Incident Analysis

Incident Reporting and Learning Overview

The Incident Reporting and Learning Overview provides a summary of the six steps involved in the incident analysis process. It includes a step-by-step approach to understand what happened, how and why it happened, and how to develop and implement actions for improvement. It is adapted from the Canadian Incident Analysis Framework (2012).

Use this tool to support incident analyses with your team!

Concise Incident Analysis Workbook

ISMP Canada has developed a concise incident analysis workbook for use in long-term care homes. It supports efficient review of low or moderate harm incidents. While comprehensive analysis provides in-depth insight, this streamlined approach enables more frequent analyses of a larger number of incidents and supports broader organizational learning. It is adapted from the Canadian Incident Analysis Framework (2012) and is designed to support long term care homes in conducing incident analyses with their teams.

Incident Analysis - Report, Learn, Act

To effectively improve medication safety in a long-term care home, it is important to recognize and understand what medication incidents are occurring, why, and what evidence-based actions should be taken to reduce the risk of the same incident occurring again.

ISMP Canada is pleased to assist long-term care homes to advance this Report, Learn, and Act cycle.

Report 

In addition to medication incident reporting systems in place within the home, consider reporting medication incidents to one of the options below that are free and confidential.

• Individual Practitioner Reporting Portal (ISMP Canada)
• National System for Incident Reporting (Canadian Institute for Health Information)

By reporting to one of these options, ISMP Canada will be able to analyze and share learning provincially and nationally related to the key trends of medication incidents occurring in long-term care and what actions are most effective for improving medication safety.

To ensure that medication incidents are reported, learn about how to support a Just Culture in long-term care.

Not sure how or where to report? Contact: LTC@ismpcanada.ca

Learn

There is a way to objectively and systematically analyze incidents so fewer residents & families are harmed by medications.

Learn about the Canadian Incident Analysis Framework and practice your skills at our LTC Incident Analysis Workshops (no registration fee for those working in Ontario Long-Term Care Sector)

Download: Incident Analysis Templates

Learn about the risks in medication safety reported by long-term care homes in Ontario

• Med Safety Signal: Vaccine Error
• Med Safety Signal: A Patchy Approach to Transdermal Fentanyl Safety
• Med Safety Signal: Vulnerabilities in Quarterly Medication Review Process
• Med Safety Signal: Hydromorphone dosing confusion
• Med Safety Signal: Problems with Conditional Medication Orders
• Med Safety Signal: Missed Methotrexate
• Med Safety Signal: Quantitative Analysis of Medication Errors in Ontario Long-Term Care Homes

Obtain more support for your local medication incident analysis process by contacting: LTC@ismpcanada.ca

Act

Some actions for improving medication safety are stronger and more effective than others. The Hierarchy of Effectiveness is a great tool for deciding what to change locally.

Obtain more support for deciding what medication safety actions to take locally by contacting: LTC@ismpcanada.ca

Use incident analysis to understand key risks at the home and target actions for improvement

Let us know how the Strengthening Medication Safety in Long-Term Care initiative is making a difference in your setting. Contact us with your stories, photos, and videos. With your permission we’ll post it here to inspire others to make a difference. Together we will make a difference.