ISMP Canada Safety Bulletins

Electronic Prescribing in Primary Care: Effects on Medication Safety

This bulletin explores the effects of electronic prescribing (e-prescribing) on medication safety. Some key medication safety benefits are an improvement in prescription communication, support for opioid safety strategies, support for better medication adherence and patient engagement through online patient-facing applications. However, there may also be an unintended introduction of risk, through prescription modifications missed by the system, loss of prescription bundling, confusing free-text entries, and reduced patient engagement.
Key Words:
- PrescribeIT
- electronic medical record (EMR)
- automation complacency

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Canada’s National Incident Data Repository for Community Pharmacies
- Have Unused Medications Overstayed Their Welcome?

Do Not Use a Syringe for a Topical Product – A Focus on Chlorhexidine Disinfectant Solutions

This bulletin provides recommendations to eliminate the unacceptable practice of using syringes for topical products. To prevent inadvertent injection of topical solutions, hospitals should ensure topical solutions are available in ready-to-use labelled formats. They should also develop separate, easily differentiated processes for the storage, preparation, and handling of medications intended for topical application and those intended for parenteral injection.
Key Words:
- Chlorhexidine

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Updated: ISMP (US) List of High-Alert Medications in Acute Care Settings
- Opportunity to Pilot a Novel MSSA with a Focus on “Never Events”
- You Asked Us: “Should I Change My Pharmacy after a Mistake?”

Design of eMAR Systems with End-Users in Mind: Learning from a Fatal Incident in Long-Term Care

This bulletin follows a fatal incident that occurred in long-term care (LTC), where the electronic medication administration record (eMAR) was a significant contributing factor. The eMAR display had poor readability due to the placement of information, the repetition of information, the use of capital (uppercase) letters and multiple rows for administration times. Recommendations to improve usability of the eMAR are made to LTC homes, as well as the medication system software vendors and pharmacies supporting them
Key Words:
- Human factors engineering

Injecting Standardization into Vaccine Clinics

This bulletin shares learnings from a multi-incident analysis (MIA) and recent failure modes and effects analysis to help inform safe medication practices in vaccine clinics. Some safety vulnerabilities identified in vaccine clinics included clinic set up and organization factors such as clinic layout, access to technology, patient flow and documentation processes. Vaccine associated considerations included procurement, storage, cold chain requirements and administration.
Key Words:
- Host facilities
- Immunization
- Influenza, flu shot
- Cooler
- Refrigerator
- Bar code identification
- Unique identifiers

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Help Improve Medication Safety Across Canada
- Keep Your Medications Organized

Antidotes and Related Agents: Recognition of Need, Availability, and Effective Use

This bulletin addresses vulnerabilities that compromise the safety and efficacy of antidotes and offers strategies to overcome these challenges. These strategies include identifying the need for an antidote, (especially when signs and symptoms of toxicity resemble the disease state being treated), ensuring the availability of antidotes, and knowing how to use them.
Key words:
- Reversal agents
- Decontamination agents
- Neutralizing agents
- Rescue agents
- Combination order sets
- Poison control
- Naloxone

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Do NOT Delay Starting Certain Medications

Safe Storage and Disposal of Medications

This bulletin, created in partnership with the Canadian Patient Safety Institute offers guidance to clinicians and patients on the safe storage and disposal of medications in the community.
Key Words:
- Unintentional pediatric ingestion
- Relief kits

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Safety Concerns Resulting from a Concentrated Potassium Chloride Shortage in the United States
- Canada’s National Incident Data Repository for Community Pharmacies
- Using Your Own Medications While in Hospital

Reaffirming the “Do Not Use: Dangerous Abbreviations, Symbols and Dose Designations” List

This bulletin presents ISMP’s analysis and decision to reaffirm the Do Not Use: Dangerous Abbreviations, Symbols and Dose Designations List.
Key Words:
- Error-prone acronyms
- Symbols
- Dose designations
- Transitions of care
- Individual Practitioner Reporting (IPR)
- Community Pharmacy Incident Reporting (CPhIR)
- Consumer Reporting
- National System for Incident Reporting† (NSIR)

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Name Change: M-Eslon IR to M-Ediat
- New Symptoms: Could They Be Related to Your Medications?

Deprescribing: Managing Medications to Reduce Polypharmacy

This bulletin discusses deprescribing as a method to manage polypharmacy, which is the concurrent use of 5 or more medications where the theoretical benefits are outweighed by the negative effects of the sheer number of medications.

Key Words
- Seniors, geriatric medicine
- Drug-drug interaction
- Patient partnership

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Opioids for Pain After Surgery—Patient Handout
- Don’t Be Embarrassed to Talk to Your Pharmacist

Students Have a Key Role in a Culture of Safety: A Multi-Incident Analysis of Student-Associated Medication Incidents

This multi-incident analysis (MIA) was undertaken to address the lack of evidence surrounding the impact of students on medication safety. The MIA looked at student-associated medication incidents from 3 ISMP Canada databases and the National System for Incident Reporting (NSIR). The themes identified were (1) Identification, Resolution, and Reporting of Incidents by Students, (2) Preceptor-Associated Challenges, and (3) Gaps in Organizational Processes.
Key Words:
- Individual Practitioner Reporting (IPR)
- Consumer Reporting
- Community Pharmacy Incident Reporting (CPhIR)
- Canadian Incident Analysis Framework

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Substitution Error in a Naloxone Kit
- Save a Life—Get a Naloxone Kit to Treat an Opioid Overdose

Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre

This bulletin follows an incident reported to ISMP Canada of a cancer patient receiving a fatally high dose of selenium as part of an intravenous complex tissue- and wound-healing formulation at a complementary care center (CCC). The selenium solution was prepared by a compounding pharmacy and was added to the formulation on site at the CCC. Key opportunities for improvement were the compounding processes at the pharmacy, and the emergency response, and preparation, storage and administration of the admixture at the CCC.

Key Words:
- Complementary medicine, alternative medicine
- Naturopathy, naturopathic medicine
- Confirmation bias
- Microgram vs milligram
- Dangerous abbreviation
- Dose error
- 1000-fold overdose
- Weigh scale
- Conversion calculation
- Preprinted order sets
- Compounding
- Emergency response
- Vital monitoring

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Stakeholder Consultation on Naming of Biologic Drugs
- Caution: Unlabelled Marking on a Vaccine Syringe Led to Under-dosing of Adult Patients