In the fall of 2014, members of the McGill University Health Centre’s (MUHC) Nursing, Procurement, Material Management & Quality & Patient Safety (QPS) department developed, in collaboration, the Material Incident Accident Management (MIAM) program. The program is a standardized process enabling the MUHC to quickly evaluate risks associated with material related incidents/accidents and determine whether or not to proceed with a voluntary withdrawal. Materials are medical products and supplies used in patient care (ex. Intravenous tubes, catheters). When materials are defective or improperly used they can cause potentially dangerous events for patients and staff. The reporting of these events is important allowing for the quick assessment of the risks and prevents similar events from occurring elsewhere.

The MIAM program has facilitated the reporting process and management of material related events. Staff can now report events by calling a central number; where they are guided to fill a report form and package the product for pick-up. The product is picked-up within 24 hours, couriered to QPS for triage and forwarded to purchasing. An electronic email is forwarded to Health Canada (HC), whereby HC will conduct an external scan and provide MIAM with external indicators on frequency and severity of reported events. Details of the event are entered into a web based database programmed with an algorithm that conducts an internal search for frequency, potential severity and impact of introducing a substitute. The database then provides a decision whether or not to withdraw a product. If withdrawal is indicated, an automatic email is sent to members of a task force for further analysis and final decision regarding either product withdrawal or the introduction of a substitute. Purchasing will then contact the vendor to pick up the defective product for further root cause analysis.

Before its inception, suppliers took an average of 90 days to evaluate and provide a recommendation about a product withdrawal. The MIAM program has enabled the MUHC to reduce the turnaround time to 8 days and offer a more timely intervention.

The MIAM program has become a standardized process that has been integrated into the departmental mandate of the Quality, Patient Safety and Risk; Procurement; and Material Management departments. The steps of the process and work required was reorganized and incorporated into the daily tasks of the people involved in these respective departments thereby ensuring the sustainability of this practice.

Contact Person:

Title: Advisor, Quality, Patient Safety and Performance Department

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