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ISMP Canada News

May 6, 2022: Health Canada: Update - Sodium Acetate Injection – Potential for Presence of Particulate


April 20, 2022: Safety Bulletin - Pediatric Medication Errors in the Community: A Multi-Incident Analysis
This bulletin highlights the findings from a multi-incident analysis of harmful medication incidents involving pediatric patients in the community and identifies opportunities to improve...

April 20, 2022: Safety Bulletin - Preventing Pediatric COVID-19 Vaccine Errors at Mass Vaccination Sites
ISMP Canada received reports of the inadvertent administration of adult COVID-19 vaccine doses to children eligible for a pediatric vaccine. Vaccination sites have implemented various...

April 20, 2022: Safety Bulletin - Sharing Matters! Incident Spurs Implementation of Child-Resistant Closure
ISMP Canada's consumer reporting program, SafeMedicationUse.ca , described a report of a young child who drank amoxicillin suspension directly from the bottle, in the absence of caregivers....

April 13, 2022: SafeMedicationUse.ca - Cannabis for Medical Purposes—Do You Have the Right Product?
Many Canadians report using cannabis for medical purposes. Accessing cannabis for medical purposes is different from filling your prescription at a pharmacy. This may include obtaining a medical...

March 28, 2022: Safety Bulletin - ALERT: Multipronged Strategy Required to Manage Shortage of Sterile Water for Injection
On March 17, 2022, the shortage of small-volume formats of sterile water for injection packaged in vials and ampoules was assigned a Tier 3 designation by a Tier Assignment Committee that...

March 17, 2022: Safety Bulletin - Heightened Risk of Methotrexate Toxicity in End-Stage Renal Disease
Chronic kidney disease resulting from a decline in renal function affects approximately 3% of Canadians. End-stage renal disease, typically leading to the need for dialysis or kidney...

March 17, 2022: Safety Bulletin - National Poison Prevention Week (March 20 to 26, 2022)
Unintentional poisoning is the third leading cause of injury and death in Canada, with children being especially vulnerable to these preventable events. ISMP Canada—along with Parachute and...

March 11, 2022: Health Canada: Ruzurgi (amifampridine) - Removal from Canadian Market


March 9, 2022: Dr. Certina Ho recognized by the Leslie Dan Faculty of Pharmacy with the Leadership in Pharmacy Practice Award
Congratulations to Certina Ho , an integral member of the ISMP Canada leadership team, who has been recognized by the Leslie Dan Faculty of Pharmacy as an exceptional alumnus. Certina is the...

March 9, 2022: Health Canada: IV bags and potential leak during pressure infusion


February 28, 2022: Safety Bulletin - Mitigating Risk for Medication Errors Involving Paxlovid
Paxlovid (a co-packaged product containing nirmatrelvir and ritonavir tablets) was recently approved by Health Canada for the treatment of mild to moderate COVID-19 in adults at high risk...

February 28, 2022: Safety Bulletin - Sharing Matters! Reported Concern Results in Safer Jardiance Product Labelling
ISMP Canada received a report from HealthPRO Procurement Services Inc. about a potential patient safety concern with packaging for Jardiance (empagliflozin) tablets. The report described...

Jan 19, 2022: Safety Bulletin - Anti-Rejection Medications: Analysis of Reported Errors
Patients who have undergone organ transplant require multiple medications to prevent organ rejection. Therapeutic management aims to suppress the immune response that can result in damage or loss...

Jan 17, 2022: Health Canada: Paxlovid (nirmatrelvir and ritonavir) new safety information


Jan 12, 2022: SafeMedicationUse.ca - Preventing Mistakes with Your Pet's "Paw-scription"
If your pet needs a medication, it is often prescribed by the veterinarian and provided by the veterinary clinic. Sometimes a prescription is given so that the medication can be provided by a...

Jan 12, 2022: Health Canada: Xeljanz (tofacitinib) risk of serious heart issues and cancer


December 31, 2021: Health Canada: Herberex may pose serious health risks; product licence suspended


December 20, 2021: Health Canada: Multiple cold and flu powdered medications recalled


December 14, 2021: Safety Bulletin - Sharing Matters! Sentinel Medication Incident Results in Safer Product Labelling
ISMP Canada received a sentinel event report describing inadvertent bolus administration of a HYDROmorphone product that was intended for continuous infusion. A contributing factor was the...

December 14, 2021: Safety Bulletin - Quality Check: Are There Expired Vaccines in Your Fridge?
Several recent incidents, reported to ISMP Canada and shared in the media, have involved administration of expired vaccines to patients. Vaccine effectiveness cannot be guaranteed after the...

December 14, 2021: Safety Bulletin - Opportunity for Improvement: Confusing Labels for Zinc Products
Oral zinc supplements are nonprescription products that are available in several salt forms (e.g., zinc citrate, zinc gluconate). The differences in expression of product strength between the salt...

December 2, 2021: SafeMedicationUse.ca - Tips for Starting Antidepressants Safely
It's important to care for your mental health the same way you care for your physical health. Just like treatments for high blood pressure or diabetes, medications may be needed to treat mental...

December 2, 2021: SafeMedicationUse.ca - Tips for Stopping Antidepressants Safely
Once you and your health care provider have decided to stop your antidepressant, the dose should be lowered slowly, rather than being stopped suddenly. This process is designed to prevent unwanted...

November 24, 2021: NEWS RELEASE - Announcing 10 Champion Homes for the Ontario Strengthening Medication Safety in Long-Term Care Initiative
Announcing 10 Champion Homes for the Ontario Strengthening Medication Safety in Long-Term Care Initiative The Institute for Safe Medication Practices Canada (ISMP Canada) is partnering...

Nov 19, 2021 : Health Canada: Comirnaty (Pfizer-BioNTech COVID-19 Vaccine, mRNA)


Nov 11, 2021: Safety Bulletin - Lack of Pediatric Formulations – A Call to Action
Many pediatric prescriptions are considered off label because the medications have not been reviewed and approved by Health Canada for pediatric use. When a medication prescribed for a pediatric...

Nov 11, 2021: Safety Bulletin - Improving the Safety of Pharmaceutical Compounding Using CAS Numbers
After the death of a young boy because of a compounding error, ISMP Canada recommended that manufacturers include a unique identification number on the label of repackaged active pharmaceutical...

