The 5W’s of medication incident reporting

By Yi Zhou Situ, Bita Janzadeh and Certina Ho

According to the Institute for Safe Medication Practices Canada (ISMP Canada) “Definition of Terms” , a medication incident is “a mistake with medication, or a problem that could cause a mistake with medication”. Medication incidents can, and on occasion, do occur. Unfortunately, such incidents or events can sometimes have serious consequences for a patient’s well-being (and long-lasting psychological impact on the healthcare providers involved).

Medication incident (or medication error) reporting

Reporting and sharing the learning of medication incidents (including near misses and medication errors) are vital to error prevention and patient/medication safety, as this will provide us with the opportunity not only to identify potential underlying or contributing factors of the incidents, but also to learn from mistakes and reduce the chance of error recurrence through implementation of prevention strategies.


Advancing patient/medication safety

In Canada, the Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program of Health Canada, the Canadian Institute for Health Information (CIHI), the ISMP Canada, and the Canadian Patient Safety Institute (CPSI). The goal of CMIRPS is to reduce and prevent harmful medication incidents in Canada. Reporting of medication incidents is the first step. In order to learn from our mistakes, analysis of medication incidents, which typically involve a comprehensive review and discussion with stakeholders involved in the incident (including the patient) of “what happened”, “why happened”, and “what we can do to prevent the same incident from happening again”. Interventions or prevention strategies will then be implemented by applying a plan-do-study-act quality improvement approach. It is through ongoing and iterative finetuning of prevention strategies, with support from leadership and management, as well as frontline healthcare providers that our reporting efforts will help create a safer healthcare system.

It is important to note that adverse drug reactions (or commonly known as side effects) are undesirable effects, which may occur under normal use conditions of medications. They, typically, cannot be prevented, and should be reported to the Health Canada’s Canada Vigilance Program. As a reminder, mandatory reporting of serious adverse drug reactions and medical device incidents by hospitals to Health Canada is effective as of December 16, 2019.

Yi Zhou Situ and Bita Janzadeh are PharmD Students at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto