ISMP Canada News

July 2006

Canadian Manufacturer Adds Warning to Vial for Neuromuscular Blocking Agent

Hospira is a member of a collaborative initiative led by ISMP Canada to enhance the labelling and packaging of neuromuscular blocking agents in Canada. Pursuant to a consensus on ideal packaging and labelling features for these drugs, Hospira has quickly revised its vial ferrule and cap to include the following content: “Warning: Paralyzing Agent”. ISMP Canada will continue to provide updates on this important collaborative initiative, a first in Canada.

Need for Canadian Practitioners to Assist with Review of Proposed Drug Names

With a mission to lower the risk of medication errors, Med-E.R.R.S., (a subsidiary of ISMP [US]), works proactively with pharmaceutical companies to test trademark drug names and package labelling. As part of the process, Med-E.R.R.S. incorporates feedback from health care practitioners regarding the potential for similarity of potential drug names or packages with products currently on the market.
A new Health Canada requirement for manufacturers to test proposed drug names for safety before submission for approval has created an urgent need for Canadian health care providers in active practice (e.g., nurses, pharmacists, physicians) to assist the Med-E.R.R.S. team of professionals to review labels, packaging, and nomenclature. The time commitment for each project is usually 20–30 minutes, and an honorarium is offered to practitioners. ISMP Canada encourages Canadian practitioners to take advantage of this unique opportunity to help make a difference in medication safety. Sign up to “Become a Reviewer” at www.med-errs.com.

2006-2007 JCAHO Update: Requirements Related to Medication Use

Join the ISMP (US) teleconference on August 3 (repeated on August 10) for a 2006-2007 JCAHO Update: Requirements Related to Medication Use.
This session will discuss the revised Medication Management standards for US hospitals starting July 2006, and the 2006 and 2007 JCAHO National Patient Safety Goals (NPSGs), as well as other new standards that affect medication use. In addition, medication-related standards and NPSG requirements that have given hospitals difficulty in 2005-2006 will be discussed, along with strategies for better compliance with them. Lastly, changes in the new unannounced survey process will be presented along with tips on how to best prepare for it the visit.
Visit http://www.ismp.org/teleconferences/default.asp?teleconferenceID=17 for further details.

June 2006

CCHSA and ISMP Canada Collaboration

The Canadian Council on Health Services Accreditation (CCHSA) and ISMP Canada have signed a Memorandum of Understanding to formally recognize their close working relationship as organizations that both have a mission to improve the safety of health care. ISMP Canada will continue to participate with CCHSA in the development of a national set of standards and in revision of the accreditation process for medication management and pharmaceutical services. This collaboration facilitates the translation of valuable learning from medication incident data, provided to ISMP Canada by professionals in the Canadian health care community, into standards for enhanced safety in health care systems. CCHSA and ISMP Canada will be collaborating in a number of ways to continue to foster a culture of shared learning and accountability for patient safety.

ISMP Nurse Advise-ERR^® Newsletter Free to Canadian Nurses

The ISMP Nurse Advise-ERR^® is a medication safety newsletter designed specifically to meet the needs of nurses. This monthly newsletter is offered free to nurses during 2006 and will be distributed by ISMP Canada, by email, complimentary of ISMP (US). Regular features include anonymous accounts of reported medication errors, their underlying causes, and the preferred practices for error reduction strategies, including quick tips regarding safe medication practices. It is our goal to reach as many nurses as possible. We encourage designated nursing representatives from each hospital or health care facility to subscribe and widely distribute the newsletter within their organization (e.g. posting on an internal intranet, email distribution, reproducing and circulation of hard copies). Individuals are also encouraged and welcome to subscribe. If you would like to receive this newsletter, please complete the subscription form. We thank you for your interest in promoting medication safety!

February 2006

Neuromuscular Blocking Agent Labelling and Packaging Initiative

A collaborative meeting of representatives of pharmaceutical manufacturers of neuromuscular blocking agents was convened by ISMP Canada in Toronto on February 27th, 2006. The foremost outcome was agreement among the attending stakeholders on the “ideal features” for packaging and labeling of neuromuscular blocking agents:

• Red cap with white lettering: “Paralyzing agent” or “Warning: Paralyzing Agent”
• Red ferrule with white lettering: “Paralyzing agent”
• Red lettering on the product label: “Paralyzing agent” or “Warning: Paralyzing Agent”
• Peel-off label, using the colour scheme and content information recognized by the ASA/CAS recommended standards, for application to a prepared syringe (ASA = American Society of Anesthesiologists (www.asahq.org); CAS = Canadian Anesthesiologists’ Society (www.cas.ca)
• Space on the product label for bar code application
• Development of a universal symbol for neuromuscular blocking agents and proposal for global use: placement of this symbol (e.g., on the label), to be determined
• Review of potential benefit of using TALL-man lettering for generic names of neuromuscular blocking agents

December 2005

Earlier this year, ISMP Canada held a strategic planning session involving its board of directors, selected staff members, and external advisors. One of the strategic directions adopted by participants was to increase the organization’s involvement in patient safety research.

