Issue 10
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.
Issue 10 supplements
ISSUE 9
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.
ISSUE 9 supplements
Issue 8
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.
Issue 8 supplements
Issue 7
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.
Issue 7 supplements
Issue 6
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.
Issue 6 supplements
Issue 5
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.
Issue 5 supplements
Issue 4
This bulletin follows a case reported to ISMP Canada 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.
Issue 4 supplements
Issue 3
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.
Issue 3 supplements
Issue 2
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.
Issue 2 supplements
Issue 1
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.
Issue 1 supplements