Nov 11, 2021: USA NAN Alert: Mix-Ups With COVID-19 and Influenza Vaccines
A recently released NAN Alert in the US shared numerous reports of inadvertent mix-ups between COVID-19 and influenza vaccines occurring in community/ambulatory pharmacies. Most cases...

Nov 10, 2021: Health Canada: Spikevax COVID-19 vaccine with English-only labels


Nov 9, 2021: Health Canada updating labels of Janssen and AstraZeneca COVID-19 vaccines


Nov 4, 2021: Health Canada: Two lots of TUMS Assorted Berries Extra Strength Tablets recalled


October 27, 2021: SafeMedicationUse.ca - Taking Life-Saving Medications? Ask for a Care Plan!
Anyone who takes life-saving medications should have a care plan. A care plan is a way to share important medical and medication information, as well as steps to take in an emergency. It can be...

October 26, 2021: Health Canada: Mint Pharmaceuticals Inc. recalls all lots of losartan


October 19, 2021: Health Canada: Ivermectin not authorized to prevent or treat COVID-19; may cause serious health problems


October 9, 2021: Health Canada: One lot of Riva-Risperidone 0.25 mg tablets recalled due to a packaging error


October 6, 2021: Health Canada: One lot of GENIUS Kids and Teens softgel capsules recalled due to possible bacterial contamination


October 6, 2021: Health Canada: Two lots of Novo-Gesic Forte/Acetaminophen recalled due to labelling error that may lead to overdose ...


October 3, 2021: Health Canada: Two lots of Advil Cold & Sinus Day/Night Convenience Pack recalled due to labelling error ...


September 30, 2021: Health Canada: One lot of Mirvala 28 birth control pill recalled


September 29, 2021: Safety Bulletin - Ambulatory Infusion Pumps: Analysis of Errors and Recommendations for Safe Use
The use of ambulatory infusion pumps to deliver medications parenterally has become increasingly common not only in hospitals but also in long-term care facilities and in patients' homes....

September 29, 2021: Safety Bulletin - One Needle, One Syringe, Only One Time
Recently, ISMP Canada's consumer reporting program, SafeMedicationuse.ca , received a report from a distressed patient who was one of several individuals asked to get tested for HIV and...

September 29, 2021: Safety Bulletin - Call for Shared Learning with Virtual Care Experiences
ISMP Canada, in partnership with Healthcare Excellence Canada, is working to advance safety in virtual care. We are exploring medication safety concerns, facilitators, and barriers. Help turn your...

September 25, 2021: Health Canada: One lot of the hypoglycemia treatment Glucagon recalled as it may pose serious health risks


September 23, 2021: Health Canada suspends licence and requested a recall for PURE75 gel hand sanitizer due to potential serious health risks


September 16, 2021: Health Canada: Multiple lots of irbesartan, losartan and valsartan drugs recalled due to azido impurity


August 31, 2021: Health Canada: Ivermectin not authorized to prevent or treat COVID-19; may cause serious health problems


August 26, 2021: Safety Bulletin - Updated Analysis and Shared Learning from COVID-19 Vaccine Errors
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....

August 26, 2021: Safety Bulletin - Oxytocin to Start or Advance Labour: 5 Questions to Ask
World Patient Safety Day will take place on September 17, 2021, with the theme "Safe maternal and newborn care". In support of the World Patient Safety Day theme this year, ISMP Canada is...

August 17, 2021: SafeMedicationUse.ca - Back to School: Keeping Children with Severe Allergies Safe
Back-to-school time can be stressful for parents who have children with potentially life-threatening allergies. Fortunately, there are steps parents can take to help keep children safe...

August 6, 2021: Health Canada updates Pfizer-BioNTech COVID-19 vaccine label to reflect very rare reports of Bell's Palsy


July 22, 2021: SafeMedicationUse.ca - Keep a Lid on It! Child-Resistant Safety Closures Are Not Childproof
Medications are often packaged in a container that requires some coordination to open, for example, by pushing down and turning a cap. These child-resistant safety closures are designed to keep...

July 6, 2021: Health Canada: Martin Clinic Liquid Vitamin D recalled due to incorrect dosing and missing safety information on the label


June 30, 2021: Health Canada: Champix (varenicline) – Potential Risk Posed by Long-Term Exposure to Nitrosamine Impurity ...


June 30, 2021: Safety Bulletin - 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...

June 30, 2021: Safety Bulletin - Cephalosporin Substitution Errors: A Collaborative Analysis with CIHI
Antibiotic stewardship and antibiotic safety are areas of great interest. With this interest in mind, the teams at the Canadian Institute for Health Information’s National System for Incident...

June 29, 2021: Health Canada: AstraZeneca COVID-19 Vaccine and COVISHIELD: Risk of Capillary Leak Syndrome


June 6, 2021: SafeMedicationUse.ca - What You Need to Know about Oxytocin to Start or Advance Labour
Oxytocin is a hormone that is produced naturally by the body during labour to make the uterus contract. It is also available as a medication that can be given to start or speed up labour. The "...

June 14, 2021: Health Canada: Importation of COVID-19 Vaccine Moderna with up to 15 doses per vial and English-only labels (US-labelled supply)


June 10, 2021: Health Canada: Ruzurgi (amifampridine) removed from Canadian Market: Options for continued treatment for Lambert-Eaton Myasthenic Syndrome


June 8, 2021: Health Canada: Labelling update regarding the use of NSAIDs beyond 20 weeks of pregnancy and risk of kidney damage to unborn babies


May 31, 2021: Safety Bulletin - 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 in prefilled syringes is one such critical product that has been in short supply. This...

May 31, 2021: Safety Bulletin - Let's Talk with Kids about Their Medicine
5 Questions to Ask About My Medicine is a new pediatric-focused safety resource to help children and youth learn what questions they should ask when they receive medication from their health...

May 31, 2021: Safety Bulletin - Structured Opioid Therapy
Structured Opioid Therapy is a team-based approach to opioid therapy that involves patients, prescribers (physicians and nurse practitioners), and pharmacists. It can be useful when the...

May 31, 2021: Safety Bulletin - Magnesium Sulfate 50% (500 mg/mL) Injection: Shortage of Supply
As of the date of publication, magnesium sulfate 50% (500 mg/mL) injection in 10 mL and 50 mL vials, manufactured by Fresenius Kabi Canada (the sole supplier of this concentration in Canada),...

