ISMP Canada Safety Bulletins
Canadian Medication Incident Reporting and Prevention System (CMIRPS)

2008

• Vol. 8 Issue 7 - A Near Miss Involving Cyclophosphamide
• Vol. 8 Issue 6 - Hydromorphone Intended for an Adult Patient Inadvertently Administered to an Infant
• Vol. 8 Issue 5 - Enhancing Safety with Unfractionated Heparin
• Vol. 8 Issue 4 - Prefilled Syringes of Epinephrine and Compatibility with Intravenous Tubing
• Vol. 8 Issue 3 - Drug Interaction Incident with HIV Post-exposure Prophylaxis
• Vol. 8 Issue 2 - Incidents of Inadvertent Daily Administration of Methotrexate
• Vol. 8 Issue 1 - Desmopressin Incidents Identify a Need to Evaluate Monitoring Protocols

2007

• Vol. 7 Issue 9 - Medication Reconciliation and Medication Review: Complementary Processes for Medication Safety in Long-Term Care
• Vol. 7 Issue 8 - Demystifying Medication Incident Reporting
• Vol. 7 Issue 7 - Near Miss Identification and Reporting
• Vol. 7 Issue 6 - Patient Report of Insulin Mix-Up Shared
• Vol. 7 Issue 5 - Fentanyl Patch Linked to Another Death in Canada
• Vol. 7 Issue 4 - Fluorouracil Incident Root Cause Analysis: Follow-Up
• Vol. 7 Issue 3 - Automated Dispensing Cabinets in the Canadian Environment
• Vol. 7 Issue 2 - Risk of Mix-ups between Ephedrine and Epinephrine
• Vol. 7 Issue 1 - Unexpected Hypoglycemia: Consider Medication Error in the Differential Diagnosis

2006

• Vol. 6 Issue 10 - Appropriate Anticoagulant Use — A Patient Safety Priority
• Vol. 6 Issue 9 - Shared Learning — Reported Incidents Involving Hydromorphone
• Vol. 6 Issue 8 - Failure Mode and Effects Analysis (FMEA): Proactively Identifying Risk in Healthcare
• Vol. 6 Issue 7 - Epidural Medications Given Intravenously May Result in Death
• Vol. 6 Issue 6 - ALERT: Potential for “Key Bounce” with Infusion Pumps
• Vol. 6 Issue 5 - Transdermal Fentanyl: A Misunderstood Dosage Form
• Vol. 6 Issue 4 - Eliminate Use of Dangerous Abbreviations, Symbols, and Dose Designations
• Vol. 6 Issue 3 - Medication Reconciliation — In the Hospital and Beyond
• Vol. 6 Issue 2 - Safety Strategies for Potassium Phosphates Injection
• Vol. 6 Issue 1 - Top 10 Drugs Reported as Causing Harm through Medication Error

2005

• Vol. 5 Issue 10 - Root Cause Analysis of Medication Incidents
• Vol. 5 Issue 9 - Hospital Medication Safety Self-Assessment™ Program: Update
• Vol. 5 Issue 8 - Tunneled Intrathecal Catheter Mistaken as Central Venous Line Access
• Vol. 5 Issue 7 - System Vulnerabilities across the Spectrum of Care: Another Mix-up between Choral Hydrate and Potassium Chloride
• Vol. 5 Issue 6 - Tragic Error with a Compounded Pediatric Formulation — Shared Learning
• Vol. 5 Issue 5 - Bupivacaine Injection: Check Your Supplies
• Vol. 5 Issue 4 - Report of Near Miss with Succinylcholine Warrants Action
• Vol. 5 Issue 3 - Heparin-Induced Thrombocytopenia — Effective Communication Can Prevent a Tragedy
• Vol. 5 Issue 2 - Secondary Infusions Require "Primary" Attention
• Vol. 5 Issue 1 - Lowering the Risk of Medication Errors: Independent Double Checks

