Rop Handbook 2014 en

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ca
Required Organizational Practices

Handbook 2014
Required Organizational Practices Handbook 2014

All rights reserved.
2013 Accreditation Canada
Accreditation Canada is an independent, not-for-profit organization that accredits health organizations in Canada and
around the world. Its comprehensive accreditation program
uses evidence-based standards and a rigorous peer review
process to foster ongoing quality improvement. Accreditation
Canada has been helping organizations improve health care
quality and patient safety for more than 55 years.
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Required
Organizational
Practices
About the ROP Handbook.......................................................1
Overview...................................................................................2
Chart of Required Organizational Practices..........................3
ROP development over the years.........................................73
Index........................................................................................74
ROPs
SAFETY CULTURE
Accountability for Quality
For the Governance Standards.............................................4
Adverse Events Disclosure.....................................................6
Adverse Events Reporting......................................................7
Client Safety Quarterly Reports..............................................8
Client Safety-related Prospective Analysis...........................9
COMMUNICATION
Client and Family Role in Safety...........................................10
Dangerous Abbreviations......................................................11
Information Transfer..............................................................12
Medication Reconciliation as a Strategic Priority
For the following sets of standards: Leadership,
Leadership for Small Community-based Organizations......13
Medication Reconciliation at Care Transitions
For the following sets of standards: Acquired Brain
Injury Services, Cancer Care and Oncology Services,
Correctional Service of Canada Health Services,
Critical Care Services, Emergency Department, Hospice
Palliative and End-of-Life Services, Medicine Services,
Mental Health Services, Obstetrics Services, Provincial
Correctional Health Services, Rehabilitation Services,
and Surgical Care Services.................................................16
For the following sets of standards: Aboriginal Integrated
Primary Care Services, Ambulatory Care Services,
Ambulatory Systemic Cancer Therapy Services, and
Remote/Isolated Health Services........................................19
For the Emergency Department Standards.........................22
For the following sets of standards: Case Management
Services, Community-Based Mental Health Services and
Supports, and Home Care Services....................................25
For the following sets of standards: Long-term Care
Services, and Residential Homes for Seniors.....................27
For the following sets of standards: Aboriginal Substance

Misuse Services, and Substance Abuse and Problem
Gambling Services..............................................................29
Safe Surgery Checklist..........................................................31
Two Client Identifiers.............................................................32
MEDICATION USE
Antimicrobial Stewardship ...................................................33
Concentrated Electrolytes
For on-site surveys until December 31 2014 for the
Customized Managing Medications Standards...................35
For on-site surveys starting January 2014 for the
following sets of standards: Medication Management and
Medication Management for Remote/Isolated
Health Services...................................................................36
Medication Management Standards for
Community-Based Organizations........................................36
Heparin Safety
following sets of standards: Medication Management,
and Medication Management for Remote/Isolated
Health Services...................................................................39
High-alert Medications
following sets of standards: Emergency Medical
Services, Medication Management, and Medication
Management for Remote/Isolated Health Services.............41
following sets of standards: Independent Medical
Surgical Facilities, and Medication Management
for Community-Based Organizations..................................41
Infusion Pumps Training........................................................43
Medication Concentrations
Independent Medical Surgical Facilities Standards.............44
Required
Organizational
Practices
Narcotics Safety
For on-site surveys until December 31 2014 for the following
sets of standards: Customized Medication Management, and
Independent Medical Surgical Facilities..............................45
For on-site surveys starting January 2015 the
Surgical Facilities, and Medication Management for
WORKLIFE/WORKFORCE
Client Flow
For the Leadership Standards.............................................48
Client Safety: Education and Training..................................50
Client Safety Plan...................................................................51
Preventive Maintenance Program.........................................52
Workplace Violence Prevention............................................53
INFECTION CONTROL
Hand-hygiene Compliance (formerly called
Hand-hygiene Audit).................................................................55
Hand-hygiene Compliance
For on-site surveys starting January 2015.....................56
Hand-hygiene Education and Training.................................58
Hand-hygiene Education and Training
For on-site surveys starting January 2015..........................59
Infection Rates........................................................................60
Infection Rates
Pneumococcal Vaccine..........................................................62
Reprocessing (formerly called Sterilization processes)..........63
RISK ASSESSMENT
Falls Prevention Strategy......................................................64
Home Safety Risk Assessment.............................................65
Pressure Ulcer Prevention ....................................................66
Skin and Wound Care
For the Home Care Services Standards.............................68
Suicide Prevention ................................................................70
Venous Thromboembolism (VTE) Prophylaxis...................71
Required
Organizational
Practices
ABOUT THE ROP HANDBOOK
For convenience and ease of use, all ROPs that appear in the Accreditation Canada Qmentum standards sets have been
collected into this handbook.
Most ROPs apply to more than one sector and therefore appear in multiple sets of standards.
In this handbook, the ROPs are presented as follows:
The ROP
The ROP statement defines the practice that is expected. For example:
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.
If the ROP has been customized for specific sectors or services, the applicable sets of standards are shown in this
section.
Guidelines
The guidelines provide context and rationale on why the ROP is important to patient safety and risk management. They
also show supporting evidence and provide information about meeting the tests for compliance. While the guidelines
provide insight and information, they are not requirements. In fact, the tests for compliance can be met without following
the guidelines.
Tests for Compliance (major and minor)
The tests for compliance, categorized as major or minor, are the specific expectations that surveyors assess on-site
to determine whether the organization complies with the ROP. For the ROP to be assessed as compliant, all of the
associated tests for compliance must be rated as met.
Major tests for compliance have an immediate impact on safety, while minor tests for compliance support longer-term
safety culture and quality improvement activities and may require additional time to be fully developed and/or evaluated.
As a rule, required follow-ups for major unmet tests for compliance must be submitted within five months, while those for
minor unmet tests for compliance must be submitted within eleven months.
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 the tests for compliance.
The list of reference materials does not appear in the standards.
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Required
Organizational
Practices
OVERVIEW
In the Accreditation Canada Qmentum accreditation program, Required Organizational Practices (ROPs) are evidenceinformed practices addressing high-priority areas that are central to quality and safety. Accreditation Canada defines an ROP
as an essential practice that organizations must have in place to enhance patient/client safety and minimize risk.
Accreditation Canada began developing ROPs in 2004 under the leadership of its Patient Safety Advisory Committee. The first
steps in developing a new ROP involve national and international literature reviews to identify major patient safety risk areas
and best practices, analysis of patient safety-related on-site survey results and compliance rates, and field-specific research.
The ROP is then subject to national consultation, and feedback from expert advisory committees, client organizations,
surveyors, and other stakeholders such as governments and content experts before it is released to the field.
ROPs are reviewed and updated as required. As some ROPs achieve widespread implementation, they are transitioned into
high-priority criteria within the accreditation program.
ROPs are categorized into six patient safety areas, each with its own goal, as follows:
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
For more information on ROPs, Accreditation Canada, or the Qmentum accreditation program, visit accreditation.ca.
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Required
Organizational
Practices
CHART OF REQUIRED ORGANIZATIONAL PRACTICES
SAFETY CULTURE
Accountability for quality

Adverse events disclosure
Adverse events reporting
Client safety quarterly reports
Client safety-related prospective analysis
COMMUNICATION
Client and family role in safety

Dangerous abbreviations
Information transfer
Medication reconciliation as a strategic priority
Medication reconciliation at care transitions
Safe surgery checklist
Two client identifiers
MEDICATION USE
Antimicrobial stewardship
Concentrated electrolytes
Heparin safety
High-alert medications
Infusion pumps training
Medication concentrations
Narcotics safety
WORKLIFE/WORKFORCE
Client flow
Client safety: education and training
Client safety plan
Preventive maintenance program
Workplace violence prevention
INFECTION CONTROL
Hand-hygiene compliance (formerly called Hand-hygiene audit)

Hand-hygiene education and training
Infection rates
Pneumococcal vaccine
Reprocessing (formerly called Sterilization processes)
RISK ASSESSMENT
Falls prevention strategy

Home safety risk assessment
Pressure ulcer prevention
Skin and wound care
Suicide prevention
Venous thromboembolism (VTE) prophylaxis
New for on-site surveys starting in 2015 Revised for on-site surveys starting in 2015
Revised for on-site surveys starting in 2014 or 2015, depending on the set of standards (see ROP for details).
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Required
Organizational
Practices
SAFETY CULTURE
Create a culture of safety within the organization
New
For on-site surveys starting January 2015
ACCOUNTABILITY FOR QUALITY

For the Governance Standards
The governing body demonstrates accountability for the quality of care provided by the organization.
GUIDELINES
Accreditation Canada defines quality in health care using eight dimensions that represent key service elements: accessibility,
client-centred, continuity, effectiveness, efficiency, population-focus, safety, and worklife.
Governing bodies are accountable for the quality of care provided by their organizations. When governing bodies are engaged
in overseeing quality, their organizations have better quality performance (better care, better client outcomes, better worklife,
and reduced costs).
The members of the governing body need to be aware of key quality and safety principles if they are to effectively understand,
monitor, and oversee the quality performance of the organization. Knowledge gaps among the membership can be addressed
through targeted recruitment for specific competencies (e.g., quality assurance, risk management, quality improvement, and
safety) from health care or other sectors (e.g., education or industry) or by providing education through workshops, modules,
retreats, virtual networks, or conferences.
The governing body can demonstrate a clear commitment to quality when quality is discussed at every regular meeting.
Often the governing body overestimates the quality performance of an organization, so discussions about quality need to be
supported with indicators and feedback from clients and families. A small number of easily understood performance indicators
that measure quality at the system level (i.e., big-dot indicators) such as number of clients who died or were harmed by
preventable errors, quality of worklife, number of complaints, and client experience results will help answer the question is our
care getting better?.
Quality performance indicators need to be directly linked to strategic goals and objectives and balanced across a number
of priority areas. Knowledge gained from the review of quality performance indicators can be used to set the board agenda,
inform strategic planning, and develop an integrated quality improvement plan. It can also be used to set quality performance
objectives for senior leadership and to determine whether they have met their quality performance objectives.
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Required
Organizational
Practices
ACCOUNTABILITY FOR QUALITY
TESTS FOR COMPLIANCE
Minor
Major
Major
Major
Minor
Major
The membership of the governing body has knowledge of key quality and safety principles, by recruiting members
who have this knowledge or providing access to education.
The governing body includes quality as a standing agenda item at all regular meetings.
The governing body identifies the key system-level indicators it will use to monitor the quality performance of the
organization.
At least quarterly, the governing body monitors and evaluates the quality performance of the organization against
agreed-upon goals and objectives.
The governing body uses information about the quality performance of the organization to make resource allocation
decisions and set priorities and expectations.
As part of their performance evaluation, senior leaders who report to the governing body (e.g., the CEO, Chief of
Staff) are held accountable for the quality performance of the organization.
REFERENCE MATERIALS:
5 Million Lives Campaign. (2008) Getting Started Kit: Governance Leadership Boards on Board How-to Guide. Institute for Healthcare
Improvement; Cambridge, MA. [On-line] Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuideGovernanceLeadership.aspx