May 30, 2021: Health Canada: Multiple lots of irbesartan, losartan and valsartan drugs recalled due to azido impurity


May 20, 2021: SafeMedicationUse.ca - Let's Talk with Kids about Their Medicines
Engaging children to take an interest in their medicines is important. Many errors can be prevented through awareness and understanding of treatment plans. Involving children helps to give them a...

May 11, 2021: ISMP Canada and iMD Health Global announce partnership to provide further information for prevention of harmful medication errors across Canada
The Institute for Safe Medication Practices Canada (ISMP Canada) is pleased to jointly announce an important partnership with iMD Health Global (a CloudMD Software & Services company)...

May 8, 2021: Health Canada: CanPrev recalls certain lots of Magnesium Bis-Glycinate Powder 250 because of a packaging error


May 6, 2021: Safety Bulletin - ALERT: Rocuronium Vials Lack Recommended Warning on Ferrule
Neuromuscular blocking agents are high-alert medications and, when used in error, can lead to devastating injuries or death. In accordance with recommendations established to address selection...

May 6, 2021: Safety Bulletin - Hospital Readiness to Use the Antidote Methylene Blue
ISMP Canada became aware of incidents that described an immediate need for methylene blue as an antidote to treat methemoglobinemia (resulting from sodium nitrate/nitrite exposure). In...

April 28, 2021: Health Canada: Bamlanivimab – Potential Risk of Treatment Failure Due to Circulation of Resistant SARS-CoV-2 Variants


April 28, 2021: SafeMedicationUse.ca - Vitamins May Be Needed with Some Long-Term Medications
Some medications taken for many years can lower the amount of some nutrients and vitamins in the body. By being aware of these long-term side effects, early action can be taken to prevent...

April 26, 2021: Health Canada: Importation of Janssen COVID-19 Vaccine with two types of English-only vial and carton labels


April 22, 2021: Safety Bulletin - 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...

April 22, 2021: Safety Bulletin - Sudden Clinical Deterioration: Suspect a Medication Error
ISMP Canada participated in reviewing the unexpected death of an individual who was undergoing rehabilitation in hospital after surgery. More than a week into the hospital stay, the patient began...

April 22, 2021: Health Canada: Talc: Health risks associated with inhalation and exposure to the female genital area


April 20, 2021: Health Canada: Certain lots of L'il Critters and vitafusion vitamins recalled due to metal wire fragments


April 16, 2021: Health Canada: Muscle-relaxant OrfenAce 100 mg tablets recalled because of nitrosamine impurity


April 6, 2021: Health Canada has initiated a safety review on Xeljanz and Xeljanz XR (tofacitinib), used to treat arthritis and ulcerative colitis


March 31, 2021: Health Canada: Importation of AstraZeneca COVID-19 Vaccine with English-only Vial and Carton Labels (US-Labelled Supply)


March 30, 2021: Safety Bulletin - Never Events for Community Pharmacy
"Never events" are patient safety incidents that result in serious patient harm or death, and that can be prevented by using organizational checks and balances. ISMP Canada, with support...

March 30, 2021: Safety Bulletin - Analysis of Findings from Safety Assessment of Community Pharmacies
Learning from an analysis of findings from safety assessments of more than 2 dozen Canadian community pharmacies is shared with the goal of supporting continuous improvement in pharmacy workplaces...

March 16, 2021: SafeMedicationUse.ca - Allergies to Ingredients in Medication Products
Consumers sometimes have allergies to certain medications. In some cases, the allergy may not be related to the medicinal ingredient in the medication product. Instead, it may involve one of the...

March 16, 2021: Better labelling lowers the risk of harm: HealthPRO and ISMP Canada partner to develop guidelines


March 9, 2021: Career Opportunity: Part-Time Project Manager


March 5, 2021: Health Canada: Product licence suspended for Perfect Sports Core Series Pure Creatine; all lots recalled


February 25, 2021: Safety Bulletin - 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. These practices, which incorporate learning from past vaccine errors, will evolve...

February 21, 2021: Health Canada: Recall of one lot of Perfect Sports Core Series Pure Creatine (also known as Creatine Powder) due to dangerous levels of Vit. D


February 17, 2021: SafeMedicationUse.ca - COVID-19 Vaccines: Tips for Consumers
Health Canada recently approved several vaccines to prevent COVID-19, and millions of Canadians will be getting vaccinated over the coming months. These vaccines will help prevent the spread of...

January 29, 2021:Health Canada: Update - Testing confirms Bio Life hand sanitizer poses health risks; products recalled across Canada


January 26, 2021: Safety Bulletin - Confusing Calcium Product Labels Lead to Hospitalizations
Calcium supplements are available for purchase without a prescription but may also be prescribed or recommended by health care providers for patients with confirmed or suspected calcium deficiency,...

January 26, 2021: SafeMedicationUse.ca - Antibiotic Suspension Lacking a Child-Resistant Closure Contributes to Overdose
ISMP Canada's consumer reporting program, SafeMedicationUse.ca , received a report describing a young child who drank amoxicillin suspension directly from a bottle holding the antibiotic. The...

January 22, 2021: Health Canada: Hand sanitizers labelled as "Anti-Microbe" and/or with DIN 02248351 recalled ...


January 18, 2021: Health Canada: Important safety information on Gilenya (fingolimod) and the risk of liver injury


January 14, 2021: SafeMedicationUse.ca Newsletter - Managing Changes in Your Medication Blister Pack
SafeMedicationUse.ca received a report from a consumer who picked up a blister pack from the pharmacy. The pack contained a blood pressure medication that had been stopped by the doctor. It was...

January 7, 2021: Health Canada: Suboxone and the risk of overdose or underdose when switching between dosage forms or routes of administration


December 24, 2020: Health Canada: GUM Paroex (anti-gingivitis oral rinse) being recalled due to microbial contamination


December 22, 2020: Safety Bulletin - Medications Most Frequently Reported in Harm Incidents over the Past 5 Years (2015-2020)
The Institute for Safe Medication Practices Canada (ISMP Canada) has a vision of Zero Preventable Harm from Medications . To help attain this goal, the organization is one of five national...

December 22, 2020: Safety Bulletin - Oxytocin to Start or Advance Labour: 5 Questions to Ask - Invitation to Participate in Testing
A patient handout entitled Oxytocin to Start or Advance Labour: 5 Questions to Ask has been developed by a pan-Canadian advisory group of patients and family members, clinicians, and other...

