Read the Safety Bulletins to help you strengthen your medication-use system. Learn about strategies to mitigate harm and to prevent medication errors based on analyses of medication incident reports from Canadian health care providers, facilities, pharmacies, organizations, and consumers.
Newer insulin products consist of biosimilars and faster-acting, longer-acting, or higher-concentration analogues. This safety bulletin describes a multi-incident analysis of reports involving newer insulin products and shares recommendations to enhance their safe use. Health care providers are encouraged to review their current processes and implement suggested improvements to support and promote the safe prescribing, transcribing, dispensing, and administration of insulin products.
Health Canada recently informed health care providers of an important change to the vial closure colour for cisatracurium products. Cisatracurium is a neuromuscular blocking agent (NMBA); catastrophic harm or death has resulted when NMBAs are inadvertently selected and administered without airway control and ventilation capability. This bulletin describes the results of end-user feedback on the labelling and packaging of cisatracurium products.
MedError.ca received a report from a consumer who almost ingested a boric acid vaginal suppository, mistaking it for an oral capsule. ISMP Canada shared this incident with Health Canada and the manufacturer, Szio+ Inc. Following discussions, the manufacturer has added clearer warnings to the outer box, bottle, and product insert.
Prednisone and prednisolone (the active form of prednisone) are widely used for both chronic inflammatory conditions and acute exacerbations. This bulletin highlights the findings from an analysis of medication incidents associated with prednisone or prednisolone, with a focus on community pharmacy, and shares opportunities to prevent and/or mitigate associated risks.
ISMP Canada recently received a near-miss report involving a discrepancy between different units of measure for expressing the strength of levothyroxine. Opportunities exist for harmonization among sources of drug information, which would reduce the risk of dosing errors associated with miscalculation or conversion.