News Archive

June 15, 2004

• ISMP Canada has recently developed a unique failure mode and effects analysis (FMEA) model which is being introduced in a one-day workshop in Winnipeg. This is the first of a series of patient safety workshops requested and supported by Manitoba Health for healthcare practitioners in the province. Over 60 practitioners are to participate. Plans are underway for FMEA workshops in Ontario and on Vancouver Island in the next few months.

May 12, 2004

• In accordance with our national mandate, ISMP Canada is now in the process of translating our website and bulletins into the French language in order to provide medication safety support services to French speaking practitioners and hospitals. We are pleased to have retained Marie-Claude Poulin of Montreal University Health Centre - Centre Hospitalier de l'Université de Montréal (CHUM), who will assist us with related projects. Marie-Claude is a hospital pharmacist and currently serves as the risk management advisor to CHUM. ISMP Canada has a collaborative agreement with CHUM for mutual support in patient safety initiatives.
• The Canadian Council on Health Services Accreditation (CCHSA) has recently expanded its scope on patient safety activities. There is a newly created Patient Safety Advisory Committee with ISMP Canada as a member along with other key stakeholders. There are plans to revise the standards related to medication use, identify medication safety indicators and propose specific patient safety goals for Canadian hospitals.
• The British Columbia Patient Safety Task Force, under the auspices of the BC Ministry of Health, has recently invited ISMP Canada into a patient safety collaborative. Like hospitals in the provinces of Ontario, Manitoba, Saskatchewan and Nova Scotia, hospitals in British Columbia will have the option of participating in the Medication Safety Self-Assessment™ program. Healthcare facilities and staff will also receive the ISMP (US) Medication Safety Alert! and the ISMP Canada Safety Bulletin.

Feb. 20, 2004

• Recently ISMP Canada signed a Contribution Agreement with Health Canada to operate, in conjunction with the Canadian Institute for Health Information and Health Canada, the Canadian Medication Incident Reporting and Prevention System. The goal of this national program is to collect medication incidents and near misses from healthcare practitioners and institutions in Canada so adverse medications events can be investigated, analyzed and information for error prevention strategy can be disseminated to the Canadian Healthcare System. The data collected will be invaluable in learning, conducting trending analysis and facilitating research on patient safety.
• ISMP Canada's first Medication Safety Support System project 'Removal of Concentrated Potassium Chloride (KCl) from Patient Care Areas in Ontario Hospitals' was very successful. Majority of Ontario hospitals have removed concentrated potassium chloride from their patient care areas as a result of this initiative. ISMP Canada continues to support the KCl initiative. For more information please go to the 'KCl Support' section.
• A three-day Coroner’s inquest was completed on February 12, 2004 in Peterborough to investigate the death of a hospital patient who died on January 21, 2002 after receiving concentrated potassium chloride by direct intravenous injection. The jury’s primary recommendation stressed the need for the complete removal of concentrated potassium chloride from patient care areas in hospitals. A second key recommendation was that the manufacturers of concentrated potassium chloride should package their products in a format highly distinguishable from other drug products, using packages with clear and obvious warning labels. The lawyers representing all parties, including the deceased patient’s son, agreed with all the recommendations presented by the expert witness, David U, President and CEO of ISMP Canada. A detailed list of these recommendations will be posted on the ISMP Canada website once officially released by the coroner’s office.
• Joining Ontario, the following provinces including Nova Scotia, Manitoba, and Saskatchewan have established formal collaborations with ISMP Canada who will provide medication safety services. These services include: participation in the Medication Safety Self Assessment (MSSA) program, the ISMP Newsletter and the Canadian Safety Bulletins. ISMP Canada would welcome the opportunity to work with the Ministry and Department of Health in the other provinces.
• The Medication Safety Self Assessment (MSSA) is a tool to assist hospitals in reviewing their current processes and determining areas for improvement. The Canadian Council on Health Services Accreditation has endorsed the use of this self assessment tool as reflected in their new standard guideline 14.5. The best approach is to have participating hospitals from within the same province complete the MSSA to allow aggregate data to be compared from within their own province. For more information please see the MSSA page.
• Analyze-ERR^® is a medication error reporting and analysis software program available to Canadian hospitals. This program allows hospitals to input medication incidents and analyze contributing factors to ensure a proactive approach to medication safety and to facilitate a culture of safety. Additional information can be accessed from the Analyze-ERR page.
• ISMP Canada welcomes their first Fellow, Julie Greenall. Julie has taken a one year leave of absence from her position as Manager, Pharmacy at the North Simcoe Hospital Alliance (Midland/Penetanguishene) to acquire more in depth knowledge of medication safety issues with the goal of improving patient safety.
• ISMP Canada undertook the Infusion Pump Survey project in 2003 and the preliminary results in graphical representation are posted on the Infusion Pump Survey page.

