Learning from Patient/Caregiver Reports of Methadone Errors
ISMP Canada has received reports from patients who described receiving a methadone dose intended for another patient. Key learnings from the reported incidents included how a change in taste of the prepared methadone may be a sign that an error has occurred.
ISMP Canada has received reports from patients who described receiving a methadone dose intended for another patient. Key learnings from the reported incidents are shared in a consumer newsletter,1 including how a change in taste of the prepared methadone may be a sign that an error has occurred.
The following tips for pharmacy teams are shared to ensure each patient receives their intended dose of methadone:
- Avoid pre-preparing methadone for more than one patient at a time.2 If this is not possible, label each container (e.g., with patient name, medication name and concentration, and dose/volume) according to jurisdictional regulations.
- Ask each patient what medication and dose they are expecting, then verbally confirm the patient’s name, the medication name and concentration, and the dose/volume to be ingested.2 Show the label to the patient or caregiver, where feasible, as a double check.
- To support rigorous identity checks as a part of dispensing protocols, consider scanning the patient’s photo identification into their profile and attaching it to their administration log, or use dispensing technology with fingerprint identification.2
- Standardize the methadone preparation process to support consistency in other factors that may influence taste (e.g., use of a specific diluent), apart from the amount of methadone present.
- Investigate concerns related to changes in taste of the prepared methadone to help identify potential mistakes.
- Post the following newsletter in the pharmacy to help empower patients: Are You Taking Methadone? Tips to Help Stay Safe (Figure 1).
FIGURE 1. Newsletter with safety tips for patients taking methadone.
The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program of Health Canada, the Canadian Institute for Health Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and Healthcare Excellence Canada (HEC). The goal of CMIRPS is to reduce and prevent harmful medication incidents in Canada.
Funding support provided by Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.
The Healthcare Insurance Reciprocal of Canada (HIROC) provides support for the bulletin and is a member owned expert provider of professional and general liability coverage and risk management support.
The Institute for Safe Medication Practices Canada (ISMP Canada) is an independent national not-for-profit organization committed to the advancement of medication safety in all healthcare settings. ISMP Canada’s mandate includes analyzing medication incidents, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives.
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