Baker, G.R., Denis, J., Pomey, M., MacIntosh-Murray, A. (2010) Designing effective Governance for quality and safety in Canadian
healthcare. Healthc.Q. 13(1);38-46.
Governance for Quality and Patient Safety Steering Committee (2010). Effective Governance for Quality and Patient Safety: a toolkit for
healthcare board members and senior leaders. Canadian Patient Safety Institute. Edmonton, AB. [On-line]. Available:
www.patientsafetyinstitute.ca/English/toolsResources/GovernancePatientSafety/
The Health Foundation. (2013) Quality improvement made simple: what every board should know about healthcare quality improvement.
The Health Foundation. London, UK. [On-line]. Available: www.health.org.uk/publications/quality-improvement-made-simple/
Jha, A., Epstein,A. (2010) Hospital governance and the quality of care. Health.Affairs. 29(1);182-187.
Jiang, H.J., Lockee, C., Fraser, I. (2012). Enhancing board oversight on quality of hospital care: an agency theory perspective. Health.
Care.Manage.Rev. 37(2), 144-53.
Martin, L.A., Nelson, E.C., Lloyd, R.C., Nolan, T.W. (2007) Whole System Measures. IHI Innovation Series white paper. Institute for
Healthcare Improvement; Cambridge, MA. [On-line] Available: www.ihi.org
Roberts, J., Durbin, S. (2007) The Boards Role in Quality and Safety: 7 Key Governance Questions. Providence Health
Care. Seattle, WA. [On-line] Available: www.patientsafetyinstitute.ca/English/toolsResources/GovernancePatientSafety/
CreatingExecutingPatientSafetyPlan/Pages/Tools.aspx
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Required
Organizational
Practices
SAFETY CULTURE
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.
Major
Major
Major
There is a written policy for disclosure of adverse events to clients and families.
The disclosure policy includes support mechanisms for clients, families, staff, and service providers.
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-%20RespectfulManagementofSeriousClinicalAdverseEv
ents_490ab9fb-d691-43e8-af97-6d39638cedec/IHIRespectfulManagementofSeriousClinicalAdverseEventsOct11.pdf
Disclosure Working Group (2011). Canadian disclosure guidelines: being open and honest with patients and families.
Edmonton,AB. Canadian Patient Safety Institute. [On-line]. Available:
www.patientsafetyinstitute.ca/English/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.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.
Institute for Healthcare Improvement (2011). Disclosure Toolkit and Disclosure Culture Assessment Tool. Institute for Healthcare
Improvement [On-line]. Available: www.ihi.org/knowledge/Pages/Tools/DisclosureToolkitandDisclosureCultureAssessmentTool.aspx
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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
Minor
There is a reporting policy and process to report adverse events, sentinel events, and near misses.
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.
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-%20

IHIGlobalTriggerToolforMeasuringAdverseEvents_df8a18b6-52cc-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
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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. [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
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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 At least one prospective analysis has been completed within the past year.
Minor 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.
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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 The team develops written and verbal information for clients and families about their role in promoting safety.
Major 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
Canadian Medication Incident Reporting System (CMIRPS) Consumer focused website. (2012) Available: www.safemedicationuse.ca
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.
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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, more than 600,000
medication errors were reported to the United States Pharmacopeia (USP) MEDMARX program, with a total annual cost
of $3.5 billion. Five percent 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 The list is inclusive of the abbreviations, symbols, and dose designations, as identified on the Institute of Safe
Medication Practices (ISMP) Canadas Do Not Use List.
Major 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.
Major The organizations preprinted forms, related to medication use do not include any abbreviations, symbols, and dose
designations identified on the Do Not Use List.
Major The dangerous abbreviations, symbols, and dose designations are not used on any pharmacy-generated labels and
forms.
Minor The organization educates staff about the list at orientation and when changes are made to the list.
Minor The organization updates the list and implements necessary changes to the organizations processes.
Minor 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: www.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.
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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 The team has established mechanisms for timely and accurate transfer of information at transition points.
Major 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 [Online]. Available: www.health.gov.on.ca/en/common/ministry/publications/reports/baker_2011/baker_2011.pdf
Canadian Medical Protective Association (CMPA). (2013) Patient Handovers. CMPA Risk Fact Sheet. CMPA. Ottawa, ON. [On-line].
Available: www.cmpa.org/cmpa-risk-fact-sheets
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
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MEDICATION RECONCILIATION AS A STRATEGIC PRIORITY

For the following sets of standards: Leadership, Leadership for Small Community-based Organizations
The organization has a strategy to partner with clients to collect accurate and complete information
about client medications and utilize this information during transitions of care.
NOTE: Accreditation Canada will move towards full implementation of medication reconciliation in two phases.
For on-site surveys between 2014 and 2017, medication reconciliation should be implemented in ONE service
(or program) that uses a Qmentum standard containing the Medication Reconciliation at Care Transitions ROP.
Medication reconciliation should be implemented as per the tests for compliance for each ROP.
For on-site surveys in 2018 and beyond, medication reconciliation should be implemented in ALL services (or
programs) that use Qmentum standards containing the Medication Reconciliation at Care Transitions ROP.
Medication reconciliation should be implemented as per the tests for compliance for each ROP.
GUIDELINES
Medication reconciliation is widely recognized as an important safety initiative. In Canada, Safer Healthcare Now! identifies
medication reconciliation as a patient 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. Properly
conducted medication reconciliation reduces the possibility that medications will be inadvertently omitted, duplicated, or
incorrectly ordered at transitions of care. Medication reconciliation can be a cost-effective way to reduce medication errors and
can reduce the re-work that can be associated with managing client medications.
Safer Healthcare Now! offers a Getting Started Kit for various sectors (including acute care, long-term care, and home-care)
at www.saferhealthcarenow.ca.
Medication reconciliation is a structured, shared process whereby which health care professionals:
1. Work with the client, family, and caregivers (as appropriate), and at least one other source of information, to generate a
Best Possible Medication History (BPMH). A BPMH is a list of all medications (including prescription, non-prescription,
traditional, holistic, herbal, vitamins, and supplements).
2. Identify and resolve differences (discrepancies) between the BPMH and medications ordered at transition points.
3. Document and communicate up-to-date information about client medications to the client (and their next service provider,
as appropriate).
Success at medication reconciliation requires clear commitment and direction from organization leaders. An organization
policy signals commitment to medication reconciliation and provides guiding principles (e.g., an overview of the process, roles
and responsibilities, transitions where medication reconciliation is required, exemptions, etc). Organization commitment to
medication reconciliation also requires investment, with resources allocated towards staffing, education, tools, information
technology, etc.
Implementing and sustaining medication reconciliation throughout an organization will be more successful when led by an
interdisciplinary coordination team. Depending on the organization, the coordination team could include senior leaders
(including clinical leaders representing medicine, nursing, and pharmacy staff), front-line staff who are directly involved in
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the process, information technology staff, representatives from quality, risk, and safety committees, and clients and families.
For organizations that are just starting, it can be helpful to develop the necessary forms and tools and implement them
in one service area to gain expertise. As monitoring indicates implementation is successful, a plan can be developed to
implement medication reconciliation throughout the organization, continuing to monitor and make improvements as required.
As medication reconciliation is successfully implemented, organizations need to consider the sustainability of the process,
continuing to monitor and make improvements as required.
Physician and staff education about medication reconciliation should include the rationale for and steps involved in medication
reconciliation. The Agency for Healthcare Research and Qualitys MATCH toolkit provides more information about medication
reconciliation training (www.ahrq.gov). Evidence of education can include orientation checklists, a list of education sessions
offered, attendance lists, competency evaluation forms, sign-off sheets for having read policies/procedures, etc.
It is important to monitor, in consultation with the coordination team and front-line staff, the extent to which the medication
reconciliation policy and process are being followed. Monitoring should assess compliance with the overall medication
reconciliation process (e.g., the quality of the collection of the BPMH, whether the BPMH is documented, and whether
medication discrepancies are identified and resolved). The Safer Healthcare Now! Getting Started Kit also has useful
resources to monitor implementation. ISMP Canada and the Canadian Patient Safety Institute (CPSI) have developed an audit
tool that can be used to help assess the quality of an established medication reconciliation process.
Major
Major
Major
Minor
Major
Minor
The organization has a medication reconciliation policy and process to collect and utilize accurate and complete
information about client medication at transitions of care.
The organization defines roles and responsibilities for completing medication reconciliation.
The organization has a plan to implement and sustain medication reconciliation that specifies services/programs,
locations and timelines.
The organizational plan is led and sustained by an interdisciplinary coordination team.
There is documented evidence that the organization educates staff and physicians responsible for medication
reconciliation.
The organization monitors compliance with the medication reconciliation process, and makes improvements when
required.
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REFERENCE MATERIAL
Accreditation Canada, the Canadian Institute for Health Information, the Canadian Patient Safety Institute, and the Institute for Safe
Medication Practices Canada. (2012). Medication Reconciliation in Canada: Raising The Bar Progress to date and the course ahead.
Ottawa, ON: Accreditation Canada. [On-line] Available: www.accreditation.ca/Med_Rec_Report.aspx
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/common/ministry/publications/reports/baker_2011/baker_2011.pdf
Canadian Medical Protective Association (CMPA) (2013). Medication Reconciliation. CMPA Risk Fact Sheet. CMPA. [On-line].
Available: www.cmpa.org/cmpa-risk-fact-sheets
Feldman, L.S., Costa, L.L., Feroli, E.R., Nelson, T., Poe, S.S., Frick, et al. (2012) Nurse-pharmacist collaboration on medication
reconciliation prevents potential harm. J.Hosp.Med., 7(5), 396-401.
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(8), 477-485.
Institute for Safe Medication Practices Canada (2013). Quality Medication Reconciliation Processes Are Critical. Ontario Critical
Incident Learning. Issue 3. [On-line]. Available: www.ismp-canada.org/ocil/
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/
Institute for Safe Medication Practices Canada and Canadian Patient Safety Institute (2012). National Medication Reconciliation
Strategy: Identifying practice leaders for medication reconciliation in Canada. Canadian Patient Safety Institute. [On-line]. Available:
www.saferhealthcarenow.ca/EN/Interventions/medrec/pages/resources.aspx
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.
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This ROP has been revised for the Emergency Department Standards for on-site
surveys starting January 2015. See page 22.
MEDICATION RECONCILIATION AT CARE TRANSITIONS

