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.
Since the arrival of COVID-19 vaccines in Canada, information about their availability and use continues to be updated frequently. Recently, bivalent vaccines have been introduced to combat multiple strains of COVID-19 with a single vaccine dose. ISMP Canada has received numerous reports of incidents and concerns related to the labelling of these vaccines. In particular, the inability to differentiate the monovalent and bivalent vaccines resulted in errors of incorrect product and incorrect dose. This bulletin focuses on the labelling of these products, as a key factor contributing to the errors, and shares recommendations for both manufacturers and health care providers.
Acetaminophen and ibuprofen products for pediatric patients have been in short supply across Canada. Health Canada is reviewing foreign-authorized products to mitigate the shortage and has granted a temporary exemption to import an Australian acetaminophen product for hospital inpatient use only, with a different concentration from the Canadian product. The differences between the acetaminophen products from Canada and Australia will require a coordinated risk management strategy. Read this bulletin to learn how to reduce the risk of mix-ups and dosing errors in hospitals.
Health Canada has also authorized the importation of different acetaminophen products for retailers. The bulletin sidebar shares recommendations for community pharmacists to support the safe administration of imported acetaminophen products.
During the COVID-19 pandemic, virtual care has allowed many Canadians to access health care remotely. The growth of virtual care has also highlighted the need to optimize the safety of this approach to care. This bulletin shares findings from an analysis of a cluster of medication incidents that occurred during the provision of virtual primary care. Recommendations are made to inform continuous improvement.
ISMP Canada recently received reports of fatal overdoses of intravenous (IV) N-acetylcysteine resulting from errors in pump programming. This bulletin is shared to alert stakeholders to the potentially fatal outcome of this error and to encourage review of the processes that support IV administration of N-acetylcysteine.
For individuals who are taking life-saving medications and who require urgent assessment and treatment when ill, emergency care plans can be a key mechanism for sharing medical and medication information with the receiving care team. An incident report shared with ISMP Canada highlights the value of emergency care plans to improve communication among care providers, as well as patients’ health outcomes.
ISMP Canada’s consumer reporting program, SafeMedicationUse.ca, received a report from a patient who was inadvertently given tranexamic acid into the spine as a result of a substitution error. They asked that their story be shared, “so that no one else would have to experience the same fate.”
This bulletin highlights the findings from a multi-incident analysis of harmful medication incidents involving pediatric patients in the community and identifies opportunities to improve pediatric medication safety.
On March 17, 2022, the shortage of small-volume formats of sterile water for injection packaged in vials and ampoules was assigned a Tier 3 designation by a Tier Assignment Committee that includes Health Canada and other Canadian stakeholders.
Paxlovid (a co-packaged product containing nirmatrelvir and ritonavir tablets) was recently approved by Health Canada for the treatment of mild to moderate COVID-19 in adults at high risk for progression to severe disease.
In follow-up to several recent reports of incidents involving medications used to prevent organ rejection, a multi-incident analysis was conducted. The analysis identified system vulnerabilities, and selected system safeguards to improve medication safety.