annual client safety training, tailored to staff needs and the organizations client safety focus areas.
REFERENCE MATERIAL
Haxby, E., Higton, P., & Jaggar, S. (2007). Patient safety training and education: who, what and how? Clin Risk 13, 211-215.
McKeon, L. M., Cunningham, P. D., & Oswaks, J. S. (2009). Improving patient safety: patient-focused, high-reliability team training. J.Nurs.Care
Qual., 24, 76-82.
World Health Organization. (2012). WHO Patient Safety Curriculum Guide. World Health Organization [On-line]. Available:
www.who.int/patientsafety/education/curriculum/en/index.html
Yassi, A. & Hancock, T. (2005). Patient safety--worker safety: building a culture of safety to improve healthcare worker and patient well-being.
Healthc.Q., 8 Spec No, 32-38.
41
Required
Organizational
Practices
WORKLIFE/WORKFORCE
CLIENT SAFETY PLAN

The organization develops and implements a client safety plan, and implements improvements to client safety
as required.
GUIDELINES
Client safety may be improved when organizations consider and develop a plan for addressing safety issues. Safety plans
consider the safety issues related to the organization, delivery of services, and needs of clients and families. The safety plan
includes a range of topics and approaches to addressing and evaluating safety issues. Safety plans may address mentoring
staff and service providers, the role of leadership (e.g. client safety leadership walkabouts), implementing organization-wide
client safety initiatives, accessing evidence and best practices, and recognizing staff and service providers for innovations to
improve client safety.
Minor The organization assesses client safety issues.

Minor There is a plan and process in place to address identified client safety issues.
REFERENCE MATERIAL
Botwinick L, Bisognano M, & Haraden C. (2006). Leadership Guide to Patient Safety. IHI Innovation Series White Paper [On-line]. Available:
www.ihi.org/knowledge/Knowledge%20Center%20Assets/IHIWhitePapers%20-%20LeadershipGuidetoPatientSafety_507359c3-7353-4b72-8a37e6a3c7f1e594/IHILeadershipGuidetoPtSafetyWhitePaper2006.pdf
Canadian Patient Safety Institute. (2012). Quality and Safety Plan. www.patientsafetyinstitute.ca [On-line]. Available:
www.patientsafetyinstitute.ca/english/toolsresources/governancepatientsafety/creatingexecutingpatientsafetyplan/pages/default.aspx
Zimmerman, R., Ip, I., Christoffersen, E., & Shaver, J. (2008). Developing a patient safety plan. Healthc.Q., 11, 26-30.
42
Required
Organizational
Practices
WORKLIFE/WORKFORCE
CLIENT SAFETY: ROLES AND RESPONSIBILITIES

The organization defines the roles, responsibilities, and accountabilities of the organizations leaders, staff,
service providers, and volunteers for client care and safety.
GUIDELINES
The organizations leaders, staff, service providers, and volunteers play important roles in client safety. System errors that are
a result of multiple breakdowns in processes and communication often contribute to adverse events.
Roles and responsibilities for client safety may be defined in position profiles, performance appraisals, handbooks, and
orientation material. In addition, client safety can be addressed on a regular basis in newsletters and client safety committee
minutes.
Minor Attention to client safety is demonstrated by defining roles and responsibilities for client safety.
Major The organizations leaders, staff, service providers, and volunteers can articulate how they contribute to client
safety.
Minor Policies and procedures outline behaviours to promote client safety.
REFERENCE MATERIAL
Baker R, Denis JL, Pomey MP, & MacIntosh-Murray. (2010). Effective Governance for Quality and Patient Safety in Canadian Organizations.
www.chsrf.ca [On-line]. Available: www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/11505_Baker_rpt_FINAL.pdf
Goeschel, C. A., Wachter, R. M., & Pronovost, P. J. (2010). Responsibility for quality improvement and patient safety: hospital board and medical
staff leadership challenges. Chest, 138, 171-178.
Ontario Hospital Association. (2012). Quality and Patient Safety Governance Toolkit. www.oha.com [On-line]. Available:
www.oha.com/Leadership/GCE/QPSGT/Pages/Default.aspx
Pan-Canadian Planning Committee on Unregulated Health Care Workers (2009). Maximizing Health Human Resources: Valuing Unregulated
Health Workers. http://www.cna-aiic.ca/ [On-line]. Available: www2.cna-aiic.ca/CNA/documents/pdf/publications/UHW_Final_Report_e.pdf
Report for Methods and Measures Working Group of WHO Patient Safety. (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
43
Required
Organizational
Practices
WORKLIFE/WORKFORCE
PREVENTIVE MAINTENANCE PROGRAM

The organizations leaders implement an effective preventive maintenance program for medical devices,
medical equipment, and medical technology.
GUIDELINES
An effective preventive maintenance program helps the organization ensure medical devices, medical equipment, and medical
technology are safe and functional. It also helps identify and address potential problems with medical devices, medical
equipment, or medical technology that may result in injury to staff or clients.
Major There is a preventive maintenance program in place for all medical devices, medical equipment, and medical
technology.
Major There are documented preventive maintenance reports.
Minor The organizations leaders have a process to evaluate the effectiveness of the preventive maintenance program.
Major There is documented follow-up related to investigating incidents and problems involving medical devices,
equipment, and technology.
REFERENCE MATERIAL
Brewin, D. (2001). Effectively utilizing device maintenance data to optimize a medical device maintenance program. Biomed
Instrum Technol. 35(6):383-90.
Ridgway, M. (2001). Classifying medical devices according to their maintenance sensitivity: a practical, risk-based approach
to PM program management. Biomed.Instrum.Technol., 35, 167-176.
Taghipour, S., Banjevic, D., & Jardine, A. (2010). Prioritization of medical equipment for maintenance decisions. Journal of the
Operational Research Society, 1-22.
44
Required
Organizational
Practices
WORKLIFE/WORKFORCE
WORKPLACE VIOLENCE PREVENTION

The organization implements a comprehensive strategy to prevent workplace violence.
GUIDELINES
Workplace violence is very common in health care settings, more so than in many other workplaces. One-quarter of all
incidents of workplace violence occur at health services organizations. Furthermore, workplace violence is an issue that affects
staff and health providers across the health care continuum.
Accreditation Canada has adopted the modified International Labour Organization definition of workplace violence as:
Incidents in which a person is threatened, abused or assaulted in circumstances related to their work, including all forms of
harassment, bullying, intimidation, physical threats, or assaults, robbery or other intrusive behaviours. These behaviours could
originate from customers or co-workers, at any level of the organization.
The Registered Nurses Association of Ontario describes four classifications of workplace violence:
type I (Criminal Intent): Perpetrator has no relationship to the workplace.
type II (Client or Customer): Perpetrator is a client, visitor, or family member of a client at the workplace becomes violent
toward a worker or another client.
type III (Worker-to-worker): Perpetrator is an employee or past employee of the workplace.
type IV (Personal Relationship): Perpetrator has a relationship with an employee (e.g. domestic violence in the workplace).
A strategy to prevent workplace violence should be in compliance with applicable provincial or territorial legislation, and is an
important step to respond to the growing concern about violence in health care workplaces.
Major
Major
Major
Major
Minor
The organization has a written workplace violence prevention policy.

The policy is developed in consultation with staff, service providers, and volunteers (as appropriate).
The policy names the individual(s) responsible for implementing and monitoring the policy.
The organization conducts risk assessments to ascertain the risk of workplace violence.
There is a documented process in place for staff and service providers to confidentially report incidents of
workplace violence.
Major There is a documented process in place for the organizations leaders to investigate and respond to incidents of
workplace violence.
Minor The organizations leaders review quarterly reports of incidents of workplace violence and use this information to
improve safety, reduce incidents of violence, and make improvements to the workplace violence prevention policy.
Minor The organization provides information and training to staff on the prevention of workplace violence.
Contd on next page...)
45
Required
Organizational
Practices
WORKLIFE/WORKFORCE
Workplace Violence Prevention (contd)

REFERENCE MATERIAL
Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2010). Violence against nurses working in US emergency
departments. J.Healthc.Prot.Manage., 26, 81-99.
Gates, D., Fitzwater, E., & Succop, P. (2005). Reducing assaults against nursing home caregivers. Nurs.Res., 54, 119-127.
International Labour Office, International Council of Nurses, World Health Organization, & Public Services International. (2002). Framework
guidelines for addressing workplace violence in the health sector. World Health Organization [On-line]. Available:
www.who.int/violence_injury_prevention/violence/interpersonal/en/WVguidelinesEN.pdf
Kling, R. N., Yassi, A., Smailes, E., Lovato, C. Y., & Koehoorn, M. (2009). Characterizing violence in health care in British Columbia. J.Adv.Nurs.,
65, 1655-1663.
Nursing Health Services Research Unit (2008). A review and evaluation of workplace violence prevention programs in the health sector. Nursing
Health Services Research Unit [On-line]. Available:
www.nhsru.com/wp-content/uploads/2010/11/NHSRU-U-of-T-Site-EVPP-Study-Final-Report-July-081.pdf
Peek-Asa, C., Casteel, C., Allareddy, V., Nocera, M., Goldmacher, S., Ohagan, E. et al. (2009). Workplace violence prevention programs in
psychiatric units and facilities. Arch.Psychiatr.Nurs., 23, 166-176.
Registered Nurses Association of Ontario. (2009). Preventing and Managing Violence in the Workplace. Registered Nurses Association of Ontario
[On-line]. Available: www.rnao.org/Page.asp?PageID=122&ContentID=2972
Worksafe BC (2000). Preventing violence in health care: Five steps to an effective program. Worksafe BC [On-line]. Available:
www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/violhealthcare.pdf
46
Required
Organizational
Practices
INFECTION CONTROL
Reduce the risk of health care-associated infections
and their impact across the continuum of care/service
HAND-HYGIENE AUDIT
The organization evaluates its compliance with accepted hand-hygiene practices.
GUIDELINES
Hand hygiene is considered the single most important way to reduce nosocomial infections, but compliance with hand hygiene
protocols is often poor.
Hand hygiene audits allow organizations to monitor compliance with hand hygiene protocols, improve education and training
on hand hygiene, evaluate hand hygiene facilities, and benchmark compliance practices across the organization. Studies have
shown that improvements in compliance with hand-hygiene practices has decreased the number of health-care associated
infections.
Major The organization audits its compliance with hand hygiene practices.
Minor The organization shares results from the audits with staff, service providers, and volunteers.
Minor The organization uses the results of the audits to make improvements to its hand hygiene practices.
REFERENCE MATERIAL
Bryce, E. A., Scharf, S., Walker, M., & Walsh, A. (2007). The infection control audit: the standardized audit as a tool for change. Am.J.Infect.
Control, 35, 271-283.
Canadas Hand Hygiene Challenge. (2012). Hand Hygiene Toolkit. Canadas Hand Hygiene Challenge [On-line]. Available:
www.handhygiene.ca/English/Tools/Pages/Hand-Hygiene-Toolkit.aspx
Eveillard, M., Hitoto, H., Raymond, F., Kouatchet, A., Dube, L., Guilloteau, V. et al. (2009). Measurement and interpretation of hand hygiene
compliance rates: importance of monitoring entire care episodes. J.Hosp.Infect., 72, 211-217.
Gould, D. J., Moralejo, D., Drey, N., & Chudleigh, J. H. (2010). Interventions to improve hand hygiene compliance in patient care. Cochrane.
Database.Syst.Rev., CD005186.
Howard, D. P., Williams, C., Sen, S., Shah, A., Daurka, J., Bird, R. et al. (2009). A simple effective clean practice protocol significantly improves
hand decontamination and infection control measures in the acute surgical setting. Infection, 37, 34-38.
Lederer, J. W., Jr., Best, D., & Hendrix, V. (2009). A comprehensive hand hygiene approach to reducing MRSA health care-associated infections.
Jt.Comm J.Qual.Patient Saf, 35, 180-185.
The Joint Commission. (2009). Measuring Hand Hygiene Adherence: Overcoming the Challenges.
47
Required
Organizational
Practices
INFECTION CONTROL
HAND-HYGIENE EDUCATION AND TRAINING

