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.
ISMP Canada recently received reports of fatal overdoses of intravenous (IV) N-acetylcysteine resulting from errors in pump programming. This bulletin is shared to alert stakeholders to the potentially fatal outcome of this error and to encourage review of the processes that support IV administration of N-acetylcysteine.
For individuals who are taking life-saving medications and who require urgent assessment and treatment when ill, emergency care plans can be a key mechanism for sharing medical and medication information with the receiving care team. An incident report shared with ISMP Canada highlights the value of emergency care plans to improve communication among care providers, as well as patientsโ health outcomes.
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โข Key Findings from a Death Investigation Acetaminophen Overdose: Managing a Duplication Error
โข Cannabis for Medical Purposes
โข Cannabis Resources from Health Canada
ISMP Canadaโs consumer reporting program, SafeMedicationUse.ca, received a report from a patient who was inadvertently given tranexamic acid into the spine as a result of a substitution error. They asked that their story be shared, โso that no one else would have to experience the same fate.โ
This bulletin highlights the findings from a multi-incident analysis of harmful medication incidents involving pediatric patients in the community and identifies opportunities to improve pediatric medication safety.
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โข Preventing Pediatric COVID-19 Vaccine Errors at Mass Vaccination Sites
โข Sharing Matters! Incident Spurs Implementation of Child-Resistant Closure
On March 17, 2022, the shortage of small-volume formats of sterile water for injection packaged in vials and ampoules was assigned a Tier 3 designation by a Tier Assignment Committee that includes Health Canada and other Canadian stakeholders.
Paxlovid (a co-packaged product containing nirmatrelvir and ritonavir tablets) was recently approved by Health Canada for the treatment of mild to moderate COVID-19 in adults at high risk for progression to severe disease.
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โข Sharing Matters! Reported Concern Results in Safer Jardiance Product Labelling
โข SafeMedicationUse.ca: Tips for Starting and Stopping Antidepressants Safely
In follow-up to several recent reports of incidents involving medications used to prevent organ rejection, a multi-incident analysis was conducted. The analysis identified system vulnerabilities, and selected system safeguards to improve medication safety.
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โข SafeMedicationUse.ca: Managing Changes in Your Medication Blister Pack
โข SafeMedicationUse.ca: Allergies to Ingredients in Medication Products