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 describes a reported incident in which a patient experienced pulmonary aspiration of regurgitated gastric contents during anesthesia. The patient was taking a glucagon-like peptide-1 (GLP-1) receptor agonist. Raising awareness about this newly identified risk provides an opportunity to develop medication safety strategies and prevent patient harm.
Sidebar:
- Natural Health Products: Mandatory Reporting of Serious Adverse Drug Reactions
Although safe in recommended doses, acetaminophen is a leading cause of acute liver failure due to intentional and unintentional overdoses.
Sidebars:
- Lactulose for Encephalopathy
- “Mild” or “Severe” Harm? Ensuring the Accuracy of Reported Incidents
- Join the New Canadian Medication Safety Network!
- Med Safety Exchange
Approximately 4500 Canadians are hospitalized each year because of acetaminophen overdose. Acetylcysteine (also referred to as N-acetylcysteine or NAC) is effective as an antidote for acetaminophen poisoning and indicated to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen. Although intravenous (IV) infusion has been widely accepted as a safe mode of administration for acetylcysteine, serious errors have occurred, leading to life-threatening conditions and/or death.
• TABLE 2: Contributing Factors with Corresponding Recommendations from a Multi-Incident Analysis
The introduction of vaccines to protect against COVID-19 was a turning point in the management of the pandemic. Knowledge about these products continued to evolve rapidly after they were made available, which resulted in frequent updates to stability and storage requirements and associated product labelling. These changing requirements created a challenging work environment for health care providers who were administering the vaccines. This bulletin shares learning from an analysis of a multi-patient incident involving administration of COVID-19 vaccines that were past their beyond-use date (BUD).
This bulletin is focused on an analysis of community pharmacy incidents involving newer classes of medications for diabetes treatment, and offers strategies to prevent errors.
This bulletin highlights a mix-up between 2 penicillin formulations, the proactive response of a hospital to identify other potentially affected patients, and recommended changes to the medication-use system to prevent similar incidents from occurring.
Sidebars:
- Check the Syringe! Preventing Methotrexate Dose Errors
- Canadian High-Alert Medication List: We Want to Hear from You!
The Canadian Medication Incident Reporting and Prevention System (CMIRPS) continues to receive reports from practitioners that describe concerns with labelling and packaging.
Smart pumps with dose error reduction software (DERS) support organizations in creating a tailored library of medications with associated dosing guidelines. By establishing dosing limits and alerts within DERS, organizations can use smart pumps to detect dosing and programming errors that may harm patients. This safety bulletin outlines situations in which bypassing the drug library and DERS takes the “smart” out of smart pumps. It also describes the risks associated with bypassing this software and offers strategies to increase the use of this technology.
Sidebar: New Pan-Canadian Diversion Risk Assessment Tool