Acute Care Services
For the following sets of standards: Acquired Brain Injury Services, Cancer Care and Oncology Services,
Correctional Service of Canada Health Services, Critical Care Services, Emergency Department, Hospice
Palliative and End-of-Life Services, Medicine Services, Mental Health Services, Obstetrics Services, Provincial
Correctional Health Services, Rehabilitation Services, and Surgical Care Services.
With the involvement of the client, family, or caregiver (as appropriate), the team generates a Best
Possible Medication History (BPMH) and uses it to reconcile client medications at transitions of care.
GUIDELINES
Research suggests that more than 50 percent of clients have at least one discrepancy between the medications they take at
home with those ordered upon admission to the hospital. Many of these have the potential to cause adverse drug events a
recognized patient safety issue. Conducting medication reconciliation reduces the possibility that medications will be omitted,
duplicated, or ordered incorrectly at transitions of care. Medication reconciliation can be a cost-effective way to reduce
medication errors and the re-work that can be associated with managing client medications.
Medication reconciliation is a structured process to communicate accurate and complete information about client medications
at transitions of care. This is a shared responsibility that requires discussion with the client, family, or caregiver (as
appropriate) and often requires liaison with community service providers (such as primary care providers, home care, and
community pharmacists).
Safer Healthcare Now! offers a Getting Started Toolkit for medication reconciliation in the acute care setting
(www.saferhealthcarenow.ca).
Medication reconciliation begins with generating a Best Possible Medication History (BPMH) for each client. The BPMH is a
complete list of the clients current medications, including prescription, non-prescription, traditional, holistic, herbal, vitamins,
and supplements). For each medication, the name, dose, frequency, and route of administration is listed. Creating the BPMH
involves interviewing the client, family, or caregivers (as appropriate), and consulting at least one other source of information
such as the clients previous health record, the community pharmacist, or a provincial database. Once it has been generated,
the BPMH follows the client through their health care journey and is an important reference tool for reconciling medications
at each transition of care. When a client has been receiving care in a service environment for an extended period of time
and is being transferred to another health care organization or service, the current medication list may be used as a BPMH.
The extended period of time must be specified in organizational policy. Safer Healthcare Now!s Medication Reconciliation
Community of Practice provides a number of BPMH tools and forms, at http://tools.patientsafetyinstitute.ca.
Medication reconciliation at admission can be achieved using one of two models. In the proactive model, the prescriber
uses the BPMH list to generate admission medication orders. In the retroactive model, the team generates the BPMH after
admission medication orders have been written and makes a timely comparison of the BPMH to the admission medication
orders. Regardless of the model used, it is important to identify, resolve, and document medication discrepancies.
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This process needs to be repeated at any transition of care when medications are changed or re-ordered, including internal
transfers involving a change in the level of care (e.g. from critical care to a medicine unit, or from one facility to another within
an organization). Medication reconciliation is not required for bed relocation. Similar to admission, the goal of medication
reconciliation at internal transfer is to compare the medications the client was receiving on the transferring/sending unit
with those that were being taken at home to determine if any medications need to be continued, restarted, discontinued, or
modified.
At all times a current medication list (often called a medication administration record or MAR) is retained in the client record.
When discrepancies are resolved, the current medications list is reconciled and updated in the client record.
End of service is a critical transition of care that puts clients at risk of potential adverse drug events. End of service includes
discharge home, and external transfer to another service environment or community-based service provider. Examples include
a move from acute care to long-term care or hospice, from rehabilitation to home care, or from acute care to home/self-care.
The goal of medication reconciliation at end of service is to reconcile the medications the client was taking prior to admission
with those initiated in hospital and with those that should be taken at end of service.
The result of medication reconciliation at end of service is a complete list of medications the client should be taking, including
information about medications that need to be stopped. A systematic process needs to be followed to ensure this information
is documented and shared with the client, family, and subsequent care providers (e.g., primary care provider, community
pharmacy, long-term care provider, home care provider, as appropriate). Ideally, information about client medications is part of
a Best Possible Medication Discharge Plan (BPMDP) that also includes a medication information transfer letter to the next care
provider, a structured discharge prescription to the next care provider or community pharmacist, and clear information for the
client about the medications the client should be taking (in plain language that the client can understand).
Note: For emergency departments, medication reconciliation is only expected for clients for whom the decision to admit has
been made. For clients with a decision to admit, medication reconciliation may begin in the emergency department and be
completed following admission to the inpatient unit.
Major
Major
Major
Major
Major
Upon or prior to admission, the team generates and documents a Best Possible Medication History (BPMH), with the
involvement of the client, family, or caregiver (and others, as appropriate).
The team uses the BPMH to generate admission medication orders OR compares the Best Possible Medication
History (BPMH) with current medication orders and identifies, resolves, and documents any medication discrepancies.
A current medication list is retained in the client record.
The prescriber uses the Best Possible Medication History (BPMH) and the current medication orders to generate
transfer or discharge medication orders.
The team provides the client, community-based health care provider, and community pharmacy (as appropriate) with
a complete list of medications the client should be taking following discharge.
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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
American Society of Hospital Pharmacists (AHSP) Council on Pharmacy Practice (2013). ASHP statement on the pharmacists role in
medication reconciliation. Am.J.Health.Syst.Pharm. 1, 453-6.
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 and Safer Healthcare Now! (2012). Medication Reconciliation (MedRec). Institute for
Safe Medication Practices - Canada [On-line]. 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 [On-line]. Available: www.ismp-canada.org/medrec/map/
MARQUIS Investigators (2011). MARQUIS Implementation Manual: A guide for medication reconciliation quality improvement. Society of
Hospital Medicine. Philadelphia, PA. [On-line] Availble: http://tools.hospitalmedicine.org/resource_rooms/imp_guides/MARQUIS/marquis.
html (registration required)
Safer Healthcare Now! (2012). Medication Reconciliation: Getting Started Kits. Safer Healthcare Now! [On-line]. Available:
www.saferhealthcarenow.ca/EN/Interventions/medrec/Pages/default.aspx
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Ambulatory Care
For the following sets of standards: Aboriginal Integrated Primary Care Services, Ambulatory Care Services,
Ambulatory Systemic Cancer Therapy Services, and Remote/Isolated Health Services.
With the involvement of the client, family, or caregiver (as appropriate), the team generates a Best
Possible Medication History (BPMH) and uses it to reconcile client medications at ambulatory care
visits where the client is at risk of potential adverse drug events*. Organizational policy determines
which type of ambulatory care visits require medication reconciliation, and the how often medication
reconciliation is repeated.
*Ambulatory care clients are at risk of potential adverse drug events when their care is highly dependent on medication management OR
the medications typically used are known to be associated with potential adverse drug events (based on available literature and internal
data).
GUIDELINES
Medication reconciliation is widely recognized as an important safety initiative. Evidence shows medication reconciliation
reduces the potential for medication discrepancies such as omissions, duplications, and dosing errors. In Canada, Safer
Healthcare Now! identifies medication reconciliation as a patient 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. Conducting medication reconciliation reduces the possibility that medications will be omitted, duplicated, or
ordered incorrectly at interfaces of care. Medication reconciliation can be a cost-effective way to reduce medication errors and
can reduce the re-work that can be associated with managing client medications.
at interfaces of care. This is a shared responsibility that requires interviewing the client, family, or caregiver (as appropriate)
and often requires liaison with community service providers (such as primary care providers and community pharmacists).
Ambulatory care includes a wide range of services and client populations, thus teams are encouraged to target medication
reconciliation to clients or populations who are at risk of potential adverse drug events. In order to identify clients or
populations at risk of potential adverse drug events, teams can use a screening or risk assessment approach and should
consider all ambulatory clinics/services offered by the organization. The organization must document the rationale for selecting
target clients or ambulatory clinics and how often medication reconciliation is required in their medication reconciliation policy.
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Organizations may choose to target medication reconciliation for all clients receiving selected ambulatory care services, or for
selected clients in any ambulatory care service. The organization considers its client populations and identifies clients at risk of
potential adverse drug events. For example, clients may be at risk based on:
Medication use, including:
More than four medications
High-alert medications (www.ismp.org/communityRx/tools/ambulatoryhighalert.asp)
Cardiovascular medications
Medications affecting the central nervous system
Analgesics
Anti-infectives
Hypoglycemic
Client factors, including those who:
Are at high risk for non-adherence with medication regimen
Are subject to frequent hospital admissions
Have more than three co-morbidities
Medication reconciliation begins with generating a Best Possible Medication History (BPMH) for each client. The BPMH lists
all medications (prescription, non-prescription, traditional, holistic, herbal, vitamins, and supplements) the client is actually
taking, and captures the name, dose, frequency, and route of administration for each. Creating the BPMH involves interviewing
the client, family, or caregivers (as appropriate), and consulting at least one other source of information such as the clients
previous health record, the community pharmacist, or a provincial database. Once it has been generated, the BPMH follows
the client through their health care journey and is an important reference tool for reconciling medications. When a client
has been receiving services for an extended period of time, the up-to-date current medication list may be used as a BPMH.
The period of time must be specified in 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. Safer Healthcare Now! Communities of Practice provide a number of BPMH tools and forms, at http://tools.
patientsafetyinstitute.ca/Pages/welcome.aspx.
Once the BPMH is generated, the goal of medication reconciliation is to identify and communicate what medications should
be continued, discontinued, or modified. 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 most responsible prescriber. Medication reconciliation
should be repeated periodically as appropriate for the client or population receiving services. The frequency of medication
reconciliation is determined by organizational policy. Examples of interfaces of care were clients are at risk potential adverse
drug events includes beginning of service, transfer of care between sites within the same organization, transfer to another
service environment (e.g., client moves from a renal program to a long-term care facility), or end of service. The end result of
medication reconciliation is a complete list of medications clients should be taking. Whenever possible, and always at the end
of service, the team provides clients and the clients community providers (e.g. primary care provider, community pharmacist,
home care provider) with the up-to-date BPMH. Clients should be provided with information about the medications they should
be taken in a format and language they can easily understand.
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Major
Major
Major
Major
Major
Major
Major
The organization identifies and documents the type of ambulatory care visits where medication reconciliation is
required.
For ambulatory care visits where medication reconciliation is required, the organization identifies and documents
how frequently medication reconciliation should occur.
During or prior to the initial ambulatory care visit, the team generates and documents the Best Possible Medication
History (BPMH), with the involvement of the client, family, caregiver (as appropriate).
During or prior to subsequent ambulatory care visits, the team compares the Best Possible Medication History
(BPMH) with the current medication list and identifies and documents any medication discrepancies. This is done
as per the frequency documented by the organization.
The team works with the client to resolve medication discrepancies OR communicates medication discrepancies to
the clients most responsible prescriber and documents actions taken to resolve medication discrepancies.
When medication discrepancies are resolved, the team updates the current medication list and retains it in the
client record.
The team provides the client and the next care provider (e.g., primary care provider, community pharmacist, home
care services) with a complete list of medications the client should be taking following the end of service.
REFERENCE MATERIAL
Safer Healthcare Now! (2012). Medication Reconciliation: Getting Started Kits. Safer Healthcare Now! [On-line].
Available: www.saferhealthcarenow.ca/EN/Interventions/medrec/Pages/default.aspx
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REVISED for on-site surveys starting January 2015

Emergency Department
For the Emergency Department Standards
With the involvement of the client, family, or caregiver (as appropriate), the team generates a
Best Possible Medication History (BPMH) and uses it to reconcile client medications for clients
with a decision to admit and at visits where the client is at risk of potential adverse drug events.*
Organizational policy determines which types of visits require medication reconciliation.
*Clients are at risk of potential adverse drug events when their care is highly dependent on medication
management AND client factors or the medications typically used are known (based on available literature and
internal data) to be associated with potential adverse drug events.
GUIDELINES
Medication reconciliation is widely recognized as an important safety initiative. Evidence shows medication reconciliation
reduces the 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 client
safety. Conducting medication reconciliation reduces the possibility that medications will be omitted, duplicated, or ordered
incorrectly at interfaces of care. Medication reconciliation results in better outcomes for clients and can be a cost-effective way
to reduce medication errors and can reduce the re-work that can be associated with managing client medications.
and often requires liaison with community service providers (such as primary care providers and community pharmacists).
Emergency departments serve a wide variety of clients, thus in addition to requiring medication reconciliation for all clients
with a decision to admit, teams are also expected to target medication reconciliation to visits where non-admitted clients are at
risk of potential adverse drug events. In order to identify non-admitted clients at risk of potential adverse drug events, teams
can use a risk assessment approach. The organization considers its client population and identifies clients at risk of potential
adverse drug events. For example, clients may be at risk based on:
Medication use, including:
More than four medications
High-alert medications (www.ismp.org/communityRx/tools/ambulatoryhighalert.asp)
Cardiovascular medications
Medications affecting the central nervous system
Analgesics
Anti-infectives
Hypoglycemic
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Client factors, including those who:

Are at high risk for non-adherence with medication regimen
Are subject to frequent hospital admissions
Have more than three co-morbidities.
Teams may begin with small targets focused on the most high-risk clients, and then expand as they achieve success with
medication reconciliation. It is important that the organization document the rationale for its target(s) and consider client flow
when designing their medication reconciliation process (e.g., medication reconciliation done at triage will create bottlenecks).
Medication reconciliation begins with generating a Best Possible Medication History (BPMH) for each client. The BPMH lists all
medications (prescription, non-prescription, traditional, holistic, herbal, vitamins, and supplements) the client is actually taking,
and lists the name, dose, frequency, and route of administration for each. Creating the BPMH involves interviewing the client,
family, or caregivers (as appropriate), and consulting at least one other source of information such as the clients previous
health record, the community pharmacist, or a provincial database. Once it has been generated, the BPMH follows the client
through their health care journey and is an important reference tool for reconciling medications. Safer Healthcare Now!
Communities of Practice provide a number of BPMH tools and forms.
be continued, discontinued, or modified. For non-admitted clients identified as requiring medication reconciliation, any
discrepancies identified between what the client is prescribed and what they are actually taking will be resolved during the
visit or referred to their most responsible prescriber. For all clients with a decision to admit, any discrepancies identified
can be resolved using one of two models. In the proactive model, the prescriber uses the BPMH list to generate medication
orders. In the retroactive model, the team generates the BPMH after medication orders have been written and makes a timely
comparison of the BPMH to the medication orders.
For clients with a decision to admit, the medication reconciliation process may begin in the emergency department but be
completed following admission to the inpatient unit.
Major The organization identifies and documents the type of visits where medication reconciliation is required. This
includes all clients with a decision to admit AND non-admitted clients at high risk of adverse drug events.
Major For visits where medication reconciliation is required, the team generates and documents the Best Possible
Medication History (BPMH), with the involvement of the client, family, caregiver (as appropriate). For admitted
clients, this may be completed in the emergency department or by the receiving inpatient unit.
Major For visits where medication reconciliation is required, the team identifies, documents, and resolves medication
discrepancies. For admitted clients, this may be completed in the emergency department or by the receiving
inpatient unit.
Major A current medication list is retained in the client record.
Major For non-admitted clients identified as requiring medication reconciliation, the team provides the client and the
next care provider (e.g., primary care provider, community pharmacist, home care services) with a complete list of
medications the client is taking.
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REFERENCE MATERIAL