December 21, 2020: Health Canada: Bacitracin for injection and the risk of nephrotoxicity and anaphylactic reactions


December 16, 2020: Health Canada warns Canadians not to buy COVID-19 vaccines sold online or from unauthorized sources


November 18, 2020: SafeMedicationUse.ca Newsletter - Calcium and Medications Often Don't Mix
Calcium is a mineral that is needed to keep bones and teeth healthy. Calcium is found naturally in dairy products, and is added to some drinks. It is also available as a natural health product,...

October 29, 2020: Health Canada: One lot of "ATLAS - Codeine phosphate syrup 5 mg/mL" recalled because some bottles contain isopropyl rubbing alcohol


October 29, 2020: Health Canada: Five lots of anti-gingivitis oral rinse GUM Paroex recalled due to microbial contamination


October 21, 2020: SafeMedicationUse.ca Newsletter - Conquer Silence and Ask Questions
Recently, Safemedicationuse.ca received a report about a recurring error at a pharmacy. The patient was receiving her medication in a form that was not right for her chronic condition and did not...

October 15, 2020: Health Canada: Benzocaine products should not be used in children under two years of age


October 15, 2020: Safety Bulletin - 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...

October 15, 2020: Safety Bulletin - Another Poisoning Risk: Hand Sanitizers That Look Like Food
Health Canada published an advisory for consumers warning about the risk of poisoning with hand sanitizers in packages commonly used for food, such as food pouches. Child Safety Link from the IWK...

September 30, 2020: Safety Bulletin - Unauthorized Access to Methadone in a Community Pharmacy Contributes to Death
Methadone, a full opioid agonist, is most frequently used as an evidence-based pharmacotherapy for individuals living with an opioid use disorder. Methadone has a narrow therapeutic index and...

September 30, 2020: Health Canada: Allergan Inc. voluntarily withdraws Fibristal (ulipristal acetate) from the Canadian market due to risk of liver injury


September 16, 2020: SafeMedicationUse.ca Newsletter - Safer Choices for Pain Control after Wisdom Tooth Removal
Are you (or is someone you know) scheduled to have a wisdom tooth removed? Pain after wisdom tooth removal is common, so dentists and oral surgeons often prescribe strong pain medications called...

September 16, 2020: Health Canada reviews safety of Fibristal (ulipristal acetate) again following new case of liver injury


September 14, 2020: Health Canada: Esbriet (pirfenidone) and the risk of drug-induced liver injury


September 4, 2020:Health Canada: Advisory on hand sanitizers and children's safety: What you need to know


August 20, 2020: Safety Bulletin - Opioid Diversion in Hospitals – A Safety Concern
Canadian data suggest that diversion of controlled medications from hospitals is on the rise. The consequences of controlled substance loss can be harmful for individual patients, the care...

August 20, 2020: Safety Bulletin - Learning from Canada's National Incident Data Repository for Community Pharmacies
The National Incident Data Repository for Community Pharmacies (NIDR) is a collection of medication incident reports submitted anonymously by community pharmacies for the purpose of improving...

August 13, 2020: SafeMedicationUse.ca Newsletter - Hospital to Home: Know Your Medications before You Leave
Heading home after a hospital stay can be overwhelming. An important part of going home safely is understanding your medications before you leave the hospital. Your previous medications may have...

August 4, 2020: Health Canada: Recall of certain hand sanitizers that may pose health risks


July 16, 2020: Safety Bulletin - Intravenous Medication Safety: A Multi-Incident Analysis
Administration of medication by the intravenous (IV) route is ubiquitous in hospital practice. This route of administration is often used for several high-alert medications that bear a heightened...

July 16, 2020: Health Canada: Three lots of antidiuretic DDAVP Spray recalled because of potential overdose risk


July 6, 2020: Health Canada: Counterfeit respirators - Advisory


July 3, 2020: Health Canada: Recall of certain hand sanitizers that may pose health risks


July 2, 2020: Health Canada: Use of the drug Picato (ingenol mebutate) may increase the risk of skin cancer


June 18, 2020: SafeMedicationUse.ca Newsletter - Prevent Accidental Poisoning Caused by Cleaning Products and Hand Sanitizers
Cases of poisonings caused by products used to clean our homes and our hands have been on the rise during the COVID-19 pandemic. Over the past few months, poison control centres across Canada...

June 17, 2020: Health Canada: Recall of certain hand sanitizers that may pose health risks


June 10, 2020: Health Canada: Risk of poisoning from hand sanitizers sold in beverage containers


June 9, 2020: Safety Bulletin - Delivery of Opioid Agonist Treatment during a Pandemic
The provision of uninterrupted opioid agonist treatment (OAT) is an important patient care service that pharmacies offer to treat opioid use disorder. OAT, particularly when provided as directly...

June 9, 2020: Safety Bulletin - New! Buprenorphine/Naloxone and Methadone Handouts for Patients: Your Questions Answered
Key stakeholders in Saskatchewan identified an information need among patients who are initiating opioid agonist therapy for treatment of opioid use disorder. In response, several provincial and...

June 6, 2020: Health Canada: Recall of certain hand sanitizers that may pose health risks


June 3, 2020: SafeMedicationUse.ca Newsletter - Safe Storage and Disposal of Medications during the COVID-19 Pandemic
Medications that are not securely stored can be a danger to children, pets, or visitors. These include medications that are still being used, drugs that are no longer needed, and medications that...

June 1, 2020: Health Canada advises Canadians to help support the continued supply of medications


May 29, 2020: Safety Bulletin - Propofol 2% (20 mg/mL): Safety Considerations for Introducing a Novel Product into Hospitals
Drug shortages are one of the critical issues arising from the COVID-19 pandemic. The increased worldwide demand for high-alert drugs used in the care of intubated and mechanically...

May 25, 2020: Health Canada: Cisatracurium Omega Multi-Dose Injection: Temporary change of ferrule (metal seal) colour to maintain continued supply in Canada


May 25, 2020: Health Canada: Importation of US-Labelled Rocuronium Bromide Injectiond Due to Shortage of Canadian-labelled Rocuronium


May 14, 2020: SafeMedicationUse.ca Newsletter - Managing Mild COVID-19 Symptoms at Home
If you or one of your loved ones have mild symptoms of COVID-19, you may be able to recover at home in isolation without needing hospital care. A telephone call or virtual appointment with a...

May 7, 2020: Safety Bulletin - 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....

May 7, 2020: Safety Bulletin - COVID-19: Updated Requirements for Post-Consumer Returns
Health Canada's Office of Controlled Substances published a bulletin to provide pharmacists with information on temporary exceptional measures for post-consumer returns containing...

