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									ABOUT ISMP CANADA                        www.ismp-                                 INSTITUTE FOR SAFE
The Institute for Safe Medication               MEDICATION
Practices Canada (ISMP Canada) is
                                         ISMP Canada seeks to empower
                                                                                   PRACTICES CANADA
an independent, national, nonprofit
agency committed to the                  healthcare providers in preventing
advancement of medication safety in      medication errors in their own
all healthcare settings. ISMP            organizations through consultation,
Canada works collaboratively with        tools/programs, training, and
the healthcare community, regulatory
agencies and policy makers,
provincial, national and international
                                         education. Consulting services are
                                         provided to hospitals and other
                                         healthcare organizations on safe
                                         medication use and on identification
patient safety organizations, the
pharmaceutical industry and the
public to promote safe medication
                                         of opportunities to improve
                                         medication use systems (such as
                                         Failure Mode and Effects Analysis).
                                         ISMP Canada may also be invited to
ISMP Canada carries out its
mandate through a confidential,
                                         work jointly with an organization to
                                         investigate a specific incident using a   AND
voluntary error reporting system.        process called Root Cause Analysis
Healthcare institutions and individual
practitioners provide information on
preventable adverse drug events via
                                         and to provide recommendations for
                                         avoiding similar incidents in the
several channels, including a secure
web-based reporting function, email,
or telephone. Hospitals may also
report through ISMP Canada’s                 Institute for Safe Medication
software system, Analyze-ERR®

ISMP Canada analyzes the
medication error data it receives.
                                                   Practices Canada
                                                     (ISMP Canada)
                                                  4711 Yonge Street, Suite 501
                                                     Toronto, ON M2N 6K8
Learnings from medication errors                    Phone: (416) 733-3131or
                                                        1-866-54 ISMPC
including preventative strategies and      
system safeguards are shared
through ISMP Canada Safety
Bulletins. This electronic bulletin is
distributed widely and is also
available on the ISMP Canada
FAILURE                                current Accreditation Canada Patient
                                       Safety Goals and Required
                                                                                the management of error and an
                                                                                introduction to human factors
MODE AND                               Organizational Practices.                engineering principles. The better
                                                                                part of the day is an interactive small
EFFECTS                                “Proactive process assessment
                                       tool[s]…serve to identify and
                                                                                group work and feedback process.

ANALYSIS                               prioritize those workplace and
                                                                                Groups participate in a modified
WORKSHOP                               organizational factors that are
                                       creating an adverse effect on human
                                       performance….and to direct remedial
                                       efforts at those problems most in        FACILITATORS
ISMP Canada has developed a one        need of attention.”(James Reason
day Failure Mode and Effects                                                    A ratio of one facilitator for every 12
                                       and Alan Hobbs, Managing                 participants is provided. The
Analysis (FMEA) workshop for           Maintenance Error, 2003)
Canadian healthcare facilities. FMEA                                            facilitators offer intensive support as
is a team-based, systematic and                                                 groups work through the FMEA
proactive approach for identifying:                                             process.
                                       FMEA WORKSHOP GOALS
   ways that a process or design can   1. Learn about the impact of system
   fail,                                  factors on error potential.

                                       2. Learn about human factors             FOR FURTHER
   why it might fail,
                                          engineering principles and how        INFORMATION
                                          they apply to health care
   the effects of the failure, and        environments.                         Contact us at:
   how it can be made safer.           3. Identify about the components of      (416) 733-3131 or
                                          FMEA and the processes in
FMEA has been in use for many             healthcare that lend themselves to    1-866-54-ISMPC
years in other high-risk industries       analysis by FMEA.                     (1-866-544-7672)
such as aviation and nuclear power.
It is used by practitioners, to        4. Conduct an abbreviated FMEA on
proactively assess risk without           a healthcare process.
waiting for an accident to occur.
                                       5. Develop the expertise to serve on a
The FMEA tool offered by ISMP             FMEA team in a healthcare setting.
Canada is best applied to heath care
                                       WORKSHOP FORMAT
FMEA is cited as an example of a
                                       The workshop begins with an
prospective analysis under the
                                       overview of the systems approach to

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