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Medication Safety Alerts, September 1999

This column draws primarily on US experience and includes, with permission, material from the ISMP Medication Safety Alert! biweekly bulletin, published by the Institute for Safe Medication Practices (ISMP), Huntingdon Valley, Pennsylvania, USA.


This is the first of a continuing series of columns on safe medication practices. In the US, the Institute for Safe Medication Practices (, a nonprofit organization composed of a multidisciplinary group of health professionals, is cooperating, along with the United States Pharmacopeia (, in the operation of the national Medication Errors Reporting Program. The program allows health care practitioners to voluntarily report potential or actual medication errors in a confidential manner. The goal of this successful program has been to educate the healthcare community about the causes and prevention of harmful medication errors. The program has had a positive impact upon professional practice, standards setting, and regulatory affairs, including the naming, packaging and labeling of pharmaceutical products.

Recently the Canadian Society of Hospital Pharmacists, in collaboration with other professional organizations, has taken a leadership role in exploring mechanisms to coordinate a similar medication error-reporting program here. As part of this effort, the processes for promoting safe medication practices will be considered. A Task Force on Medication Error Reporting, chaired by Dr. David Rosenbloom, has been established. Stay tuned for an update on this exciting initiative.

I hope my commitment to publish a column on safe medication practices in this journal is a contribution to this national endeavor. In the mean time, if you would like to assist with this effort, please report medication errors directly to me by phone: 416-733-3131 or by email: All identifying information will be held in strict confidence. We will utilize the information only to educate health care practitioners about safety issues and error prevention recommendations. Some of the contents in this column are drawn from reports and investigations based in the US but we will also strive to discuss issues and actual incidents occurring in Canadian settings. We intend for this effort to be the start of a long lasting relationship with our American colleagues at ISMP and USP.

Safety Briefs

(The Safety Briefs described below are taken directly from ISMP Medication Safety Alert! Volume 4, Issue 13, June 30, 1999.)

"We’ve had two instances reported where women with pregnancy-induced hypertension received overdoses of IV magnesium sulfate when the drug was mixed-up with other IV drugs. In one case, a patient had three separate IV lines with litre containers of magnesium sulfate and lactate infusing via pumps. The magnesium sulfate and oxytocin lines were turned off during delivery but left hanging on the pumps. Following delivery, an anesthetist inadvertently restarted the pump with magnesium sulfate instead of the one with oxytocin. By the time the mistake was discovered, approximately 10 grams of magnesium sulfate had already been infused. In the other case, a bag of commercially available, pre-mixed magnesium sulfate was administered instead of Ringer’s lactate. The container of magnesium sulfate had been removed from stock in anticipation of using it for a controlled slow infusion maintenance dose. However, it was placed face down on a counter and later misidentified. Fortunately, in both cases, mother and baby sustained no harm and were later discharged without further complications. When IV rates are adjusted in patients with multiple IV lines, rather than just "eyeballing" the bag and tubing, physically trace the tubing by hand from the IV bag to the pump when adjusting the rate. When giving high alert drugs like magnesium sulfate, IV tubing should be labeled near its juncture with the IV pump to assist in proper identification. Using a single-channel pump instead of a dual-channel IV pump may also reduce the potential for line confusion. Providing magnesium sulfate in a container that is different in size from other IV medications commonly used during labour and delivery, and having two individuals independently confirm solution identity, are additional ways of avoiding drug mix-ups in obstetrical patients. We have long urged manufacturers of commercially available premixed critical care drugs to prominently identify the drug and concentration on both the front and back of the immediate container to reduce he potential for IV mix-ups."

Canadian jury wants safe drug-use systems

(The Safety Briefs described below are taken directly from ISMP Medication Safety Alert! Volume 4, Issue 6, March 24,1999.)

"A Coroner’s jury in Ontario, Canada handed down recommendations last week in the medication error related death of an 11-month-old child. In June 1998, the child was hospitalized for elective foot surgery. A night shift nurse mistakenly administered morphine 10 mg instead of the prescribed drug, meperidine. Remarkably, the Jury’s insightful recommendations are all designed to improve the medication system rather than punish individuals. Further, the recommendations are not solely directly to the hospital where the error occurred. They sweep broadly across Canada’s healthcare industry to address many of the root causes of medication errors. The Jury recommended system-based changes to the involved hospital include:

1)Include recommended weight-based dose on pediatric MARs and double check the prescribed dose. 2) Limit pediatric floor stock of narcotics to those most commonly used, packaged in doses appropriate for children. 3) Monitor vital signs and O2 saturation of patients before and after narcotic administration. 4) Implement a check system for all drugs that are potentially toxic to pediatric patients. 5) Verify drugs before administration with the original order, not from memory. 6) Establish a multidisciplinary committee to openly discuss aspects of the medication system, including errors. Be proactive than reactive. 7) Provide nurses with up-to-date reference materials. 8) Include written and practice components of skills development and testing during orientation. 9) Provide monthly inservices to pediatric nurses on medication use and safety. 10) Modify computer systems to facilitate easy information entry and retrieval, timely MAR production and warnings for inappropriate doses. 11) Establish an incentive program for reporting medication errors and track by shift worked and caseload of involved staff. 12) Consider staffing ratios of 4:1, except in emergencies….."

"….One recommendation involves reviewing technology available to minimize medication errors and considering the means by which such systems can be made available to Ontario hospitals. Another calls for investigating factors that contribute to human error, such as the impact of shift work on the mental and physical health of the workforce. Finally, the Jury recommended that the Ministry of Health assist in establishing a properly funded non-profit organization "similar to the American ISMP" to collect and disseminate information on medication errors…"

David U is the Director of Pharmacy of the former Scarborough Grace Hospital. David can be reached at