COMPASS 'Community Pharmacists Advancing Safety in Saskatchewan' Continuous Quality Assurance Pilot Project
Canadian Pharmacists Conference ePoster Library. Ng M. May 28, 2015; 98461
Mr. Marvin Ng
Mr. Marvin Ng
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Abstract
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OBJECTIVE(S): The COMPASS pilot project is a continuous quality assurance (CQA) program in Saskatchewan, designed to help community pharmacists recognize, resolve, and learn from medication errors. COMPASS allows pharmacists to anonymously report errors, proactively evaluate the safety of their systems, and develop action plans to continually improve their medication-use process.

METHOD(S): From September 2013 to August 2014, 575 medication incidents were voluntarily reported to ISMP Canada by 10 community pharmacies in Phase I of COMPASS. Quantitative analysis was conducted on all 575 incidents. Qualitative analysis was conducted to approximately 50% of these incidents that were reported with rich narrative information.

RESULT(S): Of 575 incidents reported, 84% (482 of 575) were near misses, 15% (88 of 575) caused no patient harm, and 1% (5 of 575) resulted in mild harm to the patient. These incidents were commonly found at the order entry and dispensing stage, with a majority of them related to incorrect quantity of medication. Levothyroxine, estrogen containing products such as oral contraceptives, cardiovascular and psychotropic medications were commonly reported in these incidents. Multi-incident qualitative analysis categorized the incidents into three major themes: 'Patient or Caregiver Initiated Medication Safety Enhancements', 'Miscommunication of Drug Orders', and 'Incorrect Drug Product'.

CONCLUSION(S): COMPASS is a CQA pilot project that facilitates anonymous reporting of, and learning from medication incidents. Its main goal is to develop and implement system-based strategies to prevent potential errors from recurring, and ultimately, enhance patient safety. COMPASS is now expanded to Phase II in 2015 with 86 participating community pharmacies in Saskatchewan.
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