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Home and Community Care
For the following sets of standards: Case Management Services, Community-Based Mental Health Services
and Supports, and Home Care Services.
When medication management is a component of care (or deemed appropriate through clinician
assessment), and with the involvement of the client, family, or caregiver (as appropriate), the team
generates a Best Possible Medication History (BPMH) and uses it to reconcile client medications.
GUIDELINES
More than ever before, health care in Canada is being provided in the home environment and community-based care is
responding to more complex client needs. It has been demonstrated that nearly 50 percent of adults transitioning from
a hospital to home care have medication discrepancies. Many of these can lead to serious consequences for the client.
Clients are extremely vulnerable during the transition from institutional care to home care. Accurate communication about
client medications does not always occur when clients are transferred between care environments. Conducting medication
reconciliation reduces the possibility that medications will be omitted, duplicated, or ordered incorrectly at interfaces of care.
Medication reconciliation can be a cost-effective way to reduce medication errors and can reduce the re-work that can be
associated with managing client medications.
Safer Healthcare Now! offers a Getting Started Toolkit for medication reconciliation in the community setting (www.
saferhealthcarenow.ca).
and often requires liaison with primary care providers and community pharmacists.
Medication reconciliation should be considered for all home care clients where medication management is a component
of care, but when this is not possible the organization needs to establish criteria to identify home care clients at risk of
potential adverse drug events. A medication risk assessment tool can help identify clients for whom medication reconciliation
is required. Safer Healthcare Now! offers a sample medication risk assessment tool in its Getting Started Toolkit. The
organization must document the rationale for selecting target clients.
Medication reconciliation begins with generating a Best Possible Medication History (BPMH) for the client. The BPMH lists
all medications (prescription, non-prescription, traditional, holistic, herbal, vitamins, and supplements) the client is actually
taking, and captures the name, dose, frequency, and route of administration for each. The best time to generate the BPMH
is during the initial visit, but this may not be possible in all cases. Therefore, the organization needs to define the acceptable
timeline for generating the BPMH. Creating the BPMH involves interviewing the client, family, or caregivers (as appropriate),
and consulting at least one other source of information such as the clients previous health record, the community pharmacist,
or a provincial database. Once it has been generated, the BPMH follows the client through their health care journey and is an
important reference tool for reconciling medications at interfaces of care.
When a client has been receiving services for an extended period of time and did not receive a BPMH at the beginning of
service, the current medication list may be used as a BPMH. The period of time must be specified in 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 current medication list.
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Organizational
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COMMUNICATION

be continued, discontinued, or modified. Any discrepancies identified between what the client is prescribed and what they
are actually taking, are communicated to the client (and their circle of care, as appropriate) and resolved by the appropriate
prescriber.
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 medication list up-to-date and accurate is the best way to be prepared to
communicate the client medications to the clients circle of care or next provider of care.
Major
Major
Major
Minor
Major
The organization identifies and documents the types of clients who require medication reconciliation.
At the beginning of service the team generates and documents a Best Possible Medication History (BPMH), with
the involvement of the client, family, health care providers, and caregivers (as appropriate).
The team works with the client to resolve medication discrepancies OR communicates medication discrepancies to
the clients most responsible prescriber and documents actions taken to resolve medication discrepancies.
When medication discrepancies are resolved, the team updates the current medication list and provides this to the
client or family (or primary care provider, as appropriate) along with clear information about the changes.
The team educates the client and family to share the complete medication list when encountering health care
providers within the clients circle of care.
REFERENCE MATERIAL
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Organizational
Practices
COMMUNICATION


Long-term Care
For the following sets of standards: Long-term Care Services, and Residential Homes for Seniors.
With the involvement of the resident, family, or caregiver (as appropriate), the team generates a Best
Possible Medication History (BPMH) and uses it to reconcile resident medications at transitions of
care.
GUIDELINES
Poor communication about medications is common as residents transfer between other service environments (e.g., acute care,
rehabilitation services, or home care) and long-term care. This is a significant patient safety issue as it can lead to adverse
drug events that have the potential to cause serious consequences for the resident. Conducting medication reconciliation
reduces the possibility that medications will be omitted, duplicated, or ordered incorrectly at transitions of care. Medication
reconciliation can be a cost-effective way to reduce medication errors and the re-work that can be associated with managing
resident medications.
Safer Healthcare Now! offers a Getting Started Toolkit for medication reconciliation in the long-term care setting
(www.saferhealthcarenow.ca).
Medication reconciliation is a structured process to communicate accurate and complete information about resident
medications across transitions of care. This is a shared responsibility that requires discussion with the resident, family, or
caregiver (as appropriate) and often requires liaison with community service providers (such as primary care providers and
community pharmacists).
Medication reconciliation begins with generating a Best Possible Medication History (BPMH) for each resident. The BPMH lists
all medications (prescription, non-prescription, traditional, holistic, herbal, vitamins, and supplements) the resident is currently
taking, even though it may be different from what was actually prescribed. The BPMH captures the name, dose, frequency,
and route of administration for each medication. Creating the BPMH involves interviewing the resident, family, or caregivers
(as appropriate), and consulting at least one other source of information such as the residents previous health record, the
community pharmacist, or a provincial database. Safer Healthcare Now! Communities of Practice provide a number of BPMH
tools and forms, at http://tools.patientsafetyinstitute.ca.
Medication reconciliation at admission or re-admission can be achieved using one of two models. The proactive model is
used most commonly in long-term care, where the prescriber uses the BPMH to create admission medication orders. In the
retroactive model, the team generates the BPMH after admission medication orders have been written and makes a timely
comparison of the BPMH against the admission medication orders. Regardless of the model used, it is important for the team
to identify, resolve, and document medication discrepancies.
After the BPMH is generated, the goal of medication reconciliation at admission is to identify and resolve discrepancies
between what medications the resident was taking prior to admission with those ordered by the prescriber. Medication
reconciliation is not required for bed relocation. When a resident moves from long-term care to another service environment
(e.g., acute care) and returns to long-term care, the residents medications need to be reconciled at re-admission to account
for any changes made in the other service environment.
At all times a current medication list (often called a medication administration record or MAR) is retained in the resident record.
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Organizational
Practices
COMMUNICATION

Transfer out of long-term care is a transition that puts residents at risk of potential adverse drug events. This includes
transitions out of the facility (e.g., transfer to acute care for short term treatment), transfers between long-term care facilities,
and a move from long-term care facility to community-based care or home. The goal of medication reconciliation when a
resident transfers out of long-term care is to communicate a complete list of the residents current medications to the next
health care provider.
Major
Major
Major
Major
Major
Upon or prior to admission, the team generates and documents a Best Possible Medication History (BPMH), in
consultation with the resident, family, health care providers, and caregivers (as appropriate).
The team compares the Best Possible Medication History (BPMH) with the admission orders and identifies,
resolves, and documents any medication discrepancies.
The team uses the reconciled admission orders to generate a current medication list that is kept in the resident
record.
Upon or prior to re-admission from another service environment (e.g., acute care), the team compares the
discharge medication orders with the current medication list and identifies, resolves, and documents any
medication discrepancies.
Upon transfer out of long-term care, the team provides the resident and next care provider (e.g., another longterm care facility or community-based health care provider), as appropriate, with a complete list of medications the
resident should be taking.
REFERENCE MATERIAL

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Organizational
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COMMUNICATION


Substance Misuse
For the following sets of standards: Aboriginal Substance Misuse Services, and Substance Abuse and Problem
Gambling Services.
The team reconciles the clients medications with the involvement of the client, and family or personal
support system at transitions of care.
GUIDELINES
In many settings, medication reconciliation is a structured process in which team members partner with clients, families, and
other caregivers for accurate and complete transfer of medication information at transitions of care. Due to the unique service
environments and staff mix of treatment centres, key elements of the medication reconciliation process have been customized
to ensure the accurate tracking and communication of medication information in this setting. These important steps are
designed to enhance patient safety and minimize the risk of medication errors or adverse events.
Client medication information should include prescribed medications, over-the-counter medications, vitamins, supplements,
herbal remedies, and traditional medicines, along with detailed documentation of drug name, dose, frequency, and route of
administration.
Medication reconciliation is a shared responsibility which must involve the client, family, or other personal support system.
Liaison with the primary care provider, community pharmacist, healer, and other community partners may be required.
Major
Major
Major
Minor
Minor
There is a formal process to track and communicate information about client medications over the duration of
treatment.
The team generates a comprehensive list of all medications the client is taking at the beginning of service (Best
Possible Medication History).
The team documents any changes to the medication list over the duration of treatment (e.g. medications
discontinued, added, altered, or changed during a physician visit, prescriptions completed during treatment).
Upon transfer to another service provider or end of service, the team provides the client and their providers of care
(e.g. family physician) with a copy of the updated medication list.
The process is a shared responsibility involving the client, service providers, family physician, and community
pharmacists, as appropriate.
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Required
Organizational
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COMMUNICATION

REFERENCE MATERIAL
Available: www.ama-assn.org/resources/doc/cqi/med-rec-monograph.pdf\
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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 safe
surgery checklists reduces likelihood of complications following surgery, and may improve surgical outcomes.
The purpose of a safe surgery 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 OR
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
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: 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
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Required
Organizational
Practices
COMMUNICATION

