Medication Incident Reporting
A medication incident is any preventable event that may cause or lead to inappropriate medication use or patient harm that has reached the patient. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communications, product labelling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. *
All medication incidents that reach a patient need to be reported anonymously to the National Incident Data Repository and should be documented fully in pharmacy records.
Appendix B of NAPRA Model Standards of Practice for Continuous Quality Improvement and Medication Incident Reporting provides a list of levels of harm.
A near miss is an event that could have resulted in unwanted consequences but did not reach the patient either by chance or through timely intervention. *
Near misses create opportunities to analyze medication system processes, enabling a better understanding of potential gaps in existing systems which can then be addressed before an actual medication incident occurs.
The pharmacist-in-charge is responsible for establishing policies and procedures related to the documentation and reporting of near-miss events including:
- documenting the near miss using the pharmacy’s reporting platform;
- determining if the near miss must be reported to the national database according to the pharmacy’s policies and procedures; and
- when required, submitting a report of the near miss to the national database using the pharmacy’s reporting platform.
Appendix A of the NAPRA Model Standards of Practice for Continuous Quality Improvement and Medication Incident Reporting provides a list of sample criteria that may be used to determine whether a near miss should be reported to a national/provincial database and includes
- Were it to reach the patient, the near miss may cause harm.
- The near miss has been a recurrent issue in the pharmacy.
- The near miss provides a learning opportunity for the pharmacy or for pharmacy practice in general.
*Definitions provided by: https://ismpcanada.ca/resource/definitions-of-terms
As per the Standards of Practice for Continuous Quality Improvement and Medication Incident Reporting in Community Pharmacies (Standards of Practice for CQI and MIR), pharmacy professionals are required to document medication incidents and specific near-miss events in the pharmacy and submit a report to the National Incident Data Repository (NIDR) using the pharmacy’s reporting platform.
NATIONAL INCIDENT DATA REPOSITORY (NIDR)
The NIDR for Community Pharmacies, which is a component of the Canadian Medication Incident Reporting and Prevention System (CMIRPS) has been designated by NLPB as the national database for the mandatory reporting of medication incidents and near misses. The CMIRPS’ NIDR is a repository of medication and near-miss reporting data submitted across Canada. The data contained in the national database is de-identified (anonymous) of both patient and healthcare provider professionals’ personal information.
Submission of incident and near-miss information to the NIDR helps to create a national information-sharing system that facilitates the understanding of medication incidents and near-misses across the profession and supports the development of strategies and recommendations to prevent patient harm.
For more information, please refer to the ISMP CANADA NIDR FAQ.
MEDICATION INCIDENT REPORTING (MIR) PLATFORM
A Medication Incident Reporting (MIR) platform is a software program used by pharmacy professionals for recording medication incidents and near misses at the pharmacy level and submitting them to the NIDR. All community pharmacies are required to implement a MIR Platform that meets the requirements outlined in the Standards of Practice for CQI and MIR and fulfills the MedSTEP NL MIR platform criteria.