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Narcotic (Opioid) Medication Safety Initiative

The Medication Safety Support Service (MSSS) operating in Ontario has been providing guidance and assistance to hospitals for enhancing the safe use of medications.

A review of medication errors and near miss incidents reported to the Institute for Safe Medication Practices Canada (ISMP Canada) identified narcotic (opioid) drugs to be one of the more frequently reported causes of patient injury. In a July 17th, 2003 consultation session with over 140 attendees from Ontario hospitals, all participant focus groups reported concerns regarding narcotics. The Ontario MSSS Advisory Group endorsed narcotic medications as ISMP Canada’s focus as the MSSS safety initiative in 2005 and 2006.

Patient safety issues regarding narcotics can arise due to:

  • The large selection of narcotic products and available concentrations;
  • The variety of dosage forms (e.g., immediate release or controlled release products);
  • Look-alike and sound-alike names;
  • Packaging and labelling;
  • Infusion pumps and patient-controlled analgesia (PCA); and
  • Patient monitoring requirements.

As part of the MSSS, ISMP Canada assembled and distributed a comprehensive package in 2005 to assist hospitals with issues regarding narcotic medication safety. This package contains information on the rationale for making changes, the experience of many Canadian hospitals (including sample newsletters, documents and other examples), and discusses issues of culture and communication. Copies of the materials were made available, free of charge, to all Ontario hospitals. Materials and educational information were presented and discussed in collaborative workshops and interactive audiovisual presentations.

In order to understand current practices and to measure project outcomes, Ontario hospitals were invited to participate in a survey of narcotic-related medication practices. 165 Ontario hospitals responded to the survey and the responses provided baseline findings, as well as information about patient safety priorities for narcotic use. A follow-up survey was completed early 2006 with 140 Ontario hospitals responding. Findings show that 94% of hospital respondents have begun to implement narcotic system safeguards. Further information regarding these findings and also other provincial initiatives is available from longwoods.

Download Priority Recommendations from the Ontario Hospital Narcotic (Opioid) Collaborative Project.

Thank you to all Ontario hospitals who participated in the surveys and continue their efforts to enhance narcotic safety!

For further information: call 416-733-3131, toll-free at 1-866-544-7672; or e-mail

Narcotic (Opioid) Medication Safety Initiative is available for $80 CAD (including taxes and shipping for Canadian orders)

To order, please download and print the Order Form


Medication Safety Support Service (MSSS) Advisory Group Organizations
  • Ontario Ministry of Health and Long-Term Care
  • Canadian Society of Hospital Pharmacists - Ontario Branch
  • Ontario Hospital Association
  • College of Physicians and Surgeons of Ontario
  • Ontario Medical Association
  • Ontario College of Pharmacists
  • Institute for Safe Medication Practices Canada
  • Registered Nurses Association of Ontario
  • College of Nurses of Ontario
  • Ontario Pharmacists’ Association


The Ontario MSSS is a Collaborative Medication Safety Initiative of ISMP Canada, the Ontario Hospital Association and the Ontario Ministry of Health and Long-Term Care.