Assessing Hospital
Medication Safety


Medicines are the commonest medical interventions used in healthcare and safe use is important. To help fulfil Waitemata DHB's promise of providing healthcare that is safe, continuously improving and among the best in the world, a systematic assessment of hospital medication systems was needed to:

  • inform how safe systems were
  • understand where further improvement may be required
  • guide the development of an improvement strategy
  • track progress over time

A medication safety strategy to guide improvement initiatives

Medication Safety Self-Assessment

The Medication Safety Self-Assessment for Hospitals (MSSA®) is a  widely endorsed tool used in approximately 2000 hospitals across the US, Canada, Australia and other countries to assess medication systems.

The MSSA® is consistent with current professional knowledge, and evidence and its modified version for Australian Hospitals (MSSA®-AH) contains a criteria list of 247 items of ideal and aspirational medication safety practices.

The MSSA®-AH has apparent good face and construct validity having been tested across several Australian hospitals and promoted for use by the Australian Quality and Safety Commission.

Despite international widespread use, no published research of MSSA®-AH use in NZ was identified.

With a view to determine the utility of the MSSA-AH® for NZ hospital settings and obtain specific information for Waitemata DHB purposes, an assessment of Waitemata DHB’s hospitals' medication systems using the tool was undertaken.

A multidisciplinary group met over three 1.5 hour meetings and reviewed WDHB hospital medication systems against the widely endorsed Medication Safety Self-Assessment for Australian Hospitals (MSSA®-AH) criterion of 247 aspirational practices using a five point scale ("no" to "fully implemented"). Items with a lesser extent of implementation represented practice gaps. The MSSA®-AH database and weighted adjustment scoring system generated an overall hospital score.

Of the maximum possible score that could be obtained had all MSSA®-AH practices been implemented, Waitemata scored 63% (out of a possible 100%) and this was comparable to other demographically similar hospitals in Australia.

Lowest scoring practices needing improvement related to staffing. Conflict resolution was a previously unidentified practice gap. Previously identified gaps, such as those relating to electronic medication systems suggested ongoing implementation was required.

Data obtained informed the development of WDHB’s medication safety strategy and action plan. Future repeated assessments would help WDHB track progress. Implicit benefits such as stakeholder engagement were observed. The unique generation of a percentage score helped simplify understanding for non-technical stakeholders. 

WaitemataDHB MSSA results
Waitemata DHB's assessment scores against each of the key elements from the MSSA® tool

MSSA core characteristics comp 520px
Waitemata DHB Results - 20 Core Characteristics

This was the first documented use of the MSSA®-AH’s in a New Zealand hospital setting.

We have published our findings and lessons learnt in the New Zealand Medical Journal and other DHBs have approached us to help them use, analyse and interpret data obtained from the MSSA.

The information obtained from, and the process of, assessment using the MSSA®-AH was meaningful for Waitemata DHB for a number of reasons.

Firstly, previously unidentified medication safety practice gaps were discovered and highlighted areas for intervention.

For example, it was identified that Waitemata DHB did not have a formal process that can be followed by nurses and pharmacists to resolve conflict when prescribers do not agree with their expressed concerns about the safety of an order (item 3.11).

Disrespectful behaviours towards staff who question the safety of an order may lead to unsafe medications being administered to the patient.

Interventions, such as the development of a formalised escalation pathway coupled with behaviour change management, may thus help resolve such conflicts and prevent unsafe orders from ever reaching the patient.

Based on the MSSA© findings, research evidence and inter-disciplinary feedback, we have developed a medication safety strategy to guide improvement initiatives for the next three years.

With a view to achieving our medication safety vision, we identified three broad aims and measures:

Medication Safety Aims

Measures of Success

Enhance the reliability, resiliency and responsiveness of Waitemata DHB medication systems to optimise medicines use

  1. Improve from a baseline ISMP-MSSA* score of 63% (FY2014-2015) to ≥65% by FY2018
  2. * ISMP-MSSA: Institute of Safe Medication Practice’s Medication Safety Self-Assessment score

Achieve safe outcomes

  1. To observe improved trends in medication related patient health outcomes by FY2018
  2. Defined as both adverse and beneficial consequences associated with medication use (e.g. errors, adverse drug events, falls, survival)

Achieve patient centred outcomes

  1. To improve patient experiences related to medication use to 80% by July 2018
  2. Defined by the following questions:
  3. Did a member of staff tell you about medication side effects to watch out for when you went home?
  4. Do you feel you received enough information from the hospital on how to manage your condition after your discharge?
  5. Were you involved as much as you wanted to be in decisions about your care and treatment?
  6. Overall, was the way staff involved you in decisions about your care very poor or very good (0-10)

To achieve our three medication safety aims, we have identified five priorities which span across the entire medicines management pathway.

  1. Nurture a Safe and Just Culture
    To nurture and develop a collective and shared belief in the importance of, and commitment to, medication safety among all staff and demonstrated through leadership, caring, communicative, situationally aware, learning and non-punitive attitudes, mind-sets and behaviours

  2. Optimise Capacity and Capability
    To optimise physical environments, infrastructure and workforce training programs according to current professional knowledge to increase the likelihood of safe medication use

  3. Implement Electronic Medicines Management Systems
    Automation, interoperability and clinician decision support systems are feasibly implemented at all stages of the medicines use pathway wherever possible

  4. Manage High Risk Areas
    There is a coordinated and targeted improvement system in place to identify, monitor, and manage high risk medicines areas to increase the likelihood of safe medicines use

  5. Best Care for Everyone
    Provision of patient centered care that is respectful and responsive to individual preferences, needs and value and where patients are empowered and actively participate in the use of medicines to achieve optimised health outcomes

An observed benefit from using the MSSA®-AH, was the generation of engagement from undertaking the assessment process and the nurturing of a shared belief in the importance of patient safety. Applying the MSSA®-AH forced staff to critically reflect on existing medication systems, whether in a ward, hospital or entire organisation, for patient safety and motivated individual action and system development in their respective areas to support and inform priorities. We are continuing to work towards achieving our vision and priorities and some examples of initiatives underway or completed are featured below:

  • Electronic Prescribing and Administration (ePA)
  • Electronic Medicine Reconciliation (eMedRec)
  • Safe Use of Opioids Collaborative
  • Medication Crushing Guide for Residential Aged Care

Working Group

  • Jerome Ng, i3 Lead Advisor Improvement Research + Informatics
  • Penny Andrew, Director of i3
  • Marilyn Crawley, Chief Pharmacist
  • Wynn Pevreal, Medication Safety Pharmacist
  • Jocelyn Peach, Director of Nursing + Midwifery


Dr Jerome Ng

Lead Advisor Improvement Research + Informatics

Dr Penny Andrew

Director of i3