On December 2, 2005, the Canadian Patient Safety Institute (CPSI) announced the winners of its first research funding competition. Twenty-eight winners, divided by theme into two groups (Applied Health Services Research Projects and Demonstration Projects), were selected. For full details on the selection process and the list of successful applicants, refer to the CPSI web page (http://www.patientsafetyinstitute.ca).

The Institute for Safe Medication Practices Canada (ISMP Canada) is a coapplicant and research team member in four of the winning proposals:

Theme 1: Applied Health Services Research Projects

• Neil MacKinnon, Dalhousie University, Halifax, NS — Development of medication safety indicators
• Karen Weisbaum, Queen’s University, Kingston, ON — Striking a balance: facilitating access to patient safety data while protecting privacy through creation of a national harmonized standard

Theme 2: Demonstration Projects

• Tony Easty, University Health Network, Toronto, ON — Developing and implementing an effective method for independent double checking of high-risk clinical procedures
• Kathryn Momtahan, University of Ottawa Heart Institute, Ottawa, ON — Using human factors and FMEA methods to evaluate labelling of injectables (ampoules) and the recently developed CSA standards for labelling

October 30, 2005

A collaborative meeting of stakeholders, co-led by ISMP Canada and the Canadian Patient Safety Institute (CPSI), and supported by Health Canada, was held in Toronto on September 20, 2005. Representatives from Canada’s Research-Based Pharmaceutical Companies (Rx&D), Canadian Generic Pharmaceutical Association (CGPA), the Canadian Society of Hospital Pharmacists (CSHP), the Canadian Standards Association (CSA), Canadian Emergency Health Services, Canadian Anesthesiologists’ Society, ISMP (U.S.), the U.S. Food and Drug Administration (FDA), HealthPRO Procurement Services Inc., Medbuy Corporation, Baxter Corporation (Canada), Hospira Healthcare Corporation and select pharmaceutical manufacturers were in attendance.

The intent of the meeting was to discuss concerns related to medication labelling and packaging, and to develop a consolidated approach for prioritizing issues and for implementing recommendations regarding medication label and package enhancements. An example of a high priority item is the labelling of neuromuscular blocking agents.

Incident reporting was identified as a key component in the understanding of medication safety issues and development of prevention strategies. Stakeholders were asked to encourage their members to report medication incidents to the Canadian Medication Incident Reporting and Prevention System (CMIRPS) for shared learning. See this page for information about CMIRPS.

ISMP Canada and CPSI, with the support of Health Canada, will be collaborating to create Terms of Reference for a formalized group to move forward with addressing pharmaceutical labelling and packaging issues.

October 6, 2005

Michael R. Cohen, RPh, MS, ScD, President of the Institute for Safe Medication Practices (ISMP), has been named a John D. and Catherine T. MacArthur Foundation Fellow for 2005. The highly selective Fellowships are awarded to individuals who have shown extraordinary originality and dedication in their professional pursuits, and outstanding promise for important future advances. Dr. Cohen, a founding member and current Board member of ISMP Canada, is being honored for his ability to lead national efforts to ensure safe medication use and protect patients.

The MacArthur Foundation is one of the ten largest private philanthropic foundations in the U.S., and Fellows are chosen through a rigorous process. The program does not accept applications or unsolicited nominations. Between 20 and 30 Fellows are chosen each year, each receiving an unrestricted, five-year grant totaling $500,000, which is considered an investment in their potential to use their abilities to benefit society at large. Recent Fellows include academics in the field of science and medicine at top-ranked U.S. universities such as Harvard, Yale, and Stanford.

Dr. Cohen has dedicated his 40-year career in healthcare to bringing about greater understanding of the causes of medication errors and providing the healthcare community with practical prevention strategies. Other accomplishments include helping launch a continuous, voluntary practitioner medication error reporting system; publishing extensively on medication use issues; serving on key national medication safety committees; and providing consultation, education, and assistance on safe medication use to healthcare professionals and organizations around the world.

Please join ISMP Canada in congratulating Dr. Cohen on receiving this prestigious honor for his dedication and innovative approach to medication safety.

April 2005

Med-E.R.R.S. (a subsidiary of the Institute for Safe Medication Practices [ISMP US]) works proactively with pharmaceutical companies to develop trademark drug names and package labelling designed to lower the risk of medication errors. The Med-E.R.R.S. staff consists of health care professionals with extensive experience in clinical settings. These clinicians integrate their knowledge and experience with the input of clinicians in the field to systematically analyze potential trademarks, packaging, and technology. Med-E.R.R.S. is interested in hearing from pharmacists and other health care professionals from all practice settings in Canada to help review labels, packaging, and nomenclature in the premarketing phase of pharmaceutical products. For more information or to communicate interest in joining the team, go to www.med-errs.com and click on “Become a Reviewer."