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Interview with Carolyn Hoffman, President and CEO of the Institute for Safe Medication Practices (ISMP) Canada

HealthPRO and ISMP Canada have collaborated for many years in the realm of medication safety. Together, we have worked on the Canadian Pharmaceutical Barcoding Project and the Guidelines for Outsourcing Pharmaceutical Compounding Services. HealthPRO also uses ISMP safety recommendations to inform its pharmacy product evaluation process, so we were thrilled to have a conversation with their new President and CEO, Carolyn Hoffman, RN, MN, to talk about her vision for the future.

Ms. Hoffman is a nationally recognized senior healthcare leader and author with extensive experience in advancing patient safety. She began her career as a nurse at the bedside, became a clinical nurse educator, and then moved into the developing field of patient safety and quality. Before moving to ISMP Canada, Carolyn was the SVP, Quality & Healthcare Improvement for Alberta Health Services, the largest health region in the country and most recently, was the Executive Director of the Saskatchewan Registered Nurses' Association.


Much of your career has been centred on patient safety – can you tell me more about why that has been a particular area of focus for you? 

When I graduated from nursing more than 30 years ago, errors were not discussed. As nurses we focused on our patients, and because you did your shift and were gone, you didn’t know how often errors occurred in the department or across the hospital. When a bad thing happened, it was not openly reviewed, and the focus was on the provider needing to be more careful next time.

My world opened up when I became a clinical nurse educator for the three emergency departments in Regina. My role was to educate emergency nurses and this was life-changing. Through dialogue with colleagues, conversations with patients, reviewing evidence-based publications, and by looking at things from a systems perspective, we were able to better prepare nurses to deliver safe care.

In 1997, I was offered a position as the Quality Improvement and Risk Manager for the Regina Health District. This was a completely new field and I was fortunate to have mentors and colleagues I admired like Eleanor Morton from HIROC (Health Insurance Reciprocal of Canada), Reg Watson, Lawyer, Dr. Don Berwick, CEO of IHI (Institute for Healthcare Improvement), Michael Cohen (ISMP) and Patrice Spath, one of the first to talk about root cause analysis in healthcare – all of whom helped move my career forward with knowledge and an attitude of “we can do this” and “we need to do this.” It was a great time to be entering this field – people were just starting to understand the importance of disclosing errors and how to make changes to the system to reduce preventable harm.

Now in your role as the new President and CEO of ISMP Canada, can you tell us what is on the horizon for the organization in terms of new initiatives to advance medication safety?

My first priority in this role was to work together with the board and staff to finalize and release our new three-year strategic plan (2018-20). There are five streams in the plan; Enable, Educate, Deliver, Innovate and Engage. I’m passionate about all of them. Deliver is about further developing a strong culture of sharing and learning around medication incident reporting. ISMP Canada is a key partner in CMIRPS (Canadian Medication Incident Reporting and Prevention System), along with Health Canada, Canadian Institute for Health Information, Patients for Patient Safety Canada and the Canadian Patient Safety Institute (CPSI), and over the next couple of years we are focusing on improving the volume and quality of reports sent to CMIRPS. ISMP Canada is accountable for intaking three streams of reporting: consumers, individual healthcare practitioners and community pharmacies. Underlying all of our activities is analysis, learning and taking action to attain the goal of zero preventable harm from medications in Canada.

What would you say are some of the most impactful initiatives ISMP Canada has undertaken in recent years to help improve safe medication management?

I believe that our work as a lead partner in developing the Canadian Incident Analysis Framework has had a significant impact across Canada. We provide education, and targeted consultation, in support of individuals and organizations using this rigorous methodology to understand how and why errors occur as well as what actions will be most effective in preventing a reoccurrence. We know the healthcare system still lacks expertise and resources in this area so we’re mobilizing our resources to support them.

Adverse drug reactions (ADRs) and medical device incidents (MDIs) occur frequently, but we know these events are significantly underreported. That will undoubtedly change with the implementation of The Protecting Canadians from Unsafe Drugs Act, or Vanessa's Law. ISMP Canada is working in a joint venture with the Health Standards Organization (HSO) and CPSI to assist Health Canada with outreach and education to support compliance with the law. The new legislation is going to strengthen Health Canada's ability to collect information on drugs and medical devices, and it also includes a requirement for mandatory reporting by hospitals of serious ADRs and MDIs.

In your opinion, what is the biggest obstacle to safe medication management, and has that changed over time?

I actually see a couple of challenges to safe medication management. The first is the challenge of communication and collaboration across the health system. We work in silos and there is a lack of seamless transfer of information across teams and organizations, which increases the risk to patients. This has changed over time, most notably with developments in the Electronic Health Record (EHR), but this obstacle still exists. The second challenge is a longstanding one – patients and families have not been truly engaged with the healthcare team. As healthcare practitioners and leaders, we often felt we knew what was best for the patient, but now we know that patients and families need to be full partners in their care.  Further, communities need to be fully engaged in the design and delivery of their healthcare. It’s evolving and many organizations are taking steps on this journey – including us. We’re only going to get there with hard work.

Are there any trends in healthcare, patient or medication safety that you are particularly excited about?

There are a couple of trends I’m encouraged by – the first is advancements in technology. A number of new technologies are being embraced in healthcare: things like provincial EHR systems, bar coding technology, and smart IV pump technology. All of these developments are significant and are making it easier for us to do the right thing when we provide care. I think it’s important to note that technology alone is not the full solution for attaining zero preventable medication harm – human collaboration and human understanding have to go with it. Technology is moving us forward, but we’re always going to need the human intellect and touch.

Encouraging conversations and empowering patients with ‘Questions to Ask about Your Medications’ is an initiative that began with a Medication Safety Summit. The 5 Questions have been embraced by more than 200 organizations at local, provincial and national levels; organizations can visibly demonstrate their collaboration with customized posters.

Something else that is very encouraging to me is the increasingly important role being played by system leaders; how they’re embracing accountability through governance, outcome measurement and creating a culture of quality and safety. The role of the leader is critical in furthering medication safety. This brings us full circle in the role played by ISMP Canada! We are dedicated to using our knowledge and experience in all those areas: technology, human collaboration, and supporting leadership in creating cultures of safety.

Carolyn’s Publications

Carolyn is a co-author of the Tool for the Concise Analysis of Patient Safety Incidents (2016), Canadian Incident Analysis Framework (2012); the lead author of the 2008 consultation paper on the Development of a Canadian Adverse Event Reporting and Learning System; and co-author of the Canadian Root Cause Analysis Framework (2006) as well as the Canadian Patient Safety Dictionary (2003).

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