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ISMP Canada Safety Bulletins

Canadian Medication Incident Reporting and Prevention System (CMIRPS)

Bulletin Issue 9
Ambulatory Infusion Pumps: Analysis of Errors and Recommendations for Safe Use

ISMP Canada received a number of incident reports describing severe harm or death involving ambulatory infusion pumps, which prompted a multi-incident analysis to highlight opportunities for improvement.

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Bulletin Issue 8
Updated Analysis and Shared Learning from COVID-19 Vaccine Errors

Earlier this year, an ISMP Canada Safety Bulletin was published to proactively inform stakeholders about risks associated with vaccination processes and safeguards to prevent errors. Since then, health care providers have been working with the government, public health agencies, and health care and community organizations to provide COVID-19 vaccines to as many Canadians as possible. The experiences of health care providers and consumers during this mass vaccination campaign informed an updated incident analysis, shared here.

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Bulletin Issue 7
Balancing Safety and Efficiency in Community Pharmacy

Efforts to address the high workload and multifaceted nature of patient care in community pharmacies may lead to prescription processing practices that can put patient safety at risk. This bulletin highlights the findings from a multi-incident analysis of errors reported in the community pharmacy setting and identifies opportunities for process improvements.

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Bulletin Issue 6
Shortage of Epinephrine Prefilled Syringes: System Supports for Use of Epinephrine Ampoules

Shortages of critical medications have become more common during the COVID-19 pandemic. Epinephrine prefilled syringes is one such critical product that has been in short supply. This bulletin shares a proactive approach that was developed and implemented by a regional paramedicine service to safely introduce the temporary use of epinephrine ampoules and mitigate the risk of medication errors. The example illustrates a growing interest in medication safety and the design of systems to support patient-facing practitioners.

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Bulletin Issue 5
ALERT: Rocuronium Vials Lack Recommended Warning on Ferrule

The current COVID-19 pandemic has increased the demand for certain critical medications. The neuromuscular blocking agent rocuronium is one such medication. Neuromuscular blocking agents are high-alert medications and, when used in error, can lead to devastating injuries or death.

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Bulletin Issue 4
Psychotic Decompensation after a Change to a Stabilized Medication Regimen

As part of an ongoing collaboration with a provincial death investigation service, ISMP Canada received a report describing an individual whose psychiatric conditions had been stabilized by a medication regimen that included both clozapine and fluvoxamine. A supply shortage of fluvoxamine led to a cascade of events that contributed to the individual's decompensated psychosis. This bulletin shares identified opportunities and related recommendations to avoid similar tragedies.

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Bulletin Issue 3
Never Events for Community Pharmacy

Identification of specific never events for the Canadian community pharmacy environment is intended to enhance patient safety by encouraging pharmacy teams to take action in specific areas where harmful errors are known to have occurred.

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Bulletin Issue 2
Preventing Errors with COVID-19 Vaccines: Learning from Vaccine Incidents

This bulletin shares a number of leading practices that facilitate the safe administration of a COVID-19 vaccine.

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Bulletin Issue 1
Confusing Calcium Product Labels Lead to Hospitalizations

This bulletin shares incident examples to raise awareness of the risks associated with the lack of standardization of calcium product labels, as well as to highlight opportunities to improve labelling practices.

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2020 - Volume 20
Bulletin Issue 11
Medications Most Frequently Reported in Harm Incidents over the Past 5 Years (2015-2020)

Key activities within the CMIRPS program include the capture and analysis of medication incidents (including harmful events, no-harm events, near misses, and circumstances that could lead to harmful incidents), as well as dissemination of learning to inform and support actions to improve the safety of medications for Canadians. This bulletin shares findings from analyses of incidents reported to the CMIRPS reporting components over a recent 5-year period.

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Bulletin Issue 10
ALERT: Risk of Inadvertent Reconstitution of Medications with Cleaning Products

To combat the spread of COVID-19 through enhanced surface cleaning and disinfection, community pharmacies have been purchasing and storing larger-than-usual quantities of cleaning products, including sanitizers and disinfectants (referred to collectively as "cleaning products" in this bulletin). As a result, some of these products may be purchased in bulk containers and then decanted into other, smaller containers, for ease of handling. As well, some high-strength products must be diluted before use to achieve the desired concentration, which again may involve transfer to separate containers. To accommodate the resulting product volumes, some pharmacies are preparing and/or storing the smaller volumes or diluted products in empty bottles that previously contained distilled water. This bulletin is shared to alert all pharmacy staff to the potentially harmful outcomes of this practice.

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Bulletin Issue 9
Unauthorized Access to Methadone in a Community Pharmacy Contributes to Death

As part of an ongoing collaboration with a provincial death investigation service, ISMP Canada received a report describing the death of an individual who ingested a large amount of methadone that had been inappropriately accessed in a community pharmacy. This bulletin highlights the contributing factors identified in the subsequent incident analysis and suggests strategies to improve methadone security in community pharmacies.

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Bulletin Issue 8
Opioid Diversion in Hospitals — A Safety Concern

This bulletin highlights the prevalence and associated awareness of diversion, calls attention to current work, and emphasizes the need for hospitals to take steps in strengthening their internal systems to monitor, detect and prevent diversion.

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Bulletin Issue 7
Intravenous Medication Safety: A Multi-Incident Analysis

The need for improvements to the medication-use process, predicated on an awareness of the risk of IV medication-related harm, is an important step toward system-level changes.

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Bulletin Issue 6
Delivery of Opioid Agonist Treatment during a Pandemic

This bulletin focuses on developing robust OAT-related delivery processes to support patients during the pandemic, limiting the exposure of pharmacy staff to COVID-19 by implementing virtual communication, and managing the risks for medication errors.

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Bulletin Issue 5
Propofol 2% (20 mg/mL): Safety Considerations for Introducing a Novel Product into Hospitals

Some Canadian hospitals will need to begin using an imported double-strength (2% or 20 mg/mL) propofol 100 mL product because there is a shortage of the 1% (10 mg/mL) propofol 50 mL and 100 mL products. To mitigate the risks associated with introducing this novel product into medication-use systems, the following preliminary considerations are provided:

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Bulletin Issue 4
Strategies for Safer Telephone and Other Verbal Orders in Defined Circumstances

Medication orders (prescriptions) conveyed verbally by telephone or in person are prone to errors. Problems can arise if a medication order is miscommunicated, misheard, or incorrectly transcribed.

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Bulletin Issue 3
ALERT: Hand Sanitizers That Look Like Drinks

In this time of shortages across the country, many companies have taken up the call to manufacture hand sanitizers, so there is greater access to these products. There is a risk that hand sanitizer will be swallowed by accident by an adult or child when it is provided in containers that are usually used for drinks such as soda, water, and alcoholic beverages.

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Bulletin Issue 2
Virtual Medication History Interviews and Discharge Education

ISMP Canada recommends that medication history interviews and discharge patient education be conducted by telephone, video communication, or email, with the dual goals of reducing the number of non-essential entries into patients' rooms (and the associated risk of viral transmission) and conserving personal protective equipment (PPE) during a pandemic.

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Bulletin Issue 1
Multi-Incident Analysis of Incidents Involving Paramedicine

Often referred to as emergency medical services (EMS) personnel, paramedics provide a critical link in the care of patients in the community for emergency situations and during transport (until patient transfer to receiving facilities). A multi-incident analysis was conducted to identify themes relating to medication errors in paramedicine practice and to highlight opportunities for improvement.

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