Aug. 30, 2003

Our web site is moving to a new server for improved services. The web site is undergoing a complete face lift as well. Some of the links may be outdated or otherwise non-functional yet. We apologize for any inconvenience this may have caused.

Jul. 27, 2003

Slide presentations from "The Next Step for Ontario Hospitals" meeting can be viewed here.

Ontario Hospitals are invited to complete the ISMP Canada follow-up survey on the disposition of potassium chloride injections in hospitals.

Ontario Hospitals are invited to "The Next Step for Ontario Hospitals" seminar on upcoming safety initiatives.

The July 17 session will provide:

• Demonstration of an Ontario web-access medication error database.
• Introduction to a hospital medication safety self-assessment tool provided by the Ontario Ministry of Health and Long-Term Care.
• An update on the progress of the concentrated KCl project, and support to hospitals for a proactive response to the upcoming coroner's inquest into a patient's death related to inadvertent administration of concentrated potassium chloride.
• An introduction to the next focused high alert drug strategy based on 4000 errors reported to ISMP Canada.

The session is sponsored by the Ontario Ministry of Health and Long-Term Care.

ISMP Canada and Ontario Branch, CSHP are co-sponsoring a special breakfast meeting with hospitals on sharing information on safe medication practice committees. Hospitals intending to strike a similar medication safety committee or task force are also cordially invited.

The breakfast meeting which is generously supported by Abbott Laboratory Canada will be held in conjunction with PPC on Monday, February 3 at 7:00 am at the Westin Harbor Castle Hotel (Yonge Room).

Seats are limited.
One representative from a hospital please.
Please RSVP (name and hospital) by email to service@ismp-canada.org

• The new home of ISMP Canada is now located in Sunnybrook and Women's College Health Science Centre, Toronto, Ontario. As part of a new patient safety collaborative initiative with ISMP Canada, Sunnybrook and Women's has generously provided ISMP Canada the physical infrastructure and support.

• ISMP Canada will be working closely with the key professional organizations to make the Safe Medication Support Service a success. These organizations include the Ontario Medical Association, the Registered Nurse Association of Ontario, the Ontario Pharmacists Association, and the Ontario Branch of the Canadian Association of Hospital Pharmacists. More details on the programs will be made available.

May 28, 2002

• ISMP Canada welcomes our new board director. The board of ISMP Canada in its March 27, 2002 meeting unanimously approved the appointment of Carolyn Hoffman as a new board member. Carolyn has been a strong patient safety advocate. Presently she is the Provincial Quality of Care Coordinator, Saskatchewan Health, Saskatchewan.

• Analyze-ERR, the Medication Error Reporting and Analysis Software, is now available from ISMP Canada. An information page is posted in the Analyze-ERR section. Please contact ISMP Canada (info@ismp-canada.org)  for license fee structure and other information.

• The medication safety intervention project funded by Ontario Ministry of Health and Long Term Care is entering into Phase 4 where medication error prevention tools and strategies are being introduced to the "Study Group". Please see details under the Project section.

