Community Pharmacy Professionals Advancing Safety in Saskatchewan (COMPASS)
Data Sharing Agreement (DSA)

This Data Sharing Agreement is to be completed and submitted for any of the following:

Notification of  New Pharmacy Establishment

Notification of Change in Pharmacy Manager

Notification of Change in Pharmacy Ownership

Notification of Change in Pharmacy Trade Name

The above change is effective as of (Date):  May 08, 2024

Pharmacy Manager Name:  {%Usual Name%} {%CLIENT: Last Name%}

Pharmacy Permit #:  {%CLIENT: Pharmacy: Pharmacy Number%}

Pharmacy Name:  {%CLIENT: Pharmacy: Trade Business Name%} 

Pharmacy Address:  {%CLIENT: Pharmacy: Location Address: STREET 1%} {%CLIENT: Pharmacy: Location Address: STREET 2%} {%CLIENT: Pharmacy: Location Address: CITY%} {%CLIENT: Pharmacy: Location Address: PROVINCE%} {%CLIENT: Pharmacy: Location Address: POSTAL%} 

Email Address:  {%CLIENT: Pharmacy: Pharmacy Primary Email%} 
(*Note: Issuance of password, requests for forgotten passwords/retrieval will be sent to this e-mail address)

Pharmacy Phone #:  {%CLIENT: Pharmacy: Phone%} 

Pharmacy Fax #:  {%CLIENT: Pharmacy: Fax%}

***For changes in pharmacy management or ownership***:
Is the individual named above (i.e. the new pharmacy manager/owner) different from the CQI Coordinator or main contact person for the COMPASS program at the pharmacy?

No. The pharmacy manager/owner is the CQI coordinator of the pharmacy

Yes. Name of the CQI coordinator for the pharmacy: _______________________________________

Dear {%Usual Name%},

I am following up on recent discussions regarding the submission of medication incident data to the ISMP Canada Community Pharmacy Incident Reporting (CPhIR) Program at http://www.cphir.ca. We are very pleased to learn that your pharmacy or institution is considering sharing medication incident information for the purpose of shared learning. To follow up, I would like to provide you with information about ISMP Canada and describe the process by which ISMP Canada collects and uses medication incident information.

ISMP Canada is an independent, not-for-profit, federally incorporated organization. Our mandate is to analyze medication incident reports and develop recommendations for enhancing patient safety. Our activities support this mandate and are conducted in accordance with ISMP Canada’s goals and purpose, as set out in its letters patent (July 14, 2000 under the Canada Corporations Act ) and the broad objectives of the Canada Health Act. Because the information we require for our activities is not information that can be used to identify individuals, our collection activities are consistent with the Personal Health Information Protection Act, 2004 (PHIPA)—that is, we do not collect personal health information, as it is defined in PHIPA. Our activities are also consistent with policy guidelines based on PHIPA.

To illustrate, the following categories of information are received by ISMP Canada from healthcare institutions and pharmacies. Specifically, ISMP Canada asks for the following information:

• Date of incident
• Type of incident (e.g. incorrect drug, incorrect strength/concentration)
• Discoverer of incident (e.g. pharmacist, technician, patient)
• Medication system stages involved in the incident (e.g. order entry, dispensing, administration)
• Medication(s) involved (e.g. medication name, strength)
• Degree of harm to patient due to incident (e.g. no harm, harm)
• Description of the incident
• Contributing factors of the incident (e.g. miscommunication of drug order)

We do not collect data that may identify an individual or an organization. We ask institutions or pharmacies submitting incident reports to ensure that all identifying information is removed before submission. ISMP Canada has a privacy program to guide handling of information by its employees. As part of the program, we have completed a privacy impact assessment (PIA). Privacy policy is available on the ISMP Canada web page at http://www.ismp-canada.org/privacy_policy.htm . In accordance with our policy, the data is used by ISMP Canada only for the purposes of analysis, shared learning, and incident prevention strategy formulation.

The ISMP Canada CPhIR Program supports submission of incident reports to ISMP Canada using a secure transfer protocol. The reporter will be provided with a login ID and password that also allow for viewing individual pharmacy/institution data and aggregate data from the CPhIR incident database. Such aggregate data is for your information only and cannot be published without a written permission from ISMP Canada. In addition, the CPhIR program is proprietary to ISMP Canada and ISMP Canada reserves all rights in the use of the program. The data transmission is encrypted and strict confidentiality guidelines are enforced.

I hope that this information about ISMP Canada, our goals and the purposes for which we collect medication incident information is helpful to you. If you have any further questions, please do not hesitate to contact me.

Sincerely,

Carolyn Hoffman
President and CEO
Institute for Safe Medication Practices Canada
4711 Yonge Street, Suite 501, Toronto ON, M2N 6K8
Tel: 416-733-3131
Fax: 416-733-1146

Cc:      Certina Ho, ISMP Canada
           Sylvia Hyland, ISMP Canada

I acknowledge that I have read and understood the above and agree to submit de-identified medication incident data to ISMP Canada via the ISMP Canada Community Pharmacy Incident Reporting (CPhIR) Program.

Please sign the completed form, scan it and EMAIL it to ISMP Canada at cphir@ismpcanada.ca.
Thank you.

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Pharmacy Manager's Signature

__________________________________
Pharmacy Manager's Name (Printed)

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Date