TWO CLIENT IDENTIFIERS

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.
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.safetyandquality.gov.au/wp-content/
uploads/2012/01/19794-TechnologyReview1.pdf
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.who.int/patientsafety/solutions/
patientsafety/PS-Solution2.pdf
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Required
Organizational
Practices
MEDICATION USE
Ensure the safe use of high-risk medications
ANTIMICROBIAL STEWARDSHIP
NOTE: This ROP applies to organizations providing the following services: inpatient acute care, inpatient cancer, inpatient
rehabilitation, and complex continuing care.
The organization has a program for antimicrobial stewardship to optimize antimicrobial use.
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.
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Required
Organizational
Practices
MEDICATION USE
ANTIMICROBIAL STEWARDSHIP
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. [On-line]. Available:
www.antibioticawareness.ca/?page_id=58
Centers for Disease Control and Prevention (2010). Get Smart for Healthcare - Evidence to Support Stewardship. [On-line]. Available:
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 (2012). Antimicrobial Stewardship Toolkit. [On-line]. Available: store.jcrinc.com/antimicrobial-stewardshiptoolkit
Morris, A. M., Brener, S., Dresser, L., Daneman, N., Dellit, T. H., Avdic, E. et al. (2012). Use of a structured panel process to define
quality metrics for antimicrobial stewardship programs. Infect.Control Hosp.Epidemiol., 33, 500-506.
Public Health Ontario (2012). Public Health Ontario - Antimicrobial Stewardship Program. [On-line]. Available:
www.oahpp.ca/services/antimicrobial-stewardship-program.html
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Required
Organizational
Practices
MEDICATION USE
A revised version of this ROP for select sets of standards appears on the
following pages.
CONCENTRATED ELECTROLYTES
For on-site surveys until December 31 2014 for the Customized Managing Medications Standards.
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.
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 Healthcare Improvement (IHI) (2012). Adverse Drug Events Involving Electrolytes. [On-line]. Available:
www.ihi.org/knowledge/Pages/Changes/ReduceAdverseDrugEventsInvolvingElectrolytes.aspx
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 MedicationPractices 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 [On-line]. 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:
www.who.int/patientsafety/solutions/patientsafety/PS-Solution5.pdf
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Required
Organizational
Practices
MEDICATION USE
REVISED For on-site surveys starting January 2014 or January 2015,

depending on the set of standards (see below for details).
For on-site surveys starting January 2014 for the following sets of standards: Medication Management and
Medication Management for Remote/Isolated Health Services.
For on-site surveys starting January 2015 for the Medication Management Standards for Community-Based
Organizations.
The organization evaluates and limits the availability of concentrated electrolytes to ensure that
formats with the potential to cause harmful medication incidents are not stocked in client service
areas.
GUIDELINES
There are reports of accidental death from the inadvertent administration of concentrated sodium chloride solution. Avoiding
stocking concentrated electrolytes in client service areas is a valuable use of resources to minimize the risk of death or
disabling injury associated with these agents. It also recommended that the packaging of concentrated electrolytes is in line
with their intended use.
Concentrated electrolytes to be the focus of audit and removal from client service areas include:
Calcium (all salts): concentrations greater than or equal to 10%
Magnesium sulfate: concentrations greater than 20%
Potassium (all salts): concentrations greater than or equal to 2 mmol/mL (2 mEq/mL)
Sodium (acetate and phosphate): concentrations greater than or equal to 4 mmol/mL
Sodium chloride: concentrations greater than 0.9%
For specific care circumstances, it may be necessary for concentrated electrolytes to be available in selected client service
areas.
Possible Examples:
Calcium: pre-filled syringes (1 g in 10 mL) in emergency carts or boxes only
Sodium chloride (concentrations greater than 0.9%): bags are segregated from non-medicated intravenous solutions in
selected areas (e.g. Neurology, Emergency Departments, Critical Care)
In these cases, the organizations interdisciplinary committee for medication management (e.g. Pharmacy and Therapeutics
Committee and Medical Advisory Secretariat) reviews and approves the rationale for availability and safeguards put in place to
minimize the risk of error.
Additional strategies to ensure the safe use of high-alert medications such as concentrated electrolytes may be found in
Accreditation Canadas High-Alert Medications ROP.
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Required
Organizational
Practices
MEDICATION USE

Major
Major
Major
The organization completes an audit of the following concentrated electrolytes in client service areas at least
annually:
Sodium acetate and sodium phosphate: concentrations greater than or equal to 4 mmol/mL
Sodium chloride: concentrations greater than 0.9%.
The organization avoids stocking the following concentrated electrolytes in client service areas:
Sodium acetate and sodium phosphate: concentrations greater than or equal to 4 mmol/mL
Sodium chloride: concentrations greater than 0.9%.
When it is necessary for concentrated electrolytes to be available in selected client service areas, the
organizations interdisciplinary committee for medication management reviews and approves the rationale for
availability and safeguards put in place to minimize the risk of error.
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 Healthcare Improvement (IHI) (2012). Adverse Drug Events Involving Electrolytes. [On-line]. Available:
www.ihi.org/knowledge/Pages/Changes/ReduceAdverseDrugEventsInvolvingElectrolytes.aspx
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 MedicationPractices 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 [On-line]. 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:
www.who.int/patientsafety/solutions/patientsafety/PS-Solution5.pdf
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37
Required
Organizational
Practices
MEDICATION USE
A revised version of this ROP for select sets of standards appears on the following
pages.
HEPARIN SAFETY
For on-site surveys until December 31 2014 for the Customized Managing Medications Standards.
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, i.e., 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, i.e., 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
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38
Required
Organizational
Practices
MEDICATION USE
REVISED For on-site surveys starting after January 2014 or January 2015,
HEPARIN SAFETY
For on-site surveys starting January 2014 for the following sets of standards: Medication Management, and
Medication Management for Remote/Isolated Health Services.
For on-site surveys starting January 2015 for the Medication Management Standards for Community-Based
Organizations.
The organization evaluates and limits the availability of heparin products to ensure that formats with
the potential to cause harmful medication incidents are not stocked in client service areas.
GUIDELINES
Heparin has been identified as a high-alert medication that is an area of focus for safety. Limiting availability and ensuring that
high-dose formats of heparin are not stocked in client service areas are effective strategies to minimize the risk of death or
disabling injury associated with these agents.
Heparin products to be the focus of audit to ensure that they are not stocked in client service areas include:
Unfractionated heparin (high dose, high potency): 50,000 units total per container (e.g. 50,000 units/5 mL; 50,000 units/
2 mL)
Heparin products to be the focus of audit with the goal to limit availability in client service areas include:
Low molecular weight heparin: use of multi-dose vials is limited to critical care areas for treatment doses
Unfractionated heparin (high dose): greater than or equal to 10,000 units total per container (e.g. 10,000 units/1 mL;
10,000 units/10 mL; 30,000 units/30 mL) is provided on a client-specific basis when required
Unfractionated heparin for intravenous use: E.g. 25,000 units/500 mL; 20,000 units/500 mL is provided on a clientspecific basis when required
For specific care circumstances, it may be necessary for heparin products to be available in selected client service areas. In
these cases, the organizations interdisciplinary committee for medication management (e.g. Pharmacy and Therapeutics
Committee and Medical Advisory Secretariat) reviews and approves the rationale for availability and safeguards put in place to
minimize the risk of error.
For the flushing of intravenous lines, organizations are encouraged to consult best practice guidelines to explore options
other than heparin. Additional strategies to ensure the safe use of high-alert medications such as heparin may be found in the
Accreditation Canada ROP about high-alert medications.
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Required
Organizational
Practices
MEDICATION USE

HEPARIN SAFETY
Major
Major
Major
Major
The organization completes an audit of unfractionated and low molecular weight heparin products in client service
areas at least annually.
The organization does not stock high dose unfractionated heparin (50,000 units total per container) in client service
areas.
The organization is taking steps to limit the availability of the following heparin products in client service areas:
Low molecular weight heparin: use of multi-dose vials is limited to critical care areas for treatment doses
Unfractionated heparin (high dose): greater than or equal to 10,000 units total per container (e.g. 10,000
units/1 mL; 10,000 units/10 mL; 30,000 units/30 mL) is provided on a client-specific basis when required
Unfractionated heparin for intravenous use: E.g. 25,000 units/500 mL; 20,000 units/500 mL is provided on a
client-specific basis when required.
When it is necessary for the previous heparin products to be available in selected client service areas, the
organizations interdisciplinary committee for medication management reviews and approves the rationale for
availability and safeguards put in place to minimize the risk of error.
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
accreditation.ca
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Required
Organizational
Practices
MEDICATION USE
REPLACES the Medication Concentrations ROP for on-site surveys starting January
2014 or January 2015, depending on the set of standards (see below for details).
HIGH-ALERT MEDICATIONS
For on-site surveys starting January 2014 for the following sets of standards: Emergency Medical Services,
Medication Management, and Medication Management for Remote/Isolated Health Services.
For on-site surveys starting January 2015 for the following sets of standards: Independent Medical Surgical
Facilities, and Medication Management for Community-Based Organizations.
The organization implements a comprehensive strategy for the management of high-alert
medications.
GUIDELINES
High-alert medications have an increased risk of causing significant client harm when they are administered in error.
Implementing a comprehensive strategy for the management of high-alert medications is a valuable use of resources to
enhance client safety, and to reduce the possibility of serious harm.
High-alert medications include but are not limited to: antithrombotic agents; adrenergic agents; chemotherapy agents;
concentrated electrolytes; insulin; narcotics (opioids); neuromuscular blocking agents; and sedation agents. A detailed list of
high-alert medications developed by the Institute for Safe Medication Practices (United States) can be found online and is a
valuable starting point for the identification of high-alert medications. ISMP has also produced a list of high-alert medications
specifically for community/ambulatory settings.
To prevent harm from medication errors, a policy for the management of high-alert medications is required. High-alert
medications policies identify a list of high-alert medications based on an organizations medication formulary and informed by
available organizational, provincial, or national medication error data. Strategies for the safe use of high-alert medications may
include but are not limited to:
Standardizing high-alert medication concentrations and volume options
Using pre-mixed solutions (commercially available and pharmacy prepared)
Using programmable pumps with dosing limits and automated alerts
Applying warning labels to products as soon as they are received in the pharmacy
Using visible warning and auxiliary labels according to the organizations policy
Using patient-specific labelling for unusual concentrations
Limiting access to high-alert medications in client service areas and auditing routinely to assess for items that should be
removed
Standardizing the ordering, storage, preparation, administration, and dispensing of these products through the use of
protocols, guidelines, dosing charts, and orders sets (pre-printed or electronic)
Segregating and providing directed access to reduce the likelihood of selection errors (e.g., use of automated dispensing
cabinets in client service areas)
Providing training about high-alert medications
Employing redundancies such as automated or independent double checks
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Required
Organizational
Practices
MEDICATION USE

HIGH-ALERT MEDICATIONS
A policy for the management of high-alert medications may place additional emphasis on strategies for high-risk client
populations including the elderly, paediatrics, and neonates, as well as on transition points including admission, transfer, and
discharge. Organizations should systematically evaluate each high-alert medication or class of medications and establish an
action plan to improve the safe use of these medications. Specific strategies for the safe use of concentrated electrolytes,
heparin products, and narcotics (opioids) should be developed in accordance with Accreditation Canadas medication safety
ROPs.
Major
Minor
Major
Major
Major
Minor
Minor
Major
The organization has a policy for the management of high-alert medications.

The policy names the individual(s) responsible for implementing and monitoring the policy.
The policy includes a list of high-alert medications identified by the organization.
The policy includes procedures for storage, prescribing, preparation, administration, dispensing, and
documentation for each high-alert medication, as appropriate.
The organization limits and standardizes concentrations and volume options available for high-alert medications.
The organization regularly audits client service areas for high-alert medications.
The organization establishes a mechanism to update the policy on an ongoing basis.
The organization provides information and ongoing training to staff on the management of high-alert medications.
REFERENCE MATERIAL
U, D. (2006) High-alert medications: the need for awareness and safeguards to prevent patient harm. Hospital News. [On-line]. Available:
www.ismp-canada.org/download/hnews/HNews0606.pdf
Institute for Healthcare Improvement (IHI) (2012). High-Alert Medication Safety. [On-line]. Available:
www.ihi.org/explore/highalertmedicationsafety/pages/default.aspx
Institute for Safe Medication Practices (ISMP) (2013). Your high-alert medication list relatively useless without associated risk-reduction
strategies. ISMP Medication Safety Alert Acute Care. Institute for Safe Medication Practices. April 4. [On-line].
Available: www.ismp.org/Newsletters/acutecare/showarticle.asp?id=45
Institute for Safe Medication Practices (ISMP) (2012). List of High-Alert Medications. [On-line]. Available:
www.ismp.org/Tools/highAlertMedicationLists.asp
Institute for Safe Medication Practices (ISMP) (2011). ISMP List of High-Alert Medications in Community/Ambulatory Healthcare
[On-line]. Available: www.ismp.org/communityRx/tools/ambulatoryhighalert.asp
accreditation.ca
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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.
Major There is documented evidence of ongoing, effective training on infusion pumps.