May 7, 2020: Safety Bulletin - Intravenous Tubing Extensions to Preserve Personal Protective Equipment
In an effort to conserve personal protective equipment (PPE), hospital staff have found various ways to reduce the need to enter the rooms of patients who have COVID-19. These strategies...

May 7, 2020: Health Canada: Unauthorized test kits claiming to diagnose or detect COVID-19 put your health at risk


May 5, 2020: Health Canada: Protect yourself and your family from poisonings: always read and follow the label directions when using hand sanitizers ...


May 1, 2020: Safety Bulletin - 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...

April 28, 2020: SafeMedicationUse.ca Newsletter - You Can Make a Difference: Help Prevent Medication Shortages
SafeMedicationUse.ca has heard from several consumers who are concerned about not being able to get more than a 30-day supply of their medications. Understandably, this limit on medications...

April 17, 2020: Health Canada: Salbutamol inhalers - Advisory


April 17, 2020: Health Canada: Known interference between Hemlibra (emicizumab inj) and lab assays used to diagnose coagulopathy caused by COVID-19 infection


April 16, 2020: Health Canada: COVID-19 – Updated Requirements for Post-Consumer Returns Containing Controlled Substances


April 15, 2020: SafeMedicationUse.ca Newsletter -  How to Prepare for a Virtual Meeting with Your Health Care Provider
During the COVID-19 pandemic, many health care providers have started speaking with patients by phone or video call, instead of having in-person appointments. Even hospital staff are...

April 7, 2020: Safety Bulletin - Virtual Medication History Interviews and Discharge Education
Obtaining a patient's medication history and educating patients at discharge are processes that can be adapted to ensure the safety of both patients and health care providers. The need for such...

.:Canada's National Incident Data Repository for Community Pharmacies
ISMP Canada established a national incident data repository for community pharmacies through its community pharmacy incident reporting program. Community pharmacies in several provinces are already...

.: Educational Support for Mandatory Reporting of Serious Adverse Drug Reactions and Medical Device Incidents
It will be mandatory for hospitals to report serious adverse drug reactions (serious ADRs) and medical device incidents (MDIs) to Health Canada, effective December 16, 2019. Four PowerPoint...

April 14, 2020: Health Canada: Fraudulent and unauthorized N95 respirators may not protect consumers against COVID-19


March 30, 2020: Health Canada: Stockpiling drugs can lead to local shortages: Canadians urged not to buy more medication than usual during COVID-19 pandemic


March 27, 2020: Health Canada: Health products that make false or misleading claims to prevent, treat or cure COVID-19 may put your health at risk


March 20, 2020: Health Canada: No scientific evidence that ibuprofen worsens COVID-19 symptoms


March 11, 2020: Health Canada: Cybersecurity vulnerabilities associated with some medical devices with Bluetooth Low Energy chips


March 4, 2020: SafeMedicationUse.ca Newsletter -  What You Need to Know about Your Blood Thinners
Blood clots can be dangerous. They can travel to the legs (causing leg pain), the lungs (causing chest pain or trouble breathing), the heart (causing a heart attack), or the brain (causing a...

February 19, 2020:Multi-Incident Analysis of Incidents Involving Paramedicine
Paramedicine encompasses the provision of prehospital and out-of-hospital emergency, urgent, and preventive medical care. As such, it may include assessment, treatment, and transport...

February 5, 2020: SafeMedicationUse.ca Newsletter - How Much Iron Is in Here?
SafeMedicationUse.ca received a report from a consumer who almost took 10 times the amount of iron that was prescribed. She was recommended to take 300 milligrams (mg) daily by her doctor. The...

February 3, 2020: Questionnaire destiné aux consommateurs sur le choix et l‘achat de produits de santé naturels


February 3, 2020: Consumer Questionnaire about Selection and Purchase of NATURAL HEALTH PRODUCTS


January 8, 2020: SafeMedicationUse.ca Newsletter - Who Keeps the Box? Are Your Prescriptions Properly Labelled?
The pharmacy label on your medication has important information. It identifies you as the person who will be taking the medication and tells you how to use your medication properly and safely....

January 2, 2020: Auditor's Report finds that more can be done to improve patient safety in Ontario


December 12, 2019: Change Management in Response to Preventable Tragedies
In January 2019, ISMP Canada published a safety bulletin about 2 pediatric deaths related to the use of concentrated electrolyte solutions. One incident involved the inadvertent use of concentrated...

December 12, 2019: What Have You Observed in Practice?
Following publication of the August 2019 issue of its safety bulletin , ISMP Canada has received reports from practitioners across the country regarding the interaction between polyethylene glycol...

December 12, 2019: ISMP Canada Website Survey
ISMP Canada is working to improve its website. What matters most to you? Let us know so we can serve you better. https://www.surveymonkey.com/r/L5355DB

December 2, 2019: Health Canada: Important Safety Update on XELJANZ / XELJANZ XR (tofacitinib) – Risk of Thrombosis


November 28, 2019: Dose Confusion When Switching between Insulin Delivery Devices
Insulin products are supplied predominantly as solutions with a standard concentration of 100 units/mL. However, several high-concentration products (i.e., with concentration above 100...

November 28, 2019: Communication of Special Access Programme Medications
Health Canada's Special Access Programme (SAP) provides access to nonmarketed medications for prescribers who are treating patients with serious or life-threatening conditions when...

November 13, 2019: SafeMedicationUse.ca Newsletter -  When Medications Are Not Available Due to a Drug Shortage
Your medication may not be available at the pharmacy due to a drug shortage. This problem can happen for many reasons. Sometimes the company that makes the medication does not have enough of one of...

November 4, 2019: Health Canada: Important Safety Information on Uloric (febuxostat) and the Increased Risk of Cardiovascular Fatal Outcomes


October 28, 2019: Protecting Canadians from Unsafe Drugs Act webinar
Join us on Friday, November 1 at 10am MT/ 12pm ET for our Protecting Canadians from Unsafe Drugs Act webinar. We will explore Vanessa's Law and its emphasis on mandatory reporting and how new...

October 23, 2019: Errors Associated with Oxytocin Use: A Multi-Incident Analysis
Oxytocin and its analogues are commonly administered for induction and augmentation of labour. In addition to this indication, oxytocin is widely used to prevent and treat postpartum bleeding....

