ISMP Canada Safety Bulletins

Innovative Medication Safety Improvements in Ontario Long-Term Care Homes

This bulletin provides an overview of the initiative and highlights selected examples of improvement projects completed in the first phase.

Newer Classes of Medications for Diabetes Treatment: A Multi-Incident Analysis of Reports from the Community Pharmacy Setting

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.

Sidebar: Pharmacy Automatic Refill Programs – Improvements Needed

Penicillin Formulation Mix-Ups Lead to Potential Undertreatment of Syphilis

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!

Reported Concerns with Labelling and Packaging of High-Alert Medications in Vials and Ampoules: A Multi-Incident Analysis

The Canadian Medication Incident Reporting and Prevention System (CMIRPS) continues to receive reports from practitioners that describe concerns with labelling and packaging.

“No Drug Selected” = Taking the Smart Out of Smart Pumps

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