REFERENCE MATERIAL
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: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2003-07InfusionPumps.pdf
Institute for Safe MedicationPractices - Canada (2004). Infusion Pump Project: Survey Results and Time for Action. ISMP Canada Safety
Bulletin [On-line]. Available: www.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: www.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:
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.
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Required
Organizational
Practices
MEDICATION USE
A revised version of this ROP (High-alert Medications) for select sets of

standards appears on page 41.
MEDICATION CONCENTRATIONS
For on-site surveys until December 31 2014 for the Independent Medical Surgical Facilities Standards.
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.
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 [On-line]. Available: www.ismp.org/tools/PediatricConcentrations.pdf
Institute for Safe Medication Practices - Canada (2012). Drug Shortages and Medication Safety Concerns. ISMP Canada Safety Bulletin
[On-line]. Available: www.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.
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44
Required
Organizational
Practices
MEDICATION USE
A revised version of this ROP for select sets of standards appears on the following
pages.
NARCOTICS SAFETY
For on-site surveys until December 31 2014 for the following sets of standards: Customized Managing
Medications and Independent Medical Surgical Facilities.
The organization evaluates and limits the availability of narcotic (opioid) products and removes highdose, 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
15mg/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: 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 (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/
Institute for Safe Medication Practices Canada (2013). HYDROmorphone remains a high-alert drug. Ontario Critical Incident Learning
Bulletins. 2 (Feb). [On-line]. Available: www.ismp-canada.org/ocil/
Institute for Safe Medication Practices Canada (2013). Safeguards for HYDROmorphoneresults of a targeted demonstration project.
ISMP Canada Safety Bulletin. 13(10). [On-line]. Available: www.ismp-canada.org/ISMPCSafetyBulletins.htm
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45
Required
Organizational
Practices
MEDICATION USE
REVISED For on-site surveys starting January 2014 or January 2015,

NARCOTICS SAFETY
For on-site surveys starting January 2014 for the following sets of standards: Emergency Medical Services,
Medication Management, and Medication Management for Remote/Isolated Health Services.
For on-site surveys starting January 2015 the following sets of standards: Independent Medical Surgical
Facilities, and Medication Management for Community-Based Organizations.
The organization evaluates and limits the availability of narcotic (opioid) products to ensure that
formats with the potential to cause harmful medication incidents are not stocked in client service
areas.
GUIDELINES
Opioids have been identified as high-alert medications that are an area of focus for safety. Limiting availability and ensuring that
high dose formats of opioid products are not stocked in client service areas is an effective strategy to minimize the risk of death
or disabling injury associated with these agents.
Narcotic (opioid) products to be the focus of audit to ensure that they are not stocked in client service areas include:
Fentanyl: ampoules or vials with total dose greater than 100 mcg per container
HYDROmorphone: ampoules or vials with total dose greater than 2 mg
Morphine: ampoules or vials with total dose greater than 15 mg in adult care areas and 2 mg in paediatric care areas
For specific care circumstances, it may be necessary for narcotic (opioid) products to be available in selected client service
areas.
Possible Examples:
HYDROmorphone: 10 mg/mL ampoules or vials may be provided based on the following criteria and must be removed
when no longer required: intermittent intravenous, subcutaneous or intramuscular doses greater than 4 mg
In these cases, the organization reviews and approves the rationale for availability and safeguards put in place to minimize the
risk of error.
To optimize the safe use of narcotic (opioid) products, organizations may also consider the implementation of a pain management team. Organizations serving paediatric populations are encouraged to implement recommendations from the Canadian
Association of Paediatric Health Centres and the Institute for Safe Medication Practices Canada (ISMP Canada) Paediatric Opioid Safety Resource Kit, including the use of standardized concentrations for opioid infusions. Additional strategies to ensure the
safe use of high-alert medications such as narcotics (opioids) may be found in the Accreditation Canada ROP about high-alert
medications.
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46
Required
Organizational
Practices
MEDICATION USE

NARCOTICS SAFETY
Major The organization completes an audit of the following narcotic (opioid) products in client service areas at least
annually:
Morphine: ampoules or vials with total dose greater than 15 mg in adult care areas and 2 mg in paediatric care
areas.
Major The organization avoids stocking the following narcotic (opioid) products in client service areas:
Morphine: ampoules or vials with total dose greater than 15 mg in adult care areas and 2 mg in paediatric care
areas.
Major When it is necessary for narcotic (opioid) products to be available in selected client service areas, the organizations
interdisciplinary committee for medication management reviews and approves the rationale for availability and safeguards put in place to minimize the risk of error.
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+Recommen

ded+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 (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/
Institute for Safe Medication Practices Canada (2013). HYDROmorphone remains a high-alert drug. Ontario Critical Incident Learning
Bulletins. 2 (Feb). [On-line]. Available: www.ismp-canada.org/ocil/
Institute for Safe Medication Practices Canada (2013). Safeguards for HYDROmorphoneresults of a targeted demonstration project.
ISMP Canada Safety Bulletin. 13(10). [On-line]. Available: www.ismp-canada.org/ISMPCSafetyBulletins.htm
accreditation.ca
47
Required
Organizational
Practices
WORKLIFE/WORKFORCE
Create a worklife and physical environment that

supports the safe delivery of care and service
NEW For on-site surveys starting January 2015
CLIENT FLOW
For the Leadership Standards
The organizations leaders work proactively with internal teams and teams from other sectors
to improve client flow throughout the organization and mitigate overcrowding in the emergency
department.
NOTE: This ROP only applies to acute care organizations or health systems with an emergency department.
GUIDELINES
Overcrowding occurs when the demand for services exceeds the capacity of the emergency department (ED) to provide quality and timely care. Clients need to receive the right care, in the right place, and at the right time; however, an organizations
ability to do so is compromised when the ED becomes overcrowded. When overcrowding occurs, admitted clients stay in the
ED and are cared for by the ED team instead of the designated unit and team. This creates an access block to ED, resulting in
prolonged ED wait times, diversion of ambulances, people leaving the ED without being seen, privacy challenges, poor quality
care, increased risk to clients, and poor quality worklife.
ED overcrowding is a system-wide challenge and its root cause is usually poor client flow (e.g., unavailability of inpatient beds,
inappropriate admissions, delays in the decision to admit, delays in discharge, and lack of timely access to diagnostic services
and care in the community). Poor client flow results from a mismatch between capacity and demand. By evaluating client flow
data and considering all sources of demand (emergency and planned admissions, and outpatient and follow-up care), organizations can understand the pattern of demand. Once patterns of demand are understood, organizations can develop a strategy to
meet variations in demand, reduce barriers to client flow, and prevent overcrowding. The strategy should be aligned with existing provincial and territorial indicators and strategies.
The strategy needs to specify the role of clinical and non-clinical teams within the hospital (e.g., medicine, surgery, infection
control, diagnostics, housekeeping, admitting, discharge planning, and transportation) and across the health system (e.g., longterm care, home care, palliative care, rehabilitation, and primary care).
Improving client flow requires strong leadership support. The accountability of senior leaders (including physicians) can be
demonstrated in a policy, in their roles and responsibilities, or through performance evaluation. Organizations must implement
interventions that address variations in demand and barriers to flow. Possible interventions include developing clear criteria for
admission, reducing the length of stay (especially for client groups with extended lengths of stay), improving access to ambulatory services (diagnostics, laboratory, and consults), improving discharge planning, and partnering with the community to
improve placement times. To know whether the intervention(s) led to an improvement, organizations need to continue to analyze
client flow.
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48
Required
Organizational
Practices
WORKLIFE/WORKFORCE

CLIENT FLOW
Major
Major
Major
Major
Major
Major
Major
Minor
The organizations leaders, including physicians, are held accountable for acting proactively to improve client flow
and mitigate emergency department overcrowding.
The organization uses client flow data (e.g., length of stay, turnaround times for labs or imaging, community
placement times, consultant response times) to identify variations in demand and barriers to delivering timely
emergency department services.
The organization has a documented and coordinated approach to improve client flow and address emergency
department overcrowding.
The approach specifies the role of teams within the hospital and other sectors of the health system to improve
client flow.
The strategy specifies targets for improving client flow (e.g., time to transfer clients to an inpatient bed following
a decision to admit, emergency department length of stay for non-admitted clients, transfer of care times from
emergency medical services to the emergency department).
The organization implements interventions to improve client flow, that address identified variations in demand and
barriers.
When needed, the organization implements short-term actions to manage overcrowding that mitigate risks to
client and staff (e.g., over-capacity protocols).
The organization uses client flow data to measure whether the interventions prevent or reduce overcrowding in
the emergency department, and makes improvements when needed.
REFERENCE MATERIAL:
Canadian Association of Emergency Physicians (2013). Position Statement on Emergency Department Overcrowding and Access Block.
Canadian Association of Emergency Physicians (CAEP). Ottawa, ON. [On-line]. Available:

http://caep.ca/resources/position-statements-and-guidelines
Canadian Nurses Association (2009). Overcapacity protocols and capacity in Canadas health system. CAN Position Statement. Ottawa,
ON. [On-line]. Available: www.cna-aiic.ca/en/advocacy/policy-support-tools/cna-position-statements
Guttmann, A., Schull, M.J., Vermeulen, M.J., Stukel,T.A. (2011) Association between waiting times and short term mortality and hospital
admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 342:d2983. [On-line].
Available: www.bmj.com/content/342/bmj.d2983
De Grood, J., Bota, M., Zwicker, K., et al (2012). Overview of interventions to mitigate emergency department overcrowding. In:
Review of the quality of care and safety of patients requiring access to emergency department care and cancer surgery and the
role and process of physician advocacy. p247-321. Health Quality Council of Alberta. Edmonton, AB. [On-line] Available:
http://publications.hqca.ca/preview/176
Forero, R., Hillman, K. (2008) Access block and overcrowding: a literature review. Prepared for the Australasian College for Emergency
Medicine. Simpson Centre for Health Services Research, South Western Sydney Clinical School, University of New South Wales.
Sydney, Australia. [On-line]. Available: www.acem.org.au/media/Access_Block_Literature_Review_08_Sept_3.pdf
McHugh, M. Van Dyke, K., McClelland, M. Moss, D. (2011). Improving patient flow and reducing emergency department crowding: a
guide for hospitals. Agency for Healthcare Research and Quality. Rockville, MD. [On-line]. Available:
www.ahrq.gov/research/findings/final-reports/ptflow/ptflowguide.pdf
Institute for Healthcare Improvement (2003). Optimizing patient flow: moving patients smoothly through acute care settings. IHI
Innovation Series white paper. Institute for Healthcare Improvement. Boston, MA. [On-line]. Available:
www.ihi.org/knowledge/Pages/IHIWhitePapers/OptimizingPatientFlowMovingPatientsSmoothlyThroughAcuteCareSettings.aspx
The Health Foundation (2013). Improving patient flow: How two trusts focused on flow to improve the quality of care and use available
capacity effectively. The Health Foundation. London, UK. [On-line]. Available: www.health.org.uk/publications/improving-patient-flow/
accreditation.ca
49
Required
Organizational
Practices
WORKLIFE/WORKFORCE

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.
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.
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50
Required
Organizational
Practices
WORKLIFE/WORKFORCE

CLIENT SAFETY PLAN

The organization develops and implements a client safety plan.
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.
There is an important connection between excellence in care and safety. Ensuring safety in the provision of services is one of
an organizations primary obligations to clients, staff, and service providers. Accordingly, safety should be a written as a formal
component of an organizations client safety plan.
Major
Minor
Major
Minor
The organization assesses client safety issues.