October 23, 2019: Opioid Wisely: Partnering to Promote Safe Use of Opioids after Removal of Wisdom Teeth
Dentists across Canada are being encouraged to learn about the possible harms associated with prescribing opioids after routine wisdom tooth surgery. The Canadian Association of Hospital Dentists...

October 9, 2019: SafeMedicationUse.ca Newsletter - Biologics and Biosimilars: What You Need to Know
Biologic medications (also known as "biologics") and biosimilar medications (also called "biosimilars") are used to treat many diseases, including Crohn disease, rheumatoid...

August 28, 2019: Potentially Harmful Interaction between Polyethylene Glycol Laxative and Starch-Based Thickeners
Patients with dysphagia, or difficulty swallowing, are often advised to avoid thin, watery liquids and to consume only liquids that have had their viscosity altered by thickeners (known as...

August 28, 2019: Independent Double Checks – Are Your Checks Truly Independent?
An independent double check continues to be one strategy to help detect and prevent medication errors. Independent double checks must be implemented judiciously to minimize additional workload for...

August 21, 2019: SafeMedicationUse.ca Newsletter: Protecting Canadians from Unsafe Drugs Act - What It Means for You
The Protecting Canadians from Unsafe Drugs Act is also known as Vanessa's Law . Vanessa's Law regulations will require hospitals to report serious adverse drug reactions and medical...

August 6, 2019: Survey of Manitoba pharmacists underway: gathering information about medication disposal practices
ISMP Canada is conducting a survey of Manitoba pharmacists for the Health Product Stewardship Association (HPSA) . The goal of the survey is to learn how community pharmacists in Manitoba...

July 31, 2019: Educational Support for Mandatory Reporting of Serious Adverse Drug Reactions and Medical Device Incidents
The Protecting Canadians from Unsafe Drugs Act , also known as Vanessa’s Law , is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to...

July 31, 2019: News Release: ISMP Canada supports Long-Term Care Public Inquiry Recommendations
News Release (Toronto)  –   ISMP Canada supports the recommendations released today in the Long-Term Care Public Inquiry Report. The focus of the report is to ensure...

July 31, 2019: Focus on Never Events: Medication Safety Self-Assessment
ISMP Canada and the Canadian Patient Safety Institute would like to thank all those who took part in our pilot of the Medication Safety Self-Assessment: Focus on Never Events...

July 31, 2019: Career Opportunity: Director of Education - Contract Position
ISMP Canada is looking for someone who is a recognized and well-connected leader in developing and implementing education programming for the health care system. If you're ready to build...

July 24, 2019: SafeMedicationUse.ca Newsletter -  Mistaken Identity  –  A Recurring Problem
Ever wonder why it is important that pharmacy staff ask for your birthdate, address or other identification every time you pick up a prescription? It's a way to help make sure that medication...

June 27, 2019: Health Canada: Fluoroquinolones and the Potential Risk of Aneurysms and Dissection of the Aorta
       Fluoroquinolones - Assessing the potential risk of aneurysm and dissection of the aorta        Fluoroquinolones - Évaluation du...

June 26, 2019: Palliative Care: A Multi-Incident Analysis
As defined by the World Health Organization, palliative care is an "approach that improves the quality of life of patients and their families facing the problem associated with...

June 26, 2019: Health Canada's Policy Statement on the Naming of Biologic Drugs
Health Canada recently released a policy statement on the naming of biologic drugs, including biosimilars. A biosimilar is a biologic drug that has been demonstrated to be highly similar, with no...

June 20, 2019: Health Canada: Important Safety Information on Alertec (modafinil) and the Risk of Congenital Anomalies


June 19, 2019: SafeMedicationUse.ca Newsletter - How to Safely Transfer Your Prescriptions
You may need to transfer your prescriptions from one pharmacy to another if you are moving or are looking for a more convenient location. You may also need to transfer your prescriptions if you...

May 31, 2019: Career Opportunity: Director of Education


May 30, 2019: Health Canada: Alaris Infusion Sets and Alaris 8100 Pump Module - Risk of Over-Infusion - Update


May 14, 2019: Lack of Standardized Documentation Contributes to a Mix-up between Methadone and Buprenorphine-Naloxone
Opioid use disorder is one of the most challenging forms of addiction facing the Canadian healthcare system; almost 4000 Canadians lost their lives to an opioid-related overdose in 2017. The...

May 14, 2019: Supporting Safe Medication Use during Periods of Fasting
Patients fast for many different reasons, including religious observances. This year, from May 5 to June 4, adults who observe Ramadan will not eat or take any oral medications between dawn and...

May 1, 2019: SafeMedicationUse.ca Newsletter -  Sun-Sensitive Medications
Ever wonder why it is important that pharmacy staff ask for your birthdate, address or other identification every time you pick up a prescription? It's a way to help make sure that medication...

April 28, 2019: Health Canada: Alaris Infusion Sets and Alaris 8100 Pump Module - Risk of Over-Infusion


April 17, 2019: Health Canada: Intragastric Balloons and Potential Risk of Gastric and Esophageal Perforation, Pancreatitis, and Overinflation


April 10, 2019: SafeMedicationUse.ca Newsletter - You Asked Us: Checking Medication Expiry Dates
Ever wonder why it is important that pharmacy staff ask for your birthdate, address or other identification every time you pick up a prescription? It's a way to help make sure that medication...

April 5, 2019: ISMP Canada CEO delivers successful Incident Analysis Workshop in New Brunswick
ISMP Canada President & CEO, Carolyn Hoffman, poses with Horizon Health Network workshop participants in Fredericton, New Brunswick. While in New Brunswick, Carolyn facilitated a...

April 4, 2019: Health Canada: BENLYSTA (belimumab) - Increased risk of serious depression, suicidal ideation or behaviour ...


March 23, 2019: Health Canada: Extraneal peritoneal dialysis solution -  Advisory


March 21, 2019: Medication Safety in Long-Term Care: Measuring Quality Improvement Over 12 Years
Recently, the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (otherwise known as the Long-term Care [LTC] Inquiry or Gillese Inquiry) conducted...

March 15, 2019: Health Canada: Increased risk of blood clots and of death in rheumatoid arthritis patients on high dose of tofacitinib (Xeljanz)


March 6, 2019: SafeMedicationUse.ca Newsletter -  Consumer "Good Catches" – Part 2: Know Where to Look
This is the second of a 2-part series describing how consumers can spot medication mistakes. Part 1 of this series covered the importance of knowing what to expect from a medication. This...