• ISMP Canada has been working with AstraZeneca to make packaging and labelling improvement on Potassium Chloride concentrate polyamps which have caused some concerns for its potential mix-ups with Normal Saline and Distilled Water.

• ISMP Canada is also working with Baxter Canada Inc. to make labelling improvement on Sterile Water for Injection USP one litre bag which has been reported being mixed up with Sodium Chloride 0.9 % one litre bag.

ISMP Canada is very pleased to receive very positive responses from manufacturers when they were called to discuss their product issues. Many of these issues were brought to the attention of ISMP Canada from medication errors (and near-miss) reports. We encourage hospitals and practitioners to continue sending reports so lessons can be learned and shared with the other healthcare organizations.

• Phase II of the Ontario Ministry of Health Project is being completed. Participating hospitals can now submit their Medication Safety Self-Assessment results from this web page.

• In the wake of last week's tragedy, ISMP Canada extends our utmost sincere condolences to our American friends who may have been affected. ISMP Canada stands by our American colleagues in denouncing this senseless and deplorable act of terrorism.

• The Intervention project funded by Ontario Ministry of Health had its kick off information sessions at both Toronto and Kingston. There were over 30 hospitals attending and all have received the information package as well as the study proposal. All interested hospitals are expected to receive the Letter of Agreement by mid-July. The signed agreement should be returned to ISMP Canada by the second week of September.

• ISMP Canada recently received approval and funding from Green Shield Canada to launch a pilot study to evaluate the Medication Safety Self-Assessment for community pharmacy practices. Collaborative input will be provided from CPhA. The project will begin sometime in the Fall of 2001. Further update on the this project will be posted in ISMP Canada's webpage.

• The Canadian Medical Association's Risk Management Institute is piloting a correspondence course on Medication Errors for physicians. The course Reference Group was established. Its members consists of Dr. Stuart MacLeod, Dr. Ed Etchells, Dr. William Beilby, and David U. Both Dr. Etchells and David U represent ISMP Canada. The first meeting is scheduled in mid-July, 2001.

• ISMP Canada is launching the Analyze-ERR software program very shortly. It is a brainchild of more than one year's joint effort between ISMP Canada and ISMP (US). It is an unique program that prompts hospitals to perform root cause analysis of medication errors and near-misses. Guided by the principle of non-punitive reporting culture and promoting quality improvement initiative, root cause data is not traceable to a specific medication error event. Results of aggregate root cause will identify system weakness for hospitals to focus improvement efforts.

Hospitals will soon be able to preview the Analyze-ERR program on this web site. The program will be used by hospitals on an annual subscription basis. More information on the release date of Analyze-ERR version 1.0 will be posted.

• A number of reports ISMP Canada received are on problems with infusion pumps used in hospitals. A joint initiative is being developed between University of Toronto's Cognitive engineering Laboratory and ISMP Canada on the use of infusion pumps and their problems in Canada. One of the components is the fact finding via a survey to be completed by Canadian hospitals. Hospitals' support and cooperation is greatly appreciated to make this study a success.

• The Canadian Coordinating Office of Health Technology Assessment (CCOHTA), based in Ottawa,  will be embarking on a very important initiative to assess how technology can reduce medical and medication errors. ISMP Canada has recently formed a collaborative partnership with CCOHTA, and will be working with CCOHTA on this exciting project.

• ISMP Canada teamed with ISMP (Mike Cohen and Judy Smetzer) conducted our first hospital consult in a hospital in Ontario in April. The consult took a three days onsite visit. An interim but a very informative report was presented during the last day. The final comprehensive report would be completed and delivered in about 8 weeks. It was a great success.

• The April 20 conference on "Breaking the Silence" is a great success. It was the first major conference jointed sponsored by ISMP Canada and The CQI Network. The feedback from the attendees was excellent.

Apr. 6, 2001

At the ISMP Canada board meeting of November 16, 2000, the Board unanimously appointed Sylvia Hyland into the position of Vice President of ISMP Canada.

