ISMP Canada Safety Bulletins

Alert: Polyethylene Glycol and Propylene Glycol Mix-up Causes Harm

ISMP Canada received a report describing a mix-up between polyethylene glycol and propylene glycol that resulted in patient harm. The report is shared here to heighten awareness of the risk of a selection error between these 2 products and the need for safeguards.

• Canada’s National Incident Data Repository for Community Pharmacies
• Keep Your Vaccinations Up to Date
• Severe Hyperglycemia with Incorrect Use of Insulin Pen

The Second Victim: Sharing the Journey toward Healing

This bulletin shares one pharmacist’s story, his experience as a practitioner involved in a medication incident, and his path toward healing.

• Med Safety Exchange - Web Series

Sink or Swim? Helping Patients and Practitioners to Understand Opioid Potencies and Overdose Risk

This bulletin shares a communication and risk assessment tool specific to opioids. The tool, which is designed in the form of an infographic, is directed specifically to patients and their healthcare practitioners.

Medication Incident Data in Canada: A Strategy for More Effective Sharing and Learning

Knowledge gained from a local analysis of medication incidents could benefit other healthcare providers and organizations at the provincial, national, and international levels. A cohesive, formal information-sharing strategy would facilitate a better understanding of reported medication incidents and would support the development of robust strategies for preventing patient harm, as well as creating a dynamic and supportive mechanism for shared learning.

• Web Safety Exchange - Web Series
• Take With Questions

Epinephrine Use for Anaphylaxis — A Multi-Incident Analysis

Because of the increased use of epinephrine for anaphylaxis, there is a need to better understand the potential risks and problems associated with use of this high-alert medication. This bulletin shares the learning from a multi-incident analysis of reports related to epinephrine when used for the treatment of anaphylaxis and shares strategies to prevent or minimize potential harm.

• Health Canada Seeking Feedback on Mandatory Reporting of Serious Adverse Drug Reactions and Medical Device Incidents
• Losing Medications Can Spoil Your Vacation
• Updated Labelling and Packaging Guide Will Make It Easier for Canadians to Use Health Products Safely

Death Due to Pharmacy Compounding Error Reinforces Need for Safety Focus

As part of ongoing collaboration with a provincial death investigation service, ISMP Canada received a report regarding the death of a child who had ingested a prescribed, compounded oral liquid suspension that contained the wrong medication. This bulletin shares recommendations to guide pharmacies and other compounding facilities, as well as standard-setting organizations in their efforts to reduce the likelihood of similar errors in the future.

• WHO’s Third Global Patient Safety Challenge: Medication Without Harm

Acetaminophen: Preventing Harm through Safe Use

This bulletin highlights, for both healthcare professionals and manufacturers, key safety efforts, important resources, and strategic recommendations based on recent Health Canada initiatives supporting the safe use of acetaminophen in Canada.

• Updated Paper to Electronic MedRec Implementation Toolkit Now Available!
• Suddenly Stopping a Medication Can Be Harmful
• Check Out the Updated Medication Reconciliation Kits!
• More than 100 Endorsements for 5 Questions to Ask!

Express Levothyroxine Doses in Micrograms not Milligrams

This bulletin focuses on an analysis of recent incidents involving levothyroxine: the expression of medication strength and the error-prone process of converting between different units of measure.

• Caution: M-Eslon Now Also Available as an Immediate-Release Product
• Some Medications Don’t Mix

Gaps in Medication Monitoring May Contribute to Death

As part of ongoing collaboration with several provincial offices of the Chief Coroner or Medical Examiner, ISMP Canada received a report about the death of a woman who was taking levothyroxine but had not undergone monitoring for an extensive period. This bulletin describes the suboptimal follow-up and monitoring of this patient’s hypothyroidism and suggests strategies to overcome the challenges associated with the management of patients with chronic disorders.

Errors Associated with Hospital Discharge Prescriptions: A Multi-Incident Analysis

This bulletin shared the findings of a multi-incident analysis of medication incidents involving discharge prescriptions and to share opportunities for system-based improvements.

• Diabetic Ketoacidosis with SGLT2 Inhibitors
• What to Expect if the Pharmacy Makes a Mistake