February 25, 2019: Education Pilot: Mandatory ADR/MDI reporting (Vanessa's Law) – Your chance to participate in a Pilot
Education to support mandatory ADR/MDI reporting (Vanessa’s Law) Your chance to participate in a Pilot You’re invited to participate in a unique pilot project that will provide...

February 21, 2019: Gaps in Interconnectivity of a Hospital's Electronic Systems Create Vulnerabilities at Transitions in Care
Electronic medication systems can help prevent medication errors, but these systems can also contribute to errors when they do not communicate with each other in real time. This safety bulletin...

February 21, 2019: Cannabis for Medical Use – Submit Your Incidents and Concerns


February 21, 2019: Education to Support Mandatory ADR/MDI Reporting (Vanessa's Law)  – Invitation to Participate in a Pilot
The Institute for Safe Medication Practices Canada (ISMP Canada) is working in a Joint Venture with Health Standards Organization (HSO) and the Canadian Patient Safety Institute (CPSI) to assist...

February 21, 2019: Remembering our friend and colleague: John W. Senders, 1920 -2019
ISMP Canada has lost a cherished colleague and friend with the passing of John W. Senders on February 12, 2019. John was two weeks shy of his 99 th birthday. A "systems theorist" before...

February 13, 2019: SafeMedicationUse.ca Newsletter -  Consumer "Good Catches" – Part 1: Know What to Expect
For years, consumers have reported medication mistakes to SafeMedicationUse.ca . Many of these reports describe a "good catch" – when consumers (or their caregiver, family...

February 11, 2020: Health Canada suspends licence for Performance Plus capsules: Product may pose serious health risks


January 30, 2019: SafeMedicationUse.ca Newsletter -  Natural Health Products—Improving Labels for Safety
Information on the label of a natural health product gives consumers important information that can help them decide whether the product is right for them. Information on the label also helps...

January 16, 2019: Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes
Intravenous (IV) administration of a concentrated potassium solution (greater than or equal to 2 mmol/mL) is considered to be a pharmaceutical “never event”. Despite the past...

January 16, 2019: New Regulations will Help Protect Canadians from Unsafe Medications and Medical Devices
The Protecting Canadians from Unsafe Drugs Act , also known as Vanessa's Law , strengthens regulations to report Serious Adverse Drug Reactions (ADRs) and Medical Device Incidents (MDIs). The...

December 18, 2018: ISMP Canada Strategic Plan
ISMP Canada is pleased to share our new strategic plan with you. We have set five bold strategic directions for the organization to advance our work in medication safety across Canada by 2020....

December 18, 2018: Electronic Prescribing in Primary Care: Effects on Medication Safety
A national e-prescribing service to connect primary care practices with community pharmacies is currently being implemented in Canada, led by Canada Health Infoway, together with Health Canada,...

December 13, 2018: Health Canada: Health products manufactured by Professional Botanicals Inc. may pose serious health risks


December 7: Strawberry-flavoured acetaminophen infant oral drops (24 mL bottles) recalled because of defective child-resistant safety caps


November 21, 2018: Opportunity to Pilot a Novel MSSA with a Focus on "Never Events"
ISMP Canada and the Canadian Patient Safety Institute are calling for teams from hospitals, ambulatory care centres and long-term care homes to pilot a novel Medication Safety...

November 21, 2018: Do Not Use a Syringe for a Topical Product – A Focus on Chlorhexidine Disinfectant Solutions
The practice of drawing a medication intended for topical use into a syringe is unacceptable. Most syringes are intended for parenteral administration and pose a risk for a substitution error...

November 14, 2018: Health Canada: Several children's acetaminophen syrups recalled because of defective child-resistant safety caps


November 14, 2018: SafeMedicationUse.ca Newsletter -  Medication Reviews in Long-Term Care Homes
Do you have loved ones living in a long-term care (or nursing) home? Do you have questions about their medications? A medication review with the pharmacist is a good time for residents, family...

October 24, 2018: Design of eMAR Systems with End-Users in Mind: Learning from a Fatal Incident in Long-Term Care
Most long-term care facilities have moved from a paper-based medication administration record system to an electronic medication administration record (eMAR) system. By automating...

October 17, 2018: SafeMedicationUse.ca Newsletter - Insulin Pens: Important Safety Information
With the many types of insulin pens available, knowing how to inject insulin can be confusing. It is important to use your insulin pen the right way. If you don't use the insulin pen correctly, you...

September 28, 2018: Health Canada: EpiPen and EpiPen Jr auto-injectors may stick in their carrier tube


September 24, 2018: Injecting Standardization into Vaccine Clinics
Vaccinations provided at community-based clinics (e.g., in schools, offices, and community centres) support high immunization rates, thereby helping to prevent the spread of vaccine-preventable...

September 24, 2018: Canadian Patient Safety Week: October 29 to November 2, 2018
ISMP Canada is collaborating with the Canadian Patient Safety Institute on this year's Canadian Patient Safety Week (CPSW) with the goal of reducing medication errors across Canada. The theme...

September 19, 2018: SafeMedicationUse.ca Newsletter - Have Unused Medications Overstayed Their Welcome?
Careful storage and disposal of medications is important to prevent accidents in the home. Leftover medications that are within easy reach can be dangerous to children and pets. Medications that...

August 30, 2018: Health Canada: Interim Order allowing the importation of AUVI-Q in response to shortages of EpiPen and EpiPen Jr


August 29, 2018: SafeMedicationUse.ca Newsletter - You Asked Us: "Should I Change My Pharmacy after a Mistake?"
Your pharmacist is a trained healthcare provider who has a great deal of knowledge about medications. However, pharmacists sometimes make mistakes. We should remember that mistakes can be made by...

July 25, 2018: Antidotes and Related Agents: Recognition of Need, Availability, and Effective Use
Antidotes and reversal, neutralizing, decontamination, and rescue agents (referred to collectively as "antidotes" in this bulletin) are medications used to counteract the effects of...

July 19, 2018: Announcement of new CEO
Today the Institute for Safe Medication Practices Canada (ISMP Canada) has begun a new chapter in our national mandate to improve medication safety in all healthcare settings. We are pleased to...

July 18, 2018: SafeMedicationUse.ca Newsletter -  Brand Name Extension: What Does It Mean?
Added letters or an abbreviation found after a brand name make up a "brand name extension". This extension shows that a change has been made to a product. The change could be in the...