The organization delivers hand-hygiene education and training for staff, service providers, and volunteers.
GUIDELINES
Hand hygiene is a critical element of an adequate infection control program in health care settings. However, adherence to
proper hand-hygiene protocols is often poor. Cost estimates of health care-associated infections significantly exceed those
related to hand hygiene. For example, the cost of hand-hygiene promotion corresponded to less than 1 percent of the costs
associated with nosocomial infections.
Training on hand hygiene is multimodal and addresses the importance of hand hygiene in preventing the spread of infections,
factors that have been found to influence hand-hygiene behaviour, and proper hand-hygiene techniques. Training also
includes recommendations on when to clean ones hands, such as before and after each direct contact with a client.
Major Education and training on hand hygiene and the hand-hygiene protocol is delivered.
Major Staff, service providers, and volunteers understand how to apply the hand hygiene protocol.
REFERENCE MATERIAL
Canadas Hand Hygiene Challenge (2012). Resource Links to Hand Hygiene Resources Worldwide. Canadas Hand Hygiene Challenge [On-line].
Available: www.handhygiene.ca/English/Resources/Pages/Resources-Links.aspx
Community and Hospital Infection Control Association - Canada. (2012). Information About Hand Hygiene. Community and Hospital Infection
Control Association - Canada [On-line]. Available: www.chica.org/links_handhygiene.php
Hilburn, J., Hammond, B. S., Fendler, E. J., & Groziak, P. A. (2003). Use of alcohol hand sanitizer as an infection control strategy in an acute care
facility. Am.J.Infect.Control, 31, 109-116.
Huber, M. A., Holton, R. H., & Terezhalmy, G. T. (2006). Cost analysis of hand hygiene using antimicrobial soap and water versus an alcoholbased hand rub. J.Contemp.Dent.Pract., 7, 37-45.
Institute for Healthcare Improvement (2006). How to Guide: Improving Hand Hygiene. Institute for Healthcare Improvement [On-line].
Pittet, D., Sax, H., Hugonnet, S., & Harbarth, S. (2004). Cost implications of successful hand hygiene promotion. Infect.Control Hosp.Epidemiol.,
25, 264-266.
Stone, P. W., Hasan, S., Quiros, D., & Larson, E. L. (2007). Effect of guideline implementation on costs of hand hygiene. Nurs.Econ., 25, 279-284.
World Health Organization. (2009). WHO Guidelines on Hand Hygiene in Health Care. World Health Organization [On-line]. Available:
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
48
Required
Organizational
Practices
INFECTION CONTROL
INFECTION CONTROL GUIDELINES

The organization adheres to international, federal, and provincial or territorial infection control guidelines.
GUIDELINES
Developing and implementing comprehensive infection prevention and control guidelines reduces risks of health careassociated infections and contributes to client safety.
TEST FOR COMPLIANCE
Major The organization is aware of and follows evidence-based international, federal, and provincial or territorial infection
control guidelines.
REFERENCE MATERIAL
Barbut, F., Jones, G., & Eckert, C. (2011). Epidemiology and control of Clostridium difficile infections in healthcare settings: an update. Curr.Opin.
Infect.Dis., 24, 370-376.
Community and Hospital Infection Control Association - Canada. (2012). Evidence-Based Guidelines. Community and Hospital Infection Control
Association - Canada [On-line]. Available: www.chica.org/links_evidence_guidelines.php
Gurses, A. P., Seidl, K. L., Vaidya, V., Bochicchio, G., Harris, A. D., Hebden, J. et al. (2008). Systems ambiguity and guideline compliance: a
qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual.Saf Health Care,
17, 351-359.
Nicolle, L. E. (2000). Infection control in long-term care facilities. Clin Infect.Dis., 31, 752-756.
Ploeg, J., Davies, B., Edwards, N., Gifford, W., & Miller, P. E. (2007). Factors influencing best-practice guideline implementation: lessons learned
from administrators, nursing staff, and project leaders. Worldviews.Evid.Based.Nurs., 4, 210-219.
Public Health Agency of Canada. (2007). Infection Prevention and Control Best Practices for Long Term Care, Home and Community Care
including Health Care Offices and Ambulatory Clinics . Public Health Agency of Canada [On-line]. Available:
www.phac-aspc.gc.ca/amr-ram/ipcbp-pepci/index-eng.php
Public Health Agency of Canada. (2012). About the Nosocomial Infection Control Guideline Program. Public Health Agency of Canada [On-line].
Available: www.phac-aspc.gc.ca/nois-sinp/guide/index-eng.php
Smith, P. W., Bennett, G., Bradley, S., Drinka, P., Lautenbach, E., Marx, J. et al. (2008). SHEA/APIC Guideline: Infection prevention and control in
the long-term care facility. Am.J.Infect.Control, 36, 504-535.
49
Required
Organizational
Practices
INFECTION CONTROL
INFECTION RATES
The organization tracks infection rates; analyzes the information to identify clusters, outbreaks, and trends;
and shares this information throughout the organization.
GUIDELINES
Tracking methods may focus on a particular disease or service area, or may be organization- or system-wide. They may
include virtual surveillance and data analysis techniques to help detect previously unrecognized outbreaks.
The organization identifies the infections and infectious agents most common to its services and client populations; this may
include C. difficile, surgical site infections, influenza A, Norwalk, and urinary tract infections. The organization tracks these
as well as other reportable diseases and antibiotic resistant organisms. The information tracked includes frequencies and
changes in frequencies over time, associated mortality rates, and attributed costs.
Staff who are well informed about infection rates are usually better equipped to prevent and manage infections. The
organization identifies who is responsible for receiving information about infections and diseases, e.g. the governing body,
senior management, staff, and service providers, and establishes plans to disseminate information appropriately and in a
regular and timely way, e.g. quarterly reports to all departments.
In addition to staff and service providers, the organization also keeps the governing body up-to-date about infection rates
and associated infection prevention and control issues. This may be done directly through senior management, or through a
Medical Advisory Committee.
Major
Minor
Minor
Minor
The organization tracks infection rates.

