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.
Previous safety publications have identified risks for error with the practice of pre-pouring. This bulletin describes examples from the cluster of incidents and shares recommendations to reduce the need for this practice.
Compounding is a high-risk process, and the associated complexity can increase the likelihood of medication errors. This bulletin describes two recently reported medication incidents that involved the preparation of clonidine suspension by different methods.
Sidebar:
- Oral Corticosteroid Options for Acute Respiratory Indications in Pediatrics
This bulletin describes a reported incident in which a patient experienced pulmonary aspiration of regurgitated gastric contents during anesthesia. The patient was taking a glucagon-like peptide-1 (GLP-1) receptor agonist. Raising awareness about this newly identified risk provides an opportunity to develop medication safety strategies and prevent patient harm.
Approximately 4500 Canadians are hospitalized each year because of acetaminophen overdose. Although intravenous (IV) infusion has been widely accepted as a safe mode of administration for acetylcysteine, serious errors have occurred, leading to life-threatening conditions and/or death.
The introduction of vaccines to protect against COVID-19 was a turning point in the management of the pandemic. Knowledge about these products continued to evolve rapidly after they were made available, which resulted in frequent updates to stability and storage requirements and associated product labelling.
This bulletin is focused on an analysis of community pharmacy incidents involving newer classes of medications for diabetes treatment, and offers strategies to prevent errors.
This bulletin highlights a mix-up between 2 penicillin formulations, the proactive response of a hospital to identify other potentially affected patients, and recommended changes to the medication-use system to prevent similar incidents from occurring.
Sidebars:
- Check the Syringe! Preventing Methotrexate Dose Errors
- Canadian High-Alert Medication List: We Want to Hear from You!
The Canadian Medication Incident Reporting and Prevention System (CMIRPS) continues to receive reports from practitioners that describe concerns with labelling and packaging.
Smart pumps with dose error reduction software (DERS) support organizations in creating a tailored library of medications with associated dosing guidelines. By establishing dosing limits and alerts within DERS, organizations can use smart pumps to detect dosing and programming errors that may harm patients. This safety bulletin outlines situations in which bypassing the drug library and DERS takes the “smart” out of smart pumps. It also describes the risks associated with bypassing this software and offers strategies to increase the use of this technology