Read the Safety Bulletins to help you strengthen your medication-use system. Learn about strategies to mitigate harm and to prevent medication errors based on analyses of medication incident reports from Canadian health care providers, facilities, pharmacies, organizations, and consumers.
ISMP Canada received a sentinel event report describing inadvertent bolus administration of a HYDROmorphone product that was intended for continuous infusion.
ISMP Canada received a number of incident reports describing severe harm or death involving ambulatory infusion pumps, which prompted a multi-incident analysis to highlight opportunities for improvement. Listen to the synopsis:
Earlier this year, an ISMP Canada Safety Bulletin was published to proactively inform stakeholders about risks associated with vaccination processes and safeguards to prevent errors. Since then, health care providers have been working with the government, public health agencies, and health care and community organizations to provide COVID-19 vaccines to as many Canadians as possible. The experiences of health care providers and consumers during this mass vaccination campaign informed an updated incident analysis, shared here.
Efforts to address the high workload and multifaceted nature of patient care in community pharmacies may lead to prescription processing practices that can put patient safety at risk. This bulletin highlights the findings from a multi-incident analysis of errors reported in the community pharmacy setting and identifies opportunities for process improvements.
Shortages of critical medications have become more common during the COVID-19 pandemic. Epinephrine prefilled syringes is one such critical product that has been in short supply. This bulletin shares a proactive approach that was developed and implemented by a regional paramedicine service to safely introduce the temporary use of epinephrine ampoules and mitigate the risk of medication errors. The example illustrates a growing interest in medication safety and the design of systems to support patient-facing practitioners.
The current COVID-19 pandemic has increased the demand for certain critical medications. The neuromuscular blocking agent rocuronium is one such medication. Neuromuscular blocking agents are high-alert medications and, when used in error, can lead to devastating injuries or death.
As part of an ongoing collaboration with a provincial death investigation service, ISMP Canada received a report describing an individual whose psychiatric conditions had been stabilized by a medication regimen that included both clozapine and fluvoxamine. A supply shortage of fluvoxamine led to a cascade of events that contributed to the individual's decompensated psychosis. This bulletin shares identified opportunities and related recommendations to avoid similar tragedies.
Identification of specific never events for the Canadian community pharmacy environment is intended to enhance patient safety by encouraging pharmacy teams to take action in specific areas where harmful errors are known to have occurred.
This bulletin shares incident examples to raise awareness of the risks associated with the lack of standardization of calcium product labels, as well as to highlight opportunities to improve labelling practices.