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.
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.