The organization analyzes outbreaks and makes recommendations to prevent recurrences.
Staff and service providers are aware of the infection rates and recommendations from outbreak reviews.
The organization provides quarterly updates on infection rates.
REFERENCE MATERIAL
Community and Hospital Infection Control Association - Canada. (2012). Surveillance and Statistics. Community and Hospital Infection Control
Association - Canada [On-line]. Available: www.chica.org/links_surveillance.php
Humphreys, H. & Cunney, R. (2008). Performance indicators and the public reporting of healthcare-associated infection rates. Clin Microbiol.
Infect., 14, 892-894.
Jarvis, W. R. (2003). Benchmarking for prevention: the Centers for Disease Control and Preventions National Nosocomial Infections Surveillance
(NNIS) system experience. Infection, 31 Suppl 2, 44-48.
ONeill, E. & Humphreys, H. (2009). Use of surveillance data for prevention of healthcare-associated infection: risk adjustment and reporting
dilemmas. Curr.Opin.Infect.Dis., 22, 359-363.
Public Health Agency of Canada. (2012). The Canadian Nosocomial Infection Surveillance Program. Public Health Agency of Canada [On-line].
Available: www.phac-aspc.gc.ca/nois-sinp/projects/index-eng.php
50
Required
Organizational
Practices
INFECTION CONTROL
INFLUENZA VACCINE
The organization develops and implements a policy and procedure for administration of the influenza vaccine.
GUIDELINES
Vaccination is a low cost and effective method of preventing illness. Evidence shows that an intervention to improve the
assessment and delivery of influenza vaccination to healthcare staff, service providers, and clients would improve clinical
outcomes in addition to realizing cost savings for the health system.
Major The organization has a policy and procedure for the administration of the influenza vaccine.
Major The policy and procedure includes identifying populations at increased risk of complications associated with
influenza.
Major The policy and procedure includes vaccinating staff and service providers against influenza.
REFERENCE MATERIAL
Anikeeva, O., Braunack-Mayer, A., & Rogers, W. (2009). Requiring influenza vaccination for health care workers. Am.J.Public Health, 99, 24-29.
Burls, A., Jordan, R., Barton, P., Olowokure, B., Wake, B., Albon, E. et al. (2006). Vaccinating healthcare workers against influenza to protect the
vulnerable--is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine, 24, 4212-4221.
Canadian Healthcare Influenza Immunization Network. (2012). Immunization. Canadian Healthcare Influenza Immunization Network [On-line].
Available: www.chiin.ca/immunization.html
Kimura, A. C., Nguyen, C. N., Higa, J. I., Hurwitz, E. L., & Vugia, D. J. (2007). The effectiveness of vaccine day and educational interventions on
influenza vaccine coverage among health care workers at long-term care facilities. Am.J.Public Health, 97, 684-690.
Kwong, J. C., Stukel, T. A., Lim, J., McGeer, A. J., Upshur, R. E., Johansen, H. et al. (2008). The effect of universal influenza immunization on
mortality and health care use. PLoS.Med., 5, e211.
Nichol, K. L., DHeilly, S. J., Greenberg, M. E., & Ehlinger, E. (2009). Burden of influenza-like illness and effectiveness of influenza vaccination
among working adults aged 50-64 years. Clin Infect.Dis., 48, 292-298.
Polgreen, P. M., Polgreen, L. A., Evans, T., & Helms, C. (2009). A statewide system for improving influenza vaccination rates in hospital
employees. Infect.Control Hosp.Epidemiol., 30, 474-478.
Public Health Agency of Canada. (2012). Guidance: Infection Prevention and Control Measures for Healthcare Workers in Acute Care and
Long-term Care Settings. Public Health Agency of Canada [On-line]. Available: www.phac-aspc.gc.ca/nois-sinp/guide/ac-sa-eng.php
51
Required
Organizational
Practices
INFECTION CONTROL
PNEUMOCOCCAL VACCINE
The organization develops and implements a policy and procedure for administration of the pneumococcal
vaccine.
GUIDELINES
Populations at risk of complications from pneumococcal disease may include clients and staff.
Evidence shows that immunizing high-risk clients can improve morbidity and mortality rates, and reduce costs for the
healthcare system.
Major The organization has a policy and protocol to administer the pneumococcal vaccine.
Major The policy and protocol includes identifying populations at risk of complications from pneumococcal disease.
REFERENCE MATERIAL
Bardenheier, B. H., Shefer, A., McKibben, L., Roberts, H., Rhew, D., & Bratzler, D. (2005). Factors predictive of increased influenza and
pneumococcal vaccination coverage in long-term care facilities: the CMS-CDC standing orders program Project. J.Am.Med.Dir.Assoc., 6, 291299.
Honeycutt, A. A., Coleman, M. S., Anderson, W. L., & Wirth, K. E. (2007). Cost-effectiveness of hospital vaccination programs in North Carolina.
Vaccine, 25, 1484-1496.
Public Health Agency of Canada. (2006). Canadian Immunization Guide 2006 - Pneumococcal Vaccine. Public Health Agency of Canada [Online]. Available: www.phac-aspc.gc.ca/publicat/cig-gci/p04-pneu-eng.php
Stevenson, C. G., McArthur, M. A., Naus, M., Abraham, E., & McGeer, A. J. (2001). Prevention of influenza and pneumococcal pneumonia in
Canadian long-term care facilities: how are we doing? CMAJ., 164, 1413-1419.
52
Required
Organizational
Practices
INFECTION CONTROL
STERILIZATION PROCESSES
The organization monitors its processes for reprocessing equipment, and makes improvements as
appropriate.
GUIDELINES
Monitoring the sterilization cycle helps organizations identify areas for improvement and reduce nosocomial infections.
Organizations reprocess equipment according to manufacturers instructions. If the organization does not reprocess
equipment, it has a process to ensure equipment has been appropriately reprocessed prior to use.
Major There is evidence that reprocessing processes and systems are effective.
Minor Action has been taken to examine and improve reprocessing processes where indicated.
REFERENCE MATERIAL
BC Ministry of Health. (2007). Best Practice Guidelines for the Cleaning, Disinfection and Sterilization of Medical Devices in Health Authorities.
BC Ministry of Health [On-line]. Available:
www.health.gov.bc.ca/library/publications/year/2007/BPGuidelines_Cleaning_Disinfection_Sterilization_MedicalDevices.pdf
Provincial Infectious Diseases Advisory Committee. (2010). Best Practices For Cleaning, Disinfection and Sterilization of Medical Equipment/
Devices. Ontario Agency for Health Protection and Promotion [On-line]. Available:
www.oahpp.ca/resources/documents/pidac/2010-02%20BP%20Cleaning%20Disinfection%20Sterilization.pdf
Rutala, W. A. & Weber, D. J. (2011). Sterilization, high-level disinfection, and environmental cleaning. Infect.Dis.Clin North Am., 25, 45-76.
Rutala, W., Weber, D. J., & Healthcare Infection Control Practices Advisory Committee. (2008). Guideline for Disinfection and Sterilization in
Healthcare Facilities. Centre for Disease Control [On-line]. Available: www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
53
Required
Organizational
Practices
RISK ASSESSMENT
Identify safety risks inherent in the client population
FALLS PREVENTION STRATEGY