2004

• Vol. 4 Issue 12 - Risk of Tragic Error Continues in Operating Rooms
• Vol. 4 Issue 11 - Morphine Ampoule Look-Alike Packaging ALERT
• Vol. 4 Issue 10 - A Need to “Flush” Out High Concentration Heparin Products
• Vol. 4 Issue 9 - Latent Failures Identified with CADD® Pump Error Analysis
• Vol. 4 Issue 8 - Meperidine (Demerol^®): Issues in Medication Safety
• Vol. 4 Issue 7 - “Paralyzing” Mix-ups in the Operating Room: Improve Safety with Neuromuscular Blockers
• Vol. 4 Issue 6 - An Omnipresent Risk of Morphine-Hydromorphone Mix-ups
• Vol. 4 Issue 5 - Devices with Inflation Ports – Risk for Medication Error-induced Injuries
• Vol. 4 Issue 4 - High Alert Drugs and Infusion Pumps: Extra Precautions Required
• Vol. 4 Issue 3 - Concentrated Potassium Chloride: A Recurring Danger
• Vol. 4 Issue 2 - Look-Alike/Sound-Alike Drug Names: Can We Do Better in Canada?
• Vol. 4 Issue 1 - Infusion Pump Project: Survey Results and Time for Action

2003

• Vol. 3 Issue 12 - Methadone: Not Your Typical Narcotic!
• Vol. 3 Issue 11 - More on Potassium Chloride
• Vol. 3 Issue 10 - ALERT: Alarm Not Activated after Infusion Pump Tubing Incorrectly Loaded
• Vol. 3 Issue 9 - Safeguard Against Errors with Long-Acting Oral Narcotics
• Vol. 3 Issue 8 - Chemotherapy Error Prompts Review of Medication Order Processing
• Vol. 3 Issue 7 - Infusion Pumps – Opportunities for Improvement
• Vol. 3 Issue 6 - Enhanced Sterile Water Label Paves Way for National Standard
• Vol. 3 Issue 5 - Human Factors and Substitution Errors
• Vol. 3 Issue 4 - Insulin Errors
• Vol. 3 Issue 3 - Medication Safety and Infection Control
• Vol. 3 Issue 2 - Depo-Medrol^® Confused with Solu-Medrol^®
• Vol. 3 Issue 1 - Reports of Epidural Infusion Errors

2002

• Vol. 2 Issue 12 - Neuromuscular Blocking Agents – Time for Action
• Vol. 2 Issue 11 - Report of Incorrect Administration of Epinephrine
• Vol. 2 Issue 10 - Confusion Between SEROQUEL^® and SERZONE-5HT2^® Reported in Canada
• Vol. 2 Issue 9 - Designing Labels with the End-User in Mind
• Vol. 2 Issue 8 - NCCMERP Statement on Medication Error Rates Provides A Clear Direction for Hospitals
• Vol. 2 Issue 7 - Multi-factorial System Problems Lead to a Chemotherapy Mishap
• Vol. 2 Issue 6 - WARNING: Prevent Mix-ups between Conventional amphotericin B (Fungizone^®) and Lipid-based amphotericin B products (AmBisome^® or Abelcet^®)
• Vol. 2 Issue 5 - How to Use ‘Failure Mode and Effects Analysis’ to Prevent Error-Induced Injury with Potassium Chloride
• Vol. 2 Issue 4 - Sentinel Event with Sterile Water – Lessons Shared
• Vol. 2 Issue 3 - Codeine Syrup - Dangerous ‘Near miss’ in the Community
• Vol. 2 Issue 2 - Narcotic Safeguards – The Challenge Continues
• Vol. 2 Issue 1 - Inadvertent Administration of Oral Solutions by Injection

2001

• Vol. 1 Issue 3 - Multiple Reports of Confusion Between Lamotrigine (LAMICTAL^®) and Products with ‘sound alike’ / ‘look alike’ Names
• Vol. 1 Issue 2 - Reported Error With Sodium Chloride 3% Reminds Us Of The Need For Added System Safeguards With This Product
• Vol. 1 Issue 1 - Published Data Supports Dispensing Vincristine in Minibags as a System Safeguard