ISMP Canada Safety Bulletins

Change Management in Response to Preventable Tragedies

This bulletin outlines the changes made to an institution, and how they were implemented, following the occurrence of 2 never-events involving concentrated electrolytes being administered to pediatric patients. Steps taken include the following: recognizing the need for change, building a multidisciplinary team to guide change, developing strategies to reinforce change, communicating strategies to promote buy-in, anchoring the change in organizational policies and procedures, and incorporating continuous monitoring and assessment.
Key Words:
- Preprinted label
- Computerized order sets

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Mistaken Identity – A Recurring Problem

Dose Confusion When Switching between Insulin Delivery Devices

This bulletin follows a case reported to ISMP Canada of a dosing error with a high-concentration insulin product. The case involves the incorrect dose being administered following a switch from a U-500 multi-dose vial to a U-500 insulin pen.

Errors Associated with Oxytocin Use: A Multi-Incident Analysis

Oxytocin is a high alert medication that is used during labour and postpartum. This multi-incident analysis (MIA) used cases reported to 3 ISMP Canada databases and NSIR to identify opportunities to improve safety with this drug. The themes identified were preparation and storage challenges, IV administration-associated errors and communication/documentation gaps.
Key Words:
- Preprinted label
- Automated dispensing cabinets (ADCs)
- Infusion pump
- Infusion rate
- Newborn and maternal health
- Transitions of care
- Standardized documentation

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Opioid Wisely: Partnering to Promote Safe Use of Opioids after Removal of Wisdom Teeth

Potentially Harmful Interaction between Polyethylene Glycol Laxative and Starch-Based Thickeners

Adding PEG 3350 laxative to a starch-based thickened liquid will result in a drug interaction that will make the mixture thin and watery. For patients with dysphagia, this interaction creates a risk for aspiration. This has potential to be lethal, as is seen in a case reported to ISMP Canada. Xanthan-gum based thickening products do not exhibit the same interaction with PEG 3350.
Key Words:
- Thickened fluids
- Long Term Care

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Independent Double Checks – Are Your Checks Truly Independent?

Educational Support for Mandatory Reporting of Serious Adverse Drug Reactions and Medical Device Incidents

Health Canada, ISMP Canada, Health Standards Organization (HSO) and the Canadian Patient Safety Institute (CPSI) have created 4 modules to explain and encourage reporting of serious Adverse Drug Reactions (ADR) and Medical Device Incidents (MDI) by hospitals, as mandated by the Protecting Canadians from Unsafe Drugs Act.
Key Words:
- Vanessa’s Law
- Regulatory requirements

Palliative Care: A Multi-Incident Analysis

An MIA was undertaken to identify complexities contributing to medication errors during care at end of life. The 3 themes identified were (1) hesitancy to treat opioid toxicity with naloxone, (2) errors in medication use processes such as transcription errors and administration errors, and (3) gaps in coordination of care.
Key Words:
- Terminal
- DNR
- Telephone orders and verbal orders
- Transitions of care

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Consumer “Good Catches”
- Health Canada’s Policy Statement on the Naming of Biologic Drugs

Lack of Standardized Documentation Contributes to a Mix-up between Methadone and Buprenorphine-Naloxone

This bulletin follows a case reported to ISMP of a patient who was administered methadone despite being prescribed buprenorphine-naloxone. The mix-up happened because of incomplete documentation in the medication administration record, and a lack of an independent double check.
Key Words:
- Opioid use disorder
- Opioid agonists
- Dose administration documentation
- Logs
- Dispensing protocols

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Supporting Safe Medication Use during Periods of Fasting

Medication Safety in Long-Term Care: Measuring Quality Improvement Over 12 Years

This bulletin summarizes a retrospective quantitative analysis of data submitted to the Medication Safety Self-Assessment for Long Term Care (MSSA-LTC) by facilities that have completed 3 or more assessments. The goal of this analysis was to determine the impact of repeated assessments.
Key Words:
- Canadian Medication Incident Reporting and Prevention System (CMIRPS)
- Key elements

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Natural Health Products—Improving Labels for Safety

Gaps in Interconnectivity of a Hospital’s Electronic Systems Create Vulnerabilities at Transitions of Care

This bulletin explores a case of a morphine overdose during a transition of care between 2 hospitals. The error was a result of a discrepancy created by an electronic medication system that did not communicate in real time.
Key Words:
- Integrated systems
- Communication gap
- Medication Administration Record (MAR)
- Discharge prescription
- Automation complacency
- Medication reconciliation

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- Cannabis for Medical Use – Submit Your Incidents and Concerns
- Education to Support Mandatory ADR/MDI Reporting (Vanessa’s Law)

Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes

This bulletin describes contributing factors and recommendations based on 2 never events where administration of concentrated injectable electrolytes resulted in fatalities. Contributing factors in the cases were that the concentrated electrolyte injectables were stocked in the patient care area without appropriate safeguards, prescription and preparation of these products were non-standardized processes, there was a lack of independent double checks, and look-alike packaging.
Key Words:
- Potassium chloride
- Potassium phosphate
- Confirmation bias
- Selection error
- Calculation error
- Mixing error

𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- New Regulations will Help Protect Canadians from Unsafe Medications and Medical Devices
- Medication Reviews in Long-Term Care Homes