The team implements and evaluates a falls prevention strategy to minimize client injury from falls.
GUIDELINES
Falls may lead to client injury, increased health care costs, and possibly claims of clinical negligence.
Falls prevention programs may include but are not limited to staff training, risk assessments, balance and strength training,
vision care, medication reviews, physical environment reviews, behavioural assessments, and bed exit alarms. Possible
measures to evaluate a falls prevention strategy may include tracking the percentage of clients receiving a risk assessment,
falls rates, causes of injury, and balancing measures such as restraint use. Conducting post-fall debriefings may also assist to
identify safety gaps, and to prevent the recurrence of falls..
In Canada, Safer Healthcare Now! has identified falls prevention as a safety priority. Reducing falls and fall injuries can
increase quality of life for clients and reduce costs associated with serious injury from falls.
Major
Major
Major
Minor
Minor
The team implements a falls prevention strategy.

The strategy identifies the populations at risk for falls.
The strategy addresses the specific needs of the populations at risk for falls.
The team establishes measures to evaluate the falls prevention strategy on an ongoing basis.
The team uses the evaluation information to make improvements to its falls prevention strategy.
REFERENCE MATERIAL
BC Injury Research and Prevention Unit. (2011). Falls and Related Injuries in Residential Care: A Framework and Toolkit for Prevention. BC Injury
Research and Prevention Unit [On-line]. Available:
www.injuryresearch.bc.ca/admin/DocUpload/3_20110811_100931Residential%20Care%20Framework_Aug%2010_2011.pdf
BC Injury Research and Prevention Unit. (2012). Falls Prevention. BC Injury Research and Prevention Unit [On-line]. Available:
www.injuryresearch.bc.ca/categorypages.aspx?catid=1&subcatid=7
Beard, J., Rowell, D., Scott, D., van, B. E., Barnett, L., Hughes, K. et al. (2006). Economic analysis of a community-based falls prevention
program. Public Health, 120, 742-751.
Cusimano, M. D., Kwok, J., & Spadafora, K. (2008). Effectiveness of multifaceted fall-prevention programs for the elderly in residential care.
Inj.Prev., 14, 113-122.
Local Health Integration Network Collaborative. (2011). Integrated Provincial Falls Prevention Framework & Toolkit. Local Health Integration
Network Collaborative [On-line]. Available: www.alphaweb.org/docs/lib_014321248.pdf
Oliver, D., Killick, S., Even, T., & Willmott, M. (2008). Do falls and falls-injuries in hospital indicate negligent care -- and how big is the risk? A
retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to
2006. Qual.Saf Health Care, 17, 431-436.
Safer Healthcare Now! (2010). Reducing Falls and Injury from Falls. Safer Healthcare Now! [On-line]. Available:
www.saferhealthcarenow.ca/en/interventions/falls/pages/default.aspx
54
Required
Organizational
Practices
RISK ASSESSMENT
HOME SAFETY RISK ASSESSMENT