There is a plan and process in place to address identified client safety issues.
The plan includes client safety as a written strategic priority or goal.
The organization allocates resources to support the implementation of the client safety plan.
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_50735
9c3-7353-4b72-8a37-e6a3c7f1e594/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.
accreditation.ca
51
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.
accreditation.ca
52
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 who 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 organization's leaders to investigate and respond to incidents of
workplace violence.
Minor The organization's 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.
accreditation.ca
53
Required
Organizational
Practices
WORKLIFE/WORKFORCE

WORKPLACE VIOLENCE PREVENTION
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-EVPPStudy-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.
Public Services Health and Safety Association (2009). Assessing Violence in the Community: A Handbook for the Workplace. [On-line].
Available: www.healthandsafetyontario.ca/PSHSA/Products/Product-Page-1-(4).aspx
Public Services Health and Safety Association (2010). Addressing Domestic Violence in the Workplace. [On-line]. Available:
www.healthandsafetyontario.ca/PSHSA/Products/Product-Page-1-(4).aspx
Public Services Health and Safety Association (2010). Bullying in the Workplace: A Handbook for the Workplace. [On-line]. Available:
Registered Nurses Association of Ontario (2009). Preventing and Managing Violence in the Workplace. Registered Nurses Association
of Ontario [On-line]. Available: rnao.ca/bpg/guidelines/preventing-and-managing-violence-workplace
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
accreditation.ca
54
Required
Organizational
Practices
INFECTION CONTROL
Reduce the risk of health care-associated infections and their

impact across the continuum of care/service
This ROP has been revised for 2015; details appear on the following page.
HAND-HYGIENE COMPLIANCE
(formerly called 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.

Canada's Hand Hygiene Challenge (2012). Hand Hygiene Toolkit. Canada's 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.
accreditation.ca
55
Required
Organizational
Practices
INFECTION CONTROL

(formerly called Hand-hygiene audit)
The organization measures its compliance with accepted hand-hygiene practices.
GUIDELINES
Hand hygiene is considered the single most important way to reduce health care-associated infections, but compliance with
accepted hand-hygiene practices is often poor.
Measuring compliance with hand-hygiene practices allows organizations to improve education and training about hand
hygiene, evaluate hand-hygiene facilities, and benchmark compliance practices across the organization. Studies have
shown that improvements in compliance with hand-hygiene practices have decreased the number of health care- associated
infections.
The best method for measuring compliance with accepted hand-hygiene practices is to use direct observation (audits). Direct
observation involves watching and recording the hand-hygiene behaviours of staff and observing the work environment.
Observation can be done by a trained observer within an organization, using a buddy system when two or more health care
professionals work together, or by patients/families within an organization or in the community. Safer Healthcare Now! offers
a variety of tools for measuring hand-hygiene compliance in different settings. Ideally, direct observation should measure
compliance in all four moments for hand hygiene:
1. Before initial contact with the client or their environment
2. Before a clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a client or their environment
Direct observation should be used by all organizations working out of a fixed location (i.e., clients come to them). For
organizations providing services in clients homes, direct observation is still the best method of measuring hand-hygiene
compliance. Such organizations may wish to consider having clients (and their families) measure staff compliance with
accepted hand-hygiene practices tools are available at www.handhygiene.ca. Organizations that provide services in clients
homes, and find that direct observation is not possible, can consider alternative methods such as:
Staff recording their own compliance with accepted hand-hygiene practices (self-audit)
Measuring product use
Questions on client satisfactions surveys that ask about staffs hand-hygiene compliance
Measuring the quality of hand-hygiene techniques (e.g., through the use of ultraviolet gels or lotions)
Since these alternatives are not as robust as direct observation, they should be used in combination (two or more) to give a
more accurate picture of organizational compliance with accepted hand-hygiene practices.
accreditation.ca
56
Required
Organizational
Practices
INFECTION CONTROL

Major
Minor
Minor
The organization measures its compliance with accepted hand-hygiene practices using direct observation methods
(e.g., audit). For organizations that provide services in clients homes, a combination (two or more) of alternative
methods may be used.
The organization shares the results of measuring hand-hygiene compliance with staff, service providers, and
volunteers.
The organization uses the results of measuring hand-hygiene compliance to make improvements to its handhygiene 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.
accreditation.ca
57
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
alcohol-based 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].
Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingHandHygiene.aspx
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:
whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
accreditation.ca
58
Required
Organizational
Practices
INFECTION CONTROL

HAND-HYGIENE EDUCATION AND TRAINING

The organization provides hand-hygiene education to staff, service providers, and volunteers.
GUIDELINES
Hand hygiene is a critical component of an effective infection prevention and 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.
Training on hand hygiene is multimodal and addresses the importance of hand hygiene in 1) preventing the transmission
of microorganisms, 2) factors that have been found to influence hand-hygiene behaviour, and 3) proper hand-hygiene
techniques. Training also includes recommendations about when to clean ones hands, based on the four moments for hand
hygiene:
1. Before initial contact with the client or their environment
2. Before a clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a client or their environment
Major The organization provides staff, service providers, and volunteers with education about 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
alcohol-based 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].
Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingHandHygiene.aspx
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
accreditation.ca
59
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
accreditation.ca
60
Required
Organizational
Practices
INFECTION CONTROL

INFECTION RATES
The organization tracks health care-associated infections;, analyzes the information to identify
outbreaks and trends;, and shares this information throughout the organization.
GUIDELINES
Tracking methods may focus on a particular health care-associated infection or service area, or may be organization- or
system-wide. They may include data analysis techniques to help detect previously unrecognized outbreaks.
The organization identifies the health-care associated infections most common to its services and client populations, such
as Clostridium difficile (C. difficile), surgical site infections, seasonal influenza, noroviruses, or urinary tract infections as well
as other reportable diseases and antibiotic-resistant organisms. The organization tracks these as well as other reportable
diseases and antibiotic-resistant organisms. The information tracked may include frequencies and changes in frequencies over
time, associated mortality rates, and attributed costs.
Staff and service providers who are well informed about health care-associated infection rates are usually better equipped
to prevent and manage them. The organization identifies who is responsible for receiving information about health careassociated infection rates (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 health careassociated infection rates and associated IPC issues. This may be done directly through senior management and/or a medical
advisory committee.
Major
Minor
Minor
The organization tracks health care-associated infection rates.

The organization analyzes outbreaks and makes recommendations to prevent recurrences.
The organization shares 1) information about relevant health care-associated infections and 2) recommendations
from outbreak reviews with staff, service providers, senior leadership, and the governing body.
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
accreditation.ca
61
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, 291-299.
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
[On-line]. 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.
accreditation.ca
62
Required
Organizational
Practices
INFECTION CONTROL

REPROCESSING
(formerly called Sterilization Processes)
The organization monitors its processes for reprocessing equipment, and makes improvements as
appropriate.
GUIDELINES
Reprocessing includes the processes for cleaning, disinfecting, and sterilizing, and the level of reprocessing used depends
on the risk of infection associated with the use of medical devices/equipment (Spaulding classification). Monitoring their
reprocessing processes helps organizations identify areas for improvement and reduce health care-associated infections.
Examples of methods to measure the effectiveness of reprocessing include: monitoring water quality and washer function; and
measuring organic residuals, ATP (adenosine triphosphate (ATP), and total viable count. 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
accreditation.ca
63
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/docs/3_20110811_100931Residential%20

Care%20Framework_Aug%2010_2011.pdf
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: http://c.ymcdn.com/sites/www.alphaweb.org/resource/collection/822ec60d-0d03413e-b590-afe1aa8620a9/LHIN_report_IntegratedProvincialFallsPreventionFrameworkToolkit_07-07-2011.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! (2013). Reducing Falls and Injury from Falls. Safer Healthcare Now! Getting Started Kit. [On-line]. Available:
www.saferhealthcarenow.ca/en/interventions/fallsault.aspx
accreditation.ca
64
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.
Public Services Health and Safety Association (2009). Assessing Violence in the Community: A Handbook for the Workplace. [On-line].
Available: www.healthandsafetyontario.ca/PSHSA/Products/Product-Page-1-(4).aspx
Public Services Health and Safety Association (2010). Tips for Guarding Your Personal Safety on Home Visits. [On-line]. Available:
accreditation.ca
65
Required
Organizational
Practices
RISK ASSESSMENT
PRESSURE ULCER PREVENTION

The team assesses each clients risk for developing a pressure ulcer and implements interventions to
prevent pressure ulcer development.
GUIDELINES
Pressure ulcers have a significant impact on client 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
SCIPUS (Spinal Cord Injury Pressure Ulcer 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.
accreditation.ca
66
Required
Organizational
Practices
RISK ASSESSMENT
PRESSURE ULCER PREVENTION
Major The team conducts an initial pressure ulcer risk assessment at admission, using a validated, standardized risk
assessment tool.
Major The team reassesses each client for risk of developing pressure ulcers at regular intervals, and with significant
change in client 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, clients, 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 (2011). Risk Assessment & Prevention of Pressure Ulcers. Registered Nurses Association of
Ontario [On-line]. Available: www.rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
Woodbury, M. G. & Houghton, P. E. (2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy.Wound.Manage.,
50, 22-28.
accreditation.ca
67
Required
Organizational
Practices
RISK ASSESSMENT
NEW for on-site surveys starting January 2015
SKIN AND WOUND CARE

For the Home Care Services Standards.
The organization uses an interprofessional and collaborative approach to assess clients who need
skin and wound care and provide evidence-informed care that promotes healing and reduces
morbidity and mortality.
GUIDELINES
Wound healing is a complex process that depends on client factors (e.g., co-morbidities, age, nutritional status, etc.), the type
of skin and wound, the clients environment (e.g., cleanliness, social support, mobility aids, etc.), and the system in which
the client receives care, such as different providers and settings. Many wounds can be avoided through proper skin care and
preventive measures, some of which are outlined in the Accreditation Canada ROP on preventing pressure ulcers.
Once they have occurred, most (although not all) clients wounds can be healed through proper assessment, accurate
diagnosis, appropriate treatment, and proper self-care. Appropriate care can reduce client suffering (e.g., intractable pain,
infection, amputation, hospital admission, reduced quality of life) and save lives. Clients who need skin and wound care
are a high-volume service (more than one-third of all home care clients need wound care) and wounds cost the Canadian
health care system $3.9 billion dollars annually (or 3 percent of total health care expenditures). Effective skin and wound care
programs result in better client outcomes and lower costs.
Comprehensive interprofessional collaboration using evidence-informed protocols that are standardized across the system
is the most effective way to provide skin and wound care. A wide range of expertise is needed, and interprofessional
collaboration can be achieved in different ways (e.g., interdisciplinary teams, rounds, virtual networks, telehealth). It is
important that organizations identify when and how care providers can access expertise to ensure accurate diagnosis of the
wound(s) and seamless skin and wound care. To support interprofessional collaboration, staff, as well as clients and their
families and caregivers, need information and education that is tailored to their roles in providing appropriate care.
Effective skin and wound care starts with a comprehensive assessment to obtain an accurate diagnosis of the wound; it
includes assessing the clients skin and wound and reviewing client factors, the clients environment, and the care the client
has already received. Canadian evidence-informed best practice guidelines for skin and wound care are available (e.g.,
Canadian Association for Wound Care, Registered Nurses Association of Ontario). Adopting guidelines helps organizations
strengthen the skin and wound care they provide through proper assessment, accurate diagnosis, appropriate products
and treatments, appropriate interdisciplinary referrals, and ongoing monitoring. Given the plethora of wound care products
available, care is strengthened when organizations have a standardized product list that includes criteria for use. A
standardized approach for accurate and comprehensive documentation of all aspects of care is needed for professionals to
communicate effectively.
Giving providers timely access to information about wounds has been shown to dramatically improve client outcomes and
healing time, so organizations need a process to share complete information as the client moves between providers and
services.
accreditation.ca
68
Required
Organizational
Practices
RISK ASSESSMENT

