46-275 / Medication Safety Self Assesment for Hospitals

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Ministry of Health, Social Services and Equality (MSSSI)
Institute for Safe Medication Practices – ISMP Spain


Quality improvement project
Self-evaluation system
Implementation of Patient Safety initiatives / Activities
GOP Description
Implementation level
Clinical settings
1.To provide hospitals with a self-assessment tool to identify those areas of the medication use system with the greatest opportunities for improvement
2.To encourage continuous self-assessment by hospitals and to facilitate comparison of each hospital’s data with data from the aggregate of the other participating hospitals
Hospitals quality and safety units/commissions and pharmacists
The self-assessment tool is a Spanish adaptation of the Medication Safety Self-Assessment (MSSA) for hospitals originally designed by the Institute for Safe Medication Practices in USA.
It includes 232 assessment items, which reflect specific practices or measures designed to prevent medication errors. The assessment tool is structured into 10 sections which represent the key elements that determine the safety of the medication use system. These key elements include one or more core characteristics up to a maximum of 20.
The tool is accessible through an on-line platform. Any hospital from the NHS can apply for a code and a password and access the tool and perform the self assessment. The tool provides the hospital with different statistical analysis from all the items and elements included in the questionnaire. The hospital’s data are included in a database and this facilitates comparison with the aggregated data from all the hospitals that have performed the self-assessment. The hospital can also compare its own data with previous self-assessments.
Timeframe implementation
Tool adaptation and on-line implementation: 1 year
Self-assessment: 3 team sessions around 1-2 hours long are recommended
Implementation tools available
On-line tool
Questionnaire to download
Frequently asked questions
Implementation cost
Adaptation and design: 45,000 €
Maintenance: minor
Baseline and follow-up study: 66,000 €
Method used to measure the results
National Health System baseline study in 2007 (105 hospitals) and follow-up study in 2011 (165 hospitals, 82 having participated in the 2007 study)
A comparison of the progress between the 2011 and 2007 studies show that the greatest relative increases were obtained for core characteristics 18-17-4-and-15, which refer to medication error detection and analysis by professionals (84.5%), development of an error reduction program (49.4%), communication of drug orders and other drug information (46.6%) and continued safety training (46.3%), respectively.
Significantly higher values for the whole survey were found for the hospitals that had taken the survey in 2007 (7.3% absolute difference). Statistically significant differences were found in all the core characteristics, except in characteristics 3, 10, 12, 14 and 17
Analysis of the results
The degree of implantation of safe medication practices in Spanish hospitals has increased (20_percentage_points; a_25%_relative_increase).
Increase was more pronounced in those hospitals that also participated in the 2007 evaluation (an increase of 13.3_percentage_points; 33.3%_in_relative_terms), in which improvement was seen in safe medication practices in all types of hospitals and in the 20 core characteristics. These hospitals also obtained better results in the 2011 evaluation than those hospitals that only participated in this most recent evaluation, achieving 7.3_more_percentage_points. All of the above supports the notion of using the self-assessment survey as a proactive tool for improving medication use safety.
Implementation barriers
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Other information
Other information about the GOP that you would like to add (Link or attached document)
Link to self-assessment tool: http://farmacia.flagsolutions.net/cake/