Follow up on the Labeling meeting with Health Canada and CSA International:

The meeting on the new Labeling standard for injectables held on March 7, 2001 was a success. Bill Leslie and Micheline Ho from Health Canada indicated a support from the group to submit the Letter of Intent to Health Canada for endorsing the new label format for injectables in the Health Canada Guidelines. The new label standard was developed by the Technical Committee of CSA which consisted of many stakeholders including Dr. Beverley Orser who is a founding member of ISMP Canada. New development will be posted.

ISMP Canada is in the process of implementing a project on determining the impact of ISMP Canada's interventions for improvement of medication use in Ontario hospitals. This two year project is funded by the Ontario Ministry of Health. The project will involve:

• The adaptation and the application of the Medication Self Assessment, a tool originally developed by ISMP (US)

• Development of ISMP Canada's Medication Safety Alert newsletters

• Development and application of Analyse-ERR, a medication incident reporting and analysis software program

• Design and implementation of safe medication practice workshops

There will be 30 Ontario hospitals selected in the Study. Half of the participating hospitals will be enrolled in the Intervention Group, and the other half in the Control Group. More details on the Study will be made available in the near future. Interested hospitals which would like to be on our mailing list for detailed information on the Study are asked to forward the hospital's information and the contact person to David U of ISMP Canada: davidu@ismp-canada.org.

ISMP Canada has called and organized a meeting to re-examine the labeling standards for injectable with all the stakeholders. The participants include Health Canada, Canadian Standards Association International, Canadian Society of Hospital Pharmacists, Canada's Research Based Pharmaceutical Companies, Canadian Drug Manufacturers Association, and Institute for Safe Medication Practices Canada.

The meeting will be held on Wednesday March 7, 2001 at the CSA International who has generously offered to host the meeting.

• Abboject products from Abbott Laboratory have been available to Canadian hospitals since the middle of December 2000. Now Canadian healthcare professionals have a choice to purchase the Abboject product line or the Lifeshield product line.

• Bayer Canada recently informed ISMP Canada that the work had been initiated with their international source plant in Italy to make the label change on Cipro Oral Liquid. Specification on the label changes is presently worked on. Progress and the subsequent change of label will be updated to ISMP Canada in the near future.

• ISMP Canada is currently examining other concerns on labels that have been reported. The concerns involve primarily on injectable products. A meeting is being organized by ISMP Canada inviting pharmacists, physicians, manufacturers, CSA International and Health Canada to re-visit the pharmaceutical label requirement and suggested guidelines for the purpose of improving patient safety. Practitioners and hospitals are encouraged to forward label and package concerns to ISMP Canada for corrective actions.

• Although many Canadians practitioners have found the biweekly Medication Safety Alert! newsletter published by ISMP (US) very informative and useful, ISMP Canada is planning to launch the Canadian version which should include more Canadian contents and issues which are relevant to the Canadian practice. Alert on mix-up of Canadian brand drug names; label and packaging problems are just some examples. Plans are underway to establish the proper infrastructure and resource to handle our monthly newsletter.

• ISMP Canada has just completed a prototype of a medication error reporting and analysis software program (Analyse-err). The Analyse-err program has two components: an objective factual reporting; and a root-causes analysis exercise. It is being tested by four Canadian hospitals (two teaching and two community hospitals) for a period of about three months. Results of evaluation and feedback will be presented at the two day conference in April (see the education calendar below).

• In partnership with The CQI Network, ISMP Canada will be sponsoring a major two day conference titled: "Breaking the Silence: Error in Health Care" on April 20 and 21, 2001 in Toronto. International reputable speakers will include Michael Cohen, David Bates, David Cousin (UK) and others. The conference planning committee is being chaired by Cynthia Majewski and Tom Paton. The program is being finalized and should be available to all Canadian healthcare professionals and organizations in the near future. Stay tuned.

• A glance of all educational programs on patient safety involving ISMP Canada for the next few months:

  • Medication Errors: Implementing Changes for Improved Patient Safety sponsored by OHA, Toronto, January 31, 2001.

  • Medication Safety and its Impact on Hospitals, A breakfast satellite session at the Canadian Society of Hospital Pharmacists' Professional Practice Conference, Toronto, February 6, 2001.

  • Risk Management for Long Term Care Facilities, organized by Infonex, Toronto, March 5-6, 2001.

  • Humber College Annual Pharmacy Technician Conference, Toronto, March 10-11, 2001.

  • Safe Medication Workshop sponsored by Orillia Soldier Memorial Hospital, Orillia, March 30, 2001.

  • Breaking the Silence: Error in Health Care conference, co-sponsored by ISMP Canada and The CQI Network, Toronto, April 20-21, 2001.

Bayer Canada is in the process of changing the labels on the Cipro Oral Suspension as recommended. The specific steps and the timeframe will be communicated to ISMP Canada in about two weeks. These will include getting permission from Health Canada (because of the new labels).

ISMP Canada recently has received reports expressing concerns about the labelling on both the small bottle (containing ciprofloxacin microcapsules) and the large bottle (containing the special milky diluent). The diluent bottle prominently states "Cipro Oral Suspension" while the term "diluent" is hardly visible. The problem could result in pharmacists dispensing the diluent accidentally instead of the final reconstituted Cipro suspension.

The other concern raised is the microscopic fine-print of the information on the small bottle. The dose of "10 g" is hardly visible. A similar problem existed in the US about a year ago. The November 17, 1999 issue of ISMP Medication Safety Alert! described this safety issue and offered recommendations for action. Bayer Inc. did take the initiative to make a significant change on the labels on the US product. ISMP Canada has contacted Bayer Canada and requested a similar change of labels. Bayer is investigating the situation and considering our recommendations. Stay tuned for more information soon.

Abbott Laboratories has set a timeline for the re-worked Abboject products.

ISMP Canada has become aware of a potential problem with using the Abbott Lifeshield product line. Please see the Lifeshield support page.

• ISMP Canada has been invited to participate in a three days meeting titled "Medication Error Reporting and Prevention: a shared responsibility", co-hosted by the Therapeutic Products Programme, Bureau of Licensed Product Assessment, and the Canadian Society of Hospital Pharmacists. The meeting will be held 25-27 October 2000 at Ottawa.
   
• ISMP Canada has been invited to speak at the following conferences and national meetings:
  • The Royal College of Physicians and Surgeons of Canada's Annual General Meeting held September 23 at Edmonton
  • The CQI Network Inc. annual Forum held October 22-24, 2000 at the Deerhurst Resort, Huntsville, Ontario
  • The meeting on "Medication Error Reporting and Prevention: a shared responsibility" held October 25-27, 2000 co-hosted by Health Canada and CSHP.
     
• ISMP Canada is presently publishing columns and articles on safe medication practice topics at the following professional journals and bulletins:
  • CJHP (Canadian Journal of Hospital Pharmacy)
  • The Hospital News
  • Risk Management in Canadian Healthcare

Plans are underway to publish similar columns on the medical and nursing organizations' official journals.

• A meeting was held recently between the Canadian Nurses Association and ISMP Canada in Ottawa. CNA has expressed interest and support to the ISMP Canada's patient safety principles and initiatives. Specific collaborative efforts are being explored and will be implemented. A similar meeting is being arranged with the Canadian Medical Association.
   
• ISMP Canada, in conjunction with ISMP (US) is developing the "ISMP Analyse-err", a software program that tracks medication errors and analyses data to identify areas of weakness for improvement purpose. Both Spain and Europe (via European Foundation for Advancement of Healthcare Practitioners) have also expressed interest in this program.
   
• ISMP (US) had a news release on "Canada Launches Institute for Safe Medication Practices" on August 1, 2000. It was distributed to all news media and healthcare organizations in the US.

The On-going working relationship with other healthcare organizations has been updated.

The ISMP-Canada web site is published.

The organization's vision, mission statement, and goals are formally approved by the board.