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.
This bulletin raises awareness about the contraindication of psyllium use in individuals with dysphagia and the risks of psyllium administration with an inadequate volume of liquid. Analysis of the reported incident also underscores the importance of communicating critical medication information to all members of the health care team, and to patients and caregivers, to reduce the risk of choking incidents.
ISMP Canada has received reports of elastomeric pumps delivering medications more quickly or more slowly than expected, leading to patient concerns, the need for extra monitoring, and reported side effects. Recommendations are shared to optimize the safe use of elastomeric pumps.
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.
This bulletin describes the development of an updated list through a multi-input process that included an environmental scan, incident analyses, and stakeholder consultations from health care sectors and regions across Canada.
This supplement describes identified opportunities to improve electronic presentation of medication information. Reported incidents were related to prescribing modules within electronic medical records, medication administration records, and pharmacy management software.
Monitoring patient safety alerts issued by national and international organizations can support proactive risk assessment and the strengthening of medication-use systems. This bulletin shares information published by NHS England in September 2024 describing the risks of oxytocin overdose during labour and childbirth, and considers the Canadian context.
ISMP Canada was made aware of the death of a newborn that occurred during induction of labour. Health care providers have described challenges with the preparation of misoprostol doses, either when using partial tablets or preparing a solution. Options are shared to support recommended doses and avoid dose preparation at the bedside.
In Canada, the current scope of practice for pharmacists permits provision of care beyond historical roles of medication compounding, medication dispensing, and counselling. This bulletin highlights opportunities for continuous quality improvement.
This bulletin aims to increase awareness of the potential for inadvertent selection errors (e.g., during order entry or when obtained from pharmacy shelves) involving midodrine and Midamor (amiloride), identify factors that contribute to them, and recommend risk reduction strategies to prevent harm.
ISMP Canada received several reports describing inadvertent dosing errors. A key contributing factor in all of the incidents was health care providers’ misinterpretation of the product concentration due to the proximity of the numeral 1 in the brand name and in the product concentration when displayed in drug information systems.