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Medication Safety Resources for Coroners and Medical Examiners

This web page has been developed to provide Coroners and Medical Examiners with useful information regarding death investigation in drug-related cases, including access to a secure, direct, one-way portal for the purpose of sharing information and lessons learned from investigation of medication incident associated deaths.

ISMP Canada has worked with a number of provincial and territorial Coroner's and Medical Examiner's Offices on both a formal and informal basis, including case reviews, committee membership, and providing expert witness testimony for inquests.

Analysis of case data from Coroner and Medical Examiner investigations provides insights into underlying contributing factors and can suggest opportunities for improvement that may be broadly applicable, with the potential to reduce the likelihood of future similar deaths.


This secure portal provides coroners and medical examiners with a direct, secure connection to ISMP Canada for the purpose of sharing lessons learned from case data.

ISMP Canada will review data submitted to assess opportunities for sharing generalizable learning and actions recommended to reduce the likelihood of recurrence, in a de-identified way, e.g., through an ISMP Canada bulletin.

All information submitted will be used by ISMP Canada in accordance with its privacy policies, practices and procedures.

ALL INFORMATION SUBMITTED WILL BE KEPT STRICTLY CONFIDENTIAL AND PROTECTED.

Resources for Coroners and Medical Examiners

ISMP Canada Checklist for Investigating Deaths Involving Medication Incidents

Checklist

ISMP Canada Case Review Services Available for Offices of the Chief Coroner and Chief Medical Examiner

ISMP Canada Publications and Resources

Analysis of Data from 2012-13 Health Canada Project:

A collaborative medication safety project was undertaken with 4 provincial Offices of the Chief Coroner and Chief Medical Examiner in 2012-2013, with funding support from Health Canada. This project generated a number of publications and other resources, including the following:


ISMP Canada Safety Bulletins Related to Analysis of Medication Error Associated Deaths:

ISMP Canada Safety Bulletins Related to Analysis of Medication Error Associated Deaths (by drug class)

Anesthetics

Anticoagulants

Cardiac Medications

Chemotherapeutics and biologics

Diabetic medications

Drug Interactions

Intravenous fluids and Electrolytes

Medication delivery devices

Opioids

Other

 
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