SKIN AND WOUND CARE
Indicator data related to care processes and client outcomes should be used to evaluate the effectiveness of the approach to
skin and wound care. Possible indicators include home care data (e.g., length of stay, wound dimensions, number of visits)
as well as tools such as Health Outcomes for Better Information and Care (HOBIC) and the interRAI Community Health
Assessment (interRAI-CHA).
Major The organization has a documented and coordinated approach to skin and wound care that supports physicians,
nurses, and allied health professionals to work collaboratively and provides access to the range of expertise that is
appropriate for the client population.
Major The organization provides access to education for staff on appropriate skin and wound care, including products and
technologies, assessment, treatment, and documentation.
Major The organization provides information and education to clients (and their families and caregivers) on skin and wound
self-care, in a format that they can understand.
Major The organization uses evidence-informed assessment of new clients to determine or confirm the diagnosis of the
wound and develop an individualized care plan that addresses the cause(s) of the wound.
Major The organization supports the delivery of standardized skin and wound care that optimizes skin health and promotes
healing.
Major The organization implements standardized documentation to create a comprehensive record of all aspects of the
clients skin and wound care (including the assessment, treatment goals, treatment provided, and client outcomes).
Major The organization has a process to share information between providers, and especially at care transitions, about
clients skin and wound care.
Minor The organization monitors the effectiveness of the skin and wound care program by measuring care processes (e.g.,
accurate diagnosis, appropriate treatment, etc.) and client outcomes (e.g., healing time, pain, etc.), and uses this
information to make improvements.
REFERENCE MATERIAL:
Best Practice Recommendations. Canadian Association of Wound Care. Toronto, ON. [On-line] Available at:
http://cawc.net/index.php/resources/resources/clinical-practice/
Best Practice Guidelines. Registered Nurses Association of Ontario; Toronto, ON. [On-line] Available at: www.rnao.ca
Canadian Home Care Association (2012). An ehealth evidence-based approach to wound care: target, measure, report and improve
equals enhanced client outcomes and cost savings. High Impact Practices. [On-line]. Available:
www.cdnhomecare.ca/content.php?doc=46
Canadian Institute for Health Information (2013). Compromised Wounds in Canada. Analysis in Brief. Canadian Institute for Health
Information. [On-line]. Available:
www.cihi.ca/cihi-ext-portal/internet/en/document/health+system+performance/quality+of+care+and+outcomes/release_29aug13
Lareforet, K., Allen, J.O., McIssac, C. (2012) Evidence-based wound care: home care perspective. Canadian Home Care Association;
Mississauga, ON. [On-line] Available at: www.cdnhomecare.ca/content.php?doc=263
Medical Advisory Secretariat. (2009) Community-based care for chronic wound management: an evidence-based analysis. Ontario
Health Technology Assessment Series; 9(18). [On-line] Available at:
www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series
Wound Care Alliance Canada. (2012) Wounds: National Stakeholder Round-table. Report of the June 27 2012 Meeting.
accreditation.ca
69
Required
Organizational
Practices
RISK ASSESSMENT
SUICIDE PREVENTION
The team 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
1.7percent 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 team identifies clients at risk of suicide.

The team assesses each client for risk of suicide at regular intervals, or as needs change.
The team addresses the immediate safety needs of clients who are identified as being at risk of suicide.
The team identifies treatment and monitoring strategies to ensure client safety.
The team 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/suicideeng.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
accreditation.ca
70
Required
Organizational
Practices
RISK ASSESSMENT
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS

NOTE: This ROP is not a requirement for pediatric hospitals. The ROP applies to clients 18 years of age or older.
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.
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.
accreditation.ca
71
Required
Organizational
Practices
RISK ASSESSMENT
VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS
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
th
thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8 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
post-thrombotic 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.
Ontario Hospital Association. Prevention of Venous Thromboembolism (VTE): Online Training Module (available for a fee). [On-line].
Available: media.oha.com/MediaCentre/VTEFlyer.pdf
Safer Healthcare Now! (2011). Venous Thromboembolism - Resources. Safer Healthcare Now! [On-line]. Available:
www.saferhealthcarenow.ca/EN/Interventions/vte/Pages/resources.aspx
Smith, R.E., Geerts, W., Diamantouros, A., et al. Prevention of Venous Thromboembolism (VTE) in Hospitalized Medical and Surgical
Patients: A Multi-component Toolkit for Canadian Hospitals. [available for purchase, see www.saferhealthcarenow.ca/EN/Interventions/
vte/Documents/VTE%20Prevention%20Simplified%20Multicomponent%20Toolkit%20Information.pdf
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
accreditation.ca
72
Required
Organizational
Practices
ROP DEVELOPMENT OVER THE YEARS
2006 (PreQmentum)
2010
Adverse events disclosure

Adverse events reporting
Client and family role in safety
Client safety: Education and training
Client safety plan
Client safety-related prospective analysis
Client safety quarterly reports
Client safety: Roles and responsibilities
Client safety as a strategic priority
Concentrated electrolytes
Hand-hygiene education and training
Infection rates
Infection control guidelines
Information transfer
Infusion pumps training
Medication concentrations
Medication reconciliation (MedRec) at admission
MedRec at transfer or discharge
Preventive maintenance
Sterilization processes
Verification processes for high-risk activities
MedRec as an organizational priority
2011
Home safety risk assessment
Safe surgery checklist
Venous thromboembolism prophylaxis
Workplace violence prevention
2012
No new ROPs
2013
New ROPs
Antimicrobial stewardship
Pressure ulcer prevention (added to six acute care
standards sets)
ROPs transitioned to high-priority criteria

Client safety: Roles and responsibilities
Client safety as a strategic priority (moved into the
client safety plan ROP)
Infection control guidelines
Influenza vaccine
Verification processes for high-risk activities
2007
No new ROPs
2008 (Qmentum)
Falls prevention strategy
Influenza vaccine
Pneumococcal vaccine
Two client identifiers
2014
Accountability for quality
Client flow
Skin and wound care
2009
Dangerous abbreviations
Hand-hygiene audit
Heparin safety
Narcotics safety
Pressure ulcer prevention (for long-term care)
Suicide prevention
accreditation.ca
73
Required
Organizational
Practices
INDEX
Accountability for Quality

For the Governance Standards.............................................4
Adverse Events Disclosure.....................................................6
Adverse Events Reporting......................................................7
Antimicrobial Stewardship ...................................................33
Client and Family Role in Safety...........................................10
Client Flow .............................................................................48
For the Leadership Standards.............................................48
Client Safety: Education and Training..................................50
Client Safety Plan...................................................................51
Client Safety Quarterly Reports..............................................8
Client Safety-related Prospective Analysis...........................9
Concentrated Electrolytes
following sets of standards: Medication Management and
Medication Management for Remote/Isolated
Health Services...................................................................36
Dangerous Abbreviations......................................................11
Falls Prevention Strategy......................................................64
Hand-hygiene Compliance (formerly called
Hand-hygiene Audit).................................................................55
Hand-hygiene Compliance
For on-site surveys starting January 2015.....................56
Hand-hygiene Education and Training.................................58
Hand-hygiene Education and Training
Heparin Safety
following sets of standards: Medication Management,
and Medication Management for Remote/Isolated
Health Services...................................................................39
accreditation.ca

High-alert Medications
Surgical Facilities, and Medication Management
for Community-Based Organizations..................................41
Home Safety Risk Assessment.............................................65
Infection Rates........................................................................60
Infection Rates
Information Transfer..............................................................12
Infusion Pumps Training........................................................43
Medication Concentrations
Independent Medical Surgical Facilities Standards.............44
Medication Reconciliation as a Strategic Priority
For the following sets of standards: Leadership,
Leadership for Small Community-based Organizations......13
Medication Reconciliation at Care Transitions
For the following sets of standards: Acquired Brain
Injury Services, Cancer Care and Oncology Services,
Correctional Service of Canada Health Services,
Critical Care Services, Emergency Department, Hospice
Palliative and End-of-Life Services, Medicine Services,
Mental Health Services, Obstetrics Services, Provincial
Correctional Health Services, Rehabilitation Services,
and Surgical Care Services.................................................16
For the following sets of standards: Aboriginal Integrated
Primary Care Services, Ambulatory Care Services,
Ambulatory Systemic Cancer Therapy Services, and
Remote/Isolated Health Services........................................19
For the Emergency Department Standards.........................22
For the following sets of standards: Case Management
Services, Community-Based Mental Health Services
and Supports, and Home Care Services.............................25
74
Required
Organizational
Practices
For the following sets of standards: Long-term Care
Services, and Residential Homes for Seniors.....................27
For the following sets of standards: Aboriginal Substance
Misuse Services, and Substance Abuse and Problem
Gambling Services..............................................................29
Narcotics Safety
For on-site surveys until December 31 2014 for the following
sets of standards: Customized Medication Management, and
Independent Medical Surgical Facilities..............................45
For on-site surveys starting January 2015 the
Surgical Facilities, and Medication Management for
Pneumococcal Vaccine..........................................................62
Pressure Ulcer Prevention ....................................................66
Preventive Maintenance Program.........................................52
Reprocessing (formerly called Sterilization Processes).........63
Safe Surgery Checklist..........................................................31
Skin and Wound Care
For the Home Care Services Standards.............................68
Suicide Prevention ................................................................70
Two Client Identifiers.............................................................32
Venous Thromboembolism (VTE) Prophylaxis...................71
Workplace Violence Prevention............................................53
accreditation.ca
75

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accreditation.

Required Organizational Practices

Required Organizational Practices Handbook 2014

1150 Cyrville Road, Ottawa, ON K1J 7S9

For the following sets of standards: Aboriginal Substance

SAFETY CULTURE: Create a culture of safety within the organization

Accountability for quality

Client and family role in safety

Hand-hygiene compliance (formerly called Hand-hygiene audit)

Falls prevention strategy

Create a culture of safety within the organization

For on-site surveys starting January 2015

ACCOUNTABILITY FOR QUALITY

TESTS FOR COMPLIANCE

Improvement; Cambridge, MA. [On-line] Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuideGovernanceLeadership.aspx

Create a culture of safety within the organization

ADVERSE EVENTS DISCLOSURE

IHI Innovation Series white paper [On-line]. Available:

Create a culture of safety within the organization

ADVERSE EVENTS REPORTING

Healthcare Improvement [On-line]. Available: www.ihi.org/knowledge/Knowledge%20Center%20Assets/Tools%20-%20

Create a culture of safety within the organization

CLIENT SAFETY QUARTERLY REPORTS

J.Healthc.Manag., 54, 15-29.

Create a culture of safety within the organization

CLIENT SAFETY-RELATED PROSPECTIVE ANALYSIS

Improve the effectiveness and coordination of communication among care and

CLIENT AND FAMILY ROLE IN SAFETY

Improve the effectiveness and coordination of communication among care and

ISMP Canada Safety Bulletin [On-line]. Available: www.ismp-canada.org/download/safetyBulletins/ISMPCSB2006-04Abbr.pdf

Improve the effectiveness and coordination of communication among care and

handover to enhance patient safety. Healthc.Q., 9 Spec No, 75-79.

Improve the effectiveness and coordination of communication among care and

MEDICATION RECONCILIATION AS A STRATEGIC PRIORITY

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and

MEDICATION RECONCILIATION AT CARE TRANSITIONS

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and

MEDICATION RECONCILIATION AT CARE TRANSITIONS

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and

TESTS FOR COMPLIANCE

Improve the effectiveness and coordination of communication among care and

REVISED for on-site surveys starting January 2015

MEDICATION RECONCILIATION AT CARE TRANSITIONS

Improve the effectiveness and coordination of communication among care and

Client factors, including those who:

Improve the effectiveness and coordination of communication among care and

Healthcare Improvement [On-line]. Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx

Improve the effectiveness and coordination of communication among care and

MEDICATION RECONCILIATION AT CARE TRANSITIONS

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and

MEDICATION RECONCILIATION AT CARE TRANSITIONS

Improve the effectiveness and coordination of communication among care and

Healthcare Improvement [On-line]. Available: www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx

Improve the effectiveness and coordination of communication among care and

MEDICATION RECONCILIATION AT CARE TRANSITIONS

Improve the effectiveness and coordination of communication among care and

Improve the effectiveness and coordination of communication among care and