June 27, 2018: Safe Storage and Disposal of Medications
Improper storage and disposal of medications in the home have resulted in medication errors, accidental poisonings, inappropriate use, and diversion. Children in Canada continue to experience harm...

June 27, 2018: Canada's National Incident Data Repository for Community Pharmacies
The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative pan-Canadian program designed to reduce and prevent harmful medication incidents in Canada. ISMP...

June 27, 2018: Safety Concerns Resulting from a Concentrated Potassium Chloride Shortage in the United States
In the United States, a shortage of potassium chloride for injection concentrate in vials has led providers to purchase these and related products from outsourcing facilities. The National Alert...

May 30, 2018: Reaffirming the "Do Not Use: Dangerous Abbreviations, Symbols and Dose Designations" List
In 2006, ISMP Canada published a list of dangerous abbreviations, symbols, and dose designations, which has since been widely referenced in healthcare organizations to inform safe medication...

May 30, 2018: Name Change: M-Eslon IR to M-Ediat
A concern about the brand name of an immediate-release morphine product (M-Eslon IR) was shared with practitioners in a 2017 issue of the ISMP Canada Safety Bulletin and conveyed to the...

May 29, 2018: SafeMedicationUse.ca Newsletter -  Keep Your Medications Organized
It is important for consumers to organize their medications. This is especially true for anyone who takes many medications, and for those who often forget to take their medications. For some...

April 25, 2018: SafeMedicationUse.ca Newsletter - Using Your Own Medications While in Hospital
When you are staying in a hospital, the hospital pharmacy will supply any medications that you need. Sometimes, though, the hospital may not have all the medications that you take at home. In these...

April 23, 2018: Commercial Compounding Questionnaire is now OPEN: April 23 to May 4, 2018


March 28, 2018: Deprescribing: Managing Medications to Reduce Polypharmacy
The World Health Organization has highlighted polypharmacy as one of the key focus areas of its Third Global Patient Safety Challenge, Medication Without Harm. Polypharmacy is not solely about...

March 28, 2018: Opioids for Pain After Surgery—Patient Handout
A patient handout and resource, " Opioids for pain after surgery: Your questions answered " was developed collaboratively with and endorsed by the Canadian Deprescribing Network, CPSI,...

March 28, 2018: Med Safety Exchange webinar series: We want to hear from you!


March 23, 2018: SafeMedicationUse.ca Newsletter -  Do NOT Delay Starting Certain Medications
Some medications, such as blood thinners, should be started right away. In certain cases, a delayed start could cause harm. It is important for consumers to know which medications should be started...

March 16, 2018: Health Canada: Zinbryta (daclizumab beta) - Voluntary Withdrawal in Canada due to Risk of Encephalitis


March 8, 2018: Health Canada: Chipped pills in additional packages of Alysena 21 and 28 birth control pills


February 28, 2018: Students Have a Key Role in a Culture of Safety: A Multi-Incident Analysis of Student-Associated Medication Incidents
Undergraduate and postgraduate students in healthcare fields are future practitioners who are developing the skills and experience required to deliver safe and effective patient care. As part of...

February 28, 2018: In the News: Substitution Error in a Naloxone Kit
A recent news report described provision of an incorrectly prepared naloxone kit to a patient. Naloxone is intended to temporarily reverse the effects of an opioid overdose, but the patient...

February 22, 2018: SafeMedicationUse.ca Newsletter - New Symptoms: Could They Be Related to Your Medications?
Medications can cause unwanted symptoms, which are known as side effects or adverse drug reactions. The next time you have a new symptom, ask your healthcare provider if one or more of your...

February 14, 2018: Health Canada: Tecentriq (atezolizumab)  - Risk of Myocarditis


January 18, 2018: Consultation on the Naming of Biologic Drugs is Open: January 18 to February 9, 2018
You are invited to provide input on 3 options for the naming of biologic drugs, including biosimilars, in Canada. The consultation questionnaire consists of 5 questions. Your responses to this...

January 18, 2018: Health Canada: Shortage of EpiPen (0.3 mg) auto-injector in Canada


January 17, 2018: SafeMedicationUse.ca Newsletter - Don't Be Embarrassed to Talk to Your Pharmacist
If you have a sensitive or private health problem, you may be embarrassed to discuss it with your healthcare provider. But remember—your healthcare team wants to work with you to provide the...

January 11, 2018: Health Canada: OFEV (nintedanib): Risk of Drug–Induced Liver Injury & the Need for Regular Monitoring of Liver Function


January 5, 2018: Stakeholder Consultation on Naming of Biologic Drugs - January 18 to February 9, 2018
On January 18, 2018, the Institute for Safe Medication Practices Canada (ISMP Canada) will post an online questionnaire to seek input from healthcare providers, consumers, and other interested and...

January 5, 2018: Death Associated with an IV Compounding Error and Management of Care in a Naturopathic Centre
Patients with a diagnosis of cancer may choose to use complementary and alternative medicine, such as naturopathy, to support conventional medical therapies (e.g., surgery, chemotherapy). The...

January 5, 2018: Caution: Unlabelled Marking on a Vaccine Syringe Led to Under-dosing of Adult Patients
ISMP Canada received a report that described misinterpretation of an unlabelled marking on the Influvac influenza vaccine syringe resulting in multiple adult patients being administered half the...

December 7, 2017: Canada's National Incident Data Repository for Community Pharmacies
ISMP Canada established a national incident data repository for community pharmacies through its community pharmacy incident reporting program. Community pharmacies in several provinces are already...

Dec 21:Safety Update: Eprex, Gilenya
 

December 7, 2017: Alert: Polyethylene Glycol and Propylene Glycol Mix-up Causes Harm
ISMP Canada received a report describing a mix-up between polyethylene glycol and propylene glycol that resulted in patient harm. The report is shared here to heighten awareness of the risk of...

December 7, 2017: Severe Hyperglycemia with Incorrect Use of Insulin Pen
The National Alert Network (NAN) in the United States recently issued a safety alert about a risk for severe hyperglycemia, based on several reports to ISMP (US) of patients failing to receive...

December 7, 2017: Submit Reports of Dangerous Abbreviations, Symbols, and Dose Designations
The use of some abbreviations, symbols, and dose designations has been identified as an underlying cause of serious, even fatal medication errors. These abbreviations, symbols, and dose...

December 5, 2017: SafeMedicationUse.ca Newsletter - Save a Life