The team conducts a safety risk assessment for clients receiving services in the home.
GUIDELINES
Health services provided in a clients home present unique considerations for clients, families, and health care staff. The home
health environment differs in a number of ways from facility-based health services including the unique characteristics of each
clients home, the intermittent presence of health care staff, and the larger role played by families or caregivers in providing
health services.
Home care agencies may have little direct control over risks in a clients home environment; however, the safety of clients,
families, and staff involved in home health services is enhanced when a risk assessment is conducted. Results from a home
safety risk assessment can be used to select priority service areas, and can help identify safety strategies to include in service
plans, and to communicate to clients, families, and partner organizations.
Major The team conducts a safety risk assessment for each client at the beginning of service.
Major The safety risk assessment includes a review of: internal and external physical environments; chemical, biological,
fire and falls hazards; medical conditions requiring special precautions; client risk factors; and emergency
preparedness.
Major The team uses information from the safety risk assessment when planning and delivering client services, and
shares this information with partners who may be involved in planning of care.
Minor The team regularly updates the safety risk assessment and uses the information to make improvements to the
clients health services.
Minor The team educates clients and families on home safety issues identified in the risk assessment.
REFERENCE MATERIAL
Doran, D. M., Hirdes, J., Blais, R., Ross, B. G., Pickard, J., & Jantzi, M. (2009). The nature of safety problems among
Canadian homecare clients: evidence from the RAI-HC reporting system. J.Nurs.Manag., 17, 165-174.
Lang, A., Edwards, N., & Fleiszer, A. (2008). Safety in home care: a broadened perspective of patient safety. Int.J.Qual.Health
Care, 20, 130-135.
55
Required
Organizational
Practices
RISK ASSESSMENT
PRESSURE ULCER PREVENTION
The team assesses each residents risk for developing a pressure ulcer and implements interventions to
prevent pressure ulcer development.
GUIDELINES
Pressure ulcers have a significant impact on resident quality of life, resulting in pain, hindered recovery, and increase risk
of infection. Pressure ulcers have also been associated with increased length of stay, health services costs, and mortality.
Effective pressure ulcer prevention strategies can substantially reduce the incidence of pressure ulcers, and are an indication
of higher quality care and services.
Pressure ulcer prevention strategies require an inter-disciplinary approach, as well as support from all levels of an
organization. Organizations may wish to develop a plan to support comprehensive education on pressure ulcer prevention, and
may designate individuals to facilitate the implementation of a standardized approach to risk assessments, the uptake of best
practice guidelines, and the coordination of health care teams.
As part of an organizations pressure ulcer prevention strategy, Accreditation Canada strongly encourages the use of a
validated risk assessment scale. A number of validated risk assessment scales are publicly available including:
The Braden Scale for Predicting Pressure Sore Risk
The Norton Pressure Sore Risk Assessment Scale
InterRAI Pressure Ulcer Risk Scale (long term care)
The Waterlow Score
The Gosnell Scale
The Knoll Scale
A number of best practice guidelines are also available to inform the development of pressure ulcer prevention and treatment
strategies, including risk assessments, reassessments, interventions, education, and evaluation. In Canada, comprehensive
guidelines have been developed by the Registered Nurses Association of Ontario. International guidelines have also been
developed in collaboration between the European Pressure Ulcer Advisory Panel and the American National Pressure Ulcer
Advisory Panel.
56
Required
Organizational
Practices
RISK ASSESSMENT
Pressure ulcer prevention (contd)

Major The team conducts an initial pressure ulcer risk assessment at admission, using a validated, standardized risk
assessment tool.
Long Term Care Services teams currently not using a validated risk assessment tool will be expected to adopt a
validated, standardized risk assessment tool by January 2013.
Major The team reassesses each resident for risk of developing pressure ulcers at regular intervals, and with significant
change in resident status.
Major The team implements documented protocols and procedures based on best practice guidelines to prevent the
development of pressure ulcers, which may include interventions to: prevent skin breakdown; minimize pressure,
shear, and friction; reposition; manage moisture; optimize nutrition and hydration; and enhance mobility and activity.
Minor The team supports education for health care providers, residents, and families or caregivers on the risk factors and
strategies for the prevention of pressure ulcers.
Minor The team has a system in place to measure the effectiveness of pressure ulcer prevention strategies, and uses
results to make improvements.
REFERENCE MATERIAL
European Pressure Ulcer Advisory Panel and the American National Pressure Ulcer Advisory Panel. (2009). Pressure Ulcer
Prevention. National Pressure Ulcer Advisory Panel [On-line]. Available:
www.npuap.org/Final_Quick_Prevention_for_web_2010.pdf
Institute for Healthcare Improvement. (2012). Prevent Pressure Ulcers. Institute for Healthcare Improvement [On-line].
Available: www.ihi.org/explore/pressureulcers/pages/default.aspx
Registered Nurses Association of Ontario. (2005). Risk Assessment & Prevention of Pressure Ulcers. Registered Nurses
Association of Ontario [On-line]. Available: www.rnao.org/Storage/12/638_BPG_Pressure_Ulcers_v2.pdf
Royal College of Nursing. (2001). Pressure ulcer risk assessment and prevention. Royal College of Nursing [On-line].
Available: www.rcn.org.uk/__data/assets/pdf_file/0003/78501/001252.pdf
Saskatchewan Health Quality Council. (2006). Saskatchewan Skin and Woundcare Guidelines. Saskatchewan Health Quality Council
[On-line]. Available: www.hqc.sk.ca/download.jsp?13VdwtPxeShLfYSWZpG40zBIzBf0QfLQkUwK4QBZaJs9tGrKEruxgA==
Woodbury, M. G. & Houghton, P. E. (2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy.Wound.
Manage., 50, 22-28.
57
Required
Organizational
Practices
RISK ASSESSMENT
SUICIDE PREVENTION
The organization assesses and monitors clients for risk of suicide.
GUIDELINES
Suicide is a global health concern. In 2006, the Public Health Agency of Canada reported that suicide accounted for 1.7
percent of all deaths in Canada. Risk assessment can help prevent suicide through early recognition of the signs of suicidal
thinking and appropriate intervention.
Major
Major
Major
Major
Major
The organization assesses each client for risk of suicide at regular intervals, or as needs change.
The organization identifies clients at risk of suicide.
The organization addresses the immediate safety needs of clients who are identified as being at risk of suicide.
The organization identifies treatment and monitoring strategies to ensure client safety.
The organization documents the implementation of the treatment and monitoring strategies in the clients health
record.
REFERENCE MATERIAL
Health Canada. (2009). Suicide Prevention. Health Canada [On-line]. Available: www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/suicide-eng.php
Lynch, M. A., Howard, P. B., El-Mallakh, P., & Matthews, J. M. (2008). Assessment and management of hospitalized suicidal patients.
J.Psychosoc.Nurs.Ment.Health Serv., 46, 45-52.
Ontario Hospital Association. (2012). Suicide Risk Assessment Guide. Ontario Hospital Association [On-line]. Available:
www.oha.com/KnowledgeCentre/Documents/Final%20-%20Suicide%20Risk%20Assessment%20Guidebook.pdf
Steele, M. M. & Doey, T. (2007). Suicidal behaviour in children and adolescents. Part 2: treatment and prevention. Can.J.Psychiatry, 52, 35S-45S.
World Health Organization. (2012). Preventing Suicide: A Resource Series. World Health Organization [On-line]. Available:
www.who.int/mental_health/resources/preventingsuicide/en/index.html
58
Required
Organizational
Practices
RISK ASSESSMENT
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS

The team identifies medical and surgical clients at risk of venous thromboembolism (deep vein thrombosis
and pulmonary embolism) and provides appropriate thromboprophylaxis.
GUIDELINES
Venous thromboembolism (VTE) is the collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE is a
serious and common complication for clients in hospital or undergoing surgery. Evidence shows that incidence of VTE can be
substantially reduced or prevented by identifying clients at risk and providing appropriate, evidence-based thromboprophylaxis
interventions. Currently, the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition)
are the generally accepted standard of practice for the prevention of VTE.
The widespread human and financial impact of thromboembolism is well documented. Development of VTE is associated with
increased patient mortality, and is the most common preventable cause of hospital death. In addition, both hospital costs and
median length of stay are greatly increased for patients developing VTE.
NOTE: This ROP is not a requirement for pediatric hospitals. The ROP applies to clients 18 years of age or older.
Major The organization has a written thromboprophylaxis policy or guideline.

Major The team identifies clients at risk for venous thromboembolism (VTE), [(deep vein thrombosis (DVT) and
pulmonary embolism (PE)] and provides appropriate evidence-based, VTE prophylaxis.
Minor The team establishes measures for appropriate thromboprophylaxis, audits implementation of appropriate
thromboprophylaxis, and uses this information to make improvements to their services.
Major *The team identifies major orthopaedic surgery clients (hip and knee replacements, hip fracture surgery)
who require post-discharge prophylaxis and has a mechanism in place to provide appropriate post-discharge
prophylaxis to such clients.
Minor The team provides information to health professionals and clients about the risks of VTE and how to prevent it.
* This test for compliance has been removed in the Cancer Care and Oncology Standards, Organ and Tissue Donation Standards for
Living Donors, and Organ and Tissue Transplant Standards.
REFERENCE MATERIAL
Geerts, W. (2009). Prevention of venous thromboembolism: a key patient safety priority. J.Thromb.Haemost., 7 Suppl 1, 1-8.
Geerts, W. H., Bergqvist, D., Pineo, G. F., Heit, J. A., Samama, C. M., Lassen, M. R. et al. (2008). Prevention of venous thromboembolism:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 133, 381S-453S.
MacDougall, D. A., Feliu, A. L., Boccuzzi, S. J., & Lin, J. (2006). Economic burden of deep-vein thrombosis, pulmonary embolism, and postthrombotic syndrome. Am.J.Health Syst.Pharm., 63, S5-15.
Merli, G., Ferrufino, C. P., Lin, J., Hussein, M., & Battleman, D. (2010). Hospital-based costs associated with venous thromboembolism prophylaxis
regimens. J.Thromb.Thrombolysis., 29, 449-458.
Safer Healthcare Now! (2011). Venous Thromboembolism - Resources. Safer Healthcare Now! [On-line]. Available:
www.saferhealthcarenow.ca/EN/Interventions/vte/Pages/resources.aspx
Society of Hospital Medicine. (2008). Preventing Hospital-Acquired Venous Thromboembolism: A guide for effective quality improvement. Agency
for Healthcare Research and Quality [On-line]. Available: www.ahrq.gov/qual/vtguide/vtguide.pdf
59
ReQUIReD ORGAnIZAtIOnAL PRActIces

Our objective of guiding
our clients toward safe
and quality health care
is strengthened by the
Required Organizational
Practices.
New in 2013
sAFetY cULtURe
cOMMUnIcAtIOn
MeDIcAtIOn Use
WORKLIFe/WORKFORce
InFectIOn cOntROL
RIsK AssessMent
New in 2013 for select

acute care standard sets
Adverse events disclosure

Adverse events reporting
Client safety as a strategic priority
Client safety quarterly reports
Client safety-related prospective analysis
Client and family role in safety
Dangerous abbreviations
Information transfer
Medication reconciliation at transfer or discharge
Safe surgery checklist
Verification processes for high-risk activities
Antimicrobial stewardship
Concentrated electrolytes
Heparin safety
Infusion pumps training
Medication concentrations
Narcotics safety
Client safety: education and training
Client safety plan
Client safety: roles and responsibilities
Preventive maintenance program
Workplace violence prevention
Hand-hygiene audit
Hand-hygiene education and training
Infection control guidelines
Infection rates
Influenza vaccine
Pneumococcal vaccine
Sterilization processes
Falls prevention strategy
Home safety risk assessment
Pressure ulcer prevention
Suicide prevention
Venous thromboembolism (VTE) prophylaxis
60
InDeX
Adverse events disclosure ...........................................................4
Adverse events reporting .............................................................5
Antimicrobial Stewardship .....................................................34
Client and family role in safety .....................................................9
Client safety as a strategic priority ...............................................6
Client safety: education and training ..........................................41
Client safety plan ........................................................................42
Client safety quarterly reports ......................................................7
Client safety-related prospective analysis ....................................8
Client safety: roles and responsibilities ......................................43
Concentrated electrolytes ...........................................................36
Dangerous abbreviations ...........................................................10
Falls prevention strategy ............................................................54
Hand-hygiene audit ....................................................................47
Hand-hygiene education and training.........................................48
Heparin safety ............................................................................37
Home safety risk assessment ....................................................55
Infection control guidelines .........................................................49
Infection rates .............................................................................50
Influenza vaccine ........................................................................51
Information transfer ....................................................................11
Infusion pumps training ..............................................................38
Medication concentrations ..........................................................39
For Leadership Standards .............................................12
For Ambulatory Care Services and Ambulatory
Systemic Cancer Therapy Services...............................13
For Emergency Department Standards .........................15
For Acquired Brain Injury Services, Cancer Care and
Oncology Services, Critical Care, Hospice, Paliative, and
End-of-Life Services, Long-Term Care Services, Medicine
Services, Mental Health Services, Obstetrics Services,
Rehabilitation Services, Residential Homes for Seniors,
Substance Abuse and Problem Gambling Services,
and Surgical Care Services. ..........................................17
For Case Management Services, Community-Based
Mental Health Services and Supports, and Home

