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MSSA Hospital, Canadian Version IV Draft 2026-03-30 Instructions

Instructions for Completing the Self-Assessment

1. Establish an interdisciplinary team consisting of or similar to the following:

  • Senior leadership representative
  • Patient safety, quality improvement, and/or risk management representative
  • Nursing director/manager
  • Pharmacy director/manager
  • Physician leader (e.g., chief of service)
  • Informatics/information technology
  • Patient/caregiver representative
  • Health care providers (at least one of each of the following):
    • Registered nurse/registered practical nurse
    • Pharmacist
    • Pharmacy technician
    • Nurse practitioner
    • Physician

Note: Include representation from different services within the hospital.

2. Distribute the self-assessment document before the team meeting so that team members can review and consider the questions in advance.

3. Complete the demographic section.

4. Discuss each self-assessment item and evaluate the hospital’s current success in implementing the item. As necessary, investigate and verify the level of implementation for each item with other health care providers and staff outside the assessment team.


Possible responses and corresponding scores are as follows:

  • N = 0 (Not Implemented) - Items that are not in use at this time.
  • R = 1 (Rarely) - Items that are implemented and in practice less than 25% of the time.
  • S = 2 (Sometimes) - Items that are implemented and in practice 25%-50% of the time.
  • O = 3 (Often) - Items that are implemented and in practice 51%-75% of the time.
  • A = 4 (Always) - Items that are implemented and in practice more than 75% of the time.
    For self-assessment items with multiple components, full implementation (score of A) is appropriate only if all components are present. If only one or some of the components have been partially or fully implemented throughout the hospital, self-assessment scores should not exceed "S" or “O”.
  • NA = 0(Not Applicable) - For selected items only, with criteria as described.
    Generally, this response is available for circumstances that do not exist and therefore do not impact safety in that area (e.g., a hospital that does not provide chemotherapy cannot respond to items related to this therapy).
  • Hospitals may want to consider recording any discussion generated around each assessment item and the rationale behind the selected choice. This information, meant for internal use only, can assist the team when reviewing scores for individual items or reassessing the organization at a later date.

5. Finalize your self-assessment. You will be prompted to save your responses for each key element before you proceed to the next key element page. When all responses have been entered, you will be prompted to “Check MSSA for errors” and then to submit your results. Once you have submitted your results you cannot edit them.

The web-based survey tool will immediately download the information into a secure database maintained solely by ISMP Canada. No data will be maintained on the web-based survey tool after it has been submitted. Confidentiality is assured.Individual results can be viewed or accessed only by the organization submitting them. The aggregate findings will be available for viewing by others once a minimum of 3 organizations have submitted results and may be used by ISMP Canada for research and education purposes only.

6. Print/view your completed assessment. Once your results have been submitted you will be able to print a report summarizing your results.

7. Compare your results to the aggregate. Once your results have been submitted you will immediately be able to compare your results to the aggregate response. You can compare to the total aggregate or to demographically similar organizations using the filters provided.