Care Services ................................................................19
Medication reconciliation at transfer or discharge
For teams using Ambulatory Care Services and
Ambulatory Systemic Cancer Therapy Services............21
For teams using Acquired Brain Injury Services,
Cancer Care and Oncology Services, Critical Care
Services, Emergency Departments, Hospice, Palliative,
End-of-Life Care Services, Medicine Services,
Mental Health Services, Obstetrics Services,
Rehabilitation Services, Substance Abuse and
Problem Gambling Services, and Surgical Care
Services ........................................................................ 23
For teams using Home Care Services, Case
Management Services, and Community Based
Mental Health Services and Supports. ......................... 26
For teams using Long Term Care Services and
Residential Homes for Seniors. .................................... 28
Narcotics safety ..........................................................................40
Pneumococcal vaccine ...............................................................52
Pressure ulcer prevention ......................................................56
Preventive maintenance program ..............................................44
Safe surgery checklist ................................................................30
Sterilization processes ...............................................................53
Suicide prevention ......................................................................58
For Managing Medications Standards ...........................31
For teams using standards other than Managing
Medications................................................................... 32
Venous thromboembolism (VTE) prophylaxis ............................59
Verification processes for high-risk activities..............................33
Workplace violence prevention ..................................................45
New in 2013
61
Accreditation Canada is a not-for-profit

independent organization that provides
health services organizations with a
rigorous and comprehensive accreditation
process. We foster ongoing quality
improvement based on evidence-based
standards and external peer review.
Accredited by the International Society
for Quality in Health Care, Accreditation
Canada has helped organizations strive for
excellence for more than 50 years.
1150 Cyrville Road
Ottawa, Ontario, Canada
K1J 7S9
613-738-3800 1-800-814-7769

ROP Handbook en

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

ROP Handbook en

Caricato da

Copyright:

Formati disponibili

ROPs

Required Organizational Practices

Adverse events disclosure............................................................4

Client and family role in safety......................................................9

Safe surgery checklist.................................................................30

Client safety: education and training...........................................41

Falls prevention strategy.............................................................54

SAFETY CULTURE: Create a culture of safety within the organization

MAJOR AnD MInOR tests

ADVERSE EVENTS DISCLOSURE

ADVERSE EVENTS REPORTING

CLIENT SAFETY AS A STRATEGIC PRIORITY

Major Client safety appears as a written, strategic priority or goal.

CLIENT SAFETY QUARTERLY REPORTS

CLIENT SAFETY-RELATED PROSPECTIVE ANALYSIS

CLIENT AND FAMILY ROLE IN SAFETY

MEDICATION RECONCILIATION AS AN ORGANIZATIONAL

The organization reconciles clients medications at admission, and transfer or discharge.

Major Medication reconciliation is implemented in one client service area at admission.

MEDICATION RECONCILIATION AT ADMISSION

Medication reconciliation at admission (contd)

MEDICATION RECONCILIATION AT ADMISSION

Medication reconciliation at admission (contd)

MEDICATION RECONCILIATION AT ADMISSION

Medication reconciliation at admission (contd)

MEDICATION RECONCILIATION AT ADMISSION

Medication reconciliation at admission (contd)

MEDICATION RECONCILIATION AT TRANSFER OR DISCHARGE

Medication Reconciliation at Transfer or Discharge (contd)

MEDICATION RECONCILIATION AT TRANSFER OR DISCHARGE

Medication Reconciliation at Transfer or Discharge (contd)

Medication Reconciliation at Transfer or Discharge (contd)

MEDICATION RECONCILIATION AT TRANSFER OR DISCHARGE

Medication Reconciliation at Transfer or Discharge (contd)

MEDICATION RECONCILIATION AT TRANSFER OR DISCHARGE

Medication Reconciliation at Transfer or Discharge (contd)

SAFE SURGERY CHECKLIST

TWO CLIENT IDENTIFIERS

TWO CLIENT IDENTIFIERS

VERIFICATION PROCESSES FOR HIGH-RISK ACTIVITIES

Major The team identifies high-risk activities.

Antimicrobial Stewardship (contd)

Major The organization implements an antimicrobial stewardship program.

Major There are no concentrated electrolytes stored in client service areas.

INFUSION PUMPS TRAINING

Major There is documented evidence of ongoing, effective training on infusion pumps.

CLIENT SAFETY: EDUCATION AND TRAINING

CLIENT SAFETY PLAN

Minor The organization assesses client safety issues.

CLIENT SAFETY: ROLES AND RESPONSIBILITIES

PREVENTIVE MAINTENANCE PROGRAM

WORKPLACE VIOLENCE PREVENTION

The organization has a written workplace violence prevention policy.

Workplace Violence Prevention (contd)

HAND-HYGIENE EDUCATION AND TRAINING

INFECTION CONTROL GUIDELINES

The organization tracks infection rates.

FALLS PREVENTION STRATEGY

The team implements a falls prevention strategy.

HOME SAFETY RISK ASSESSMENT

PRESSURE ULCER PREVENTION

(Contd on next page...)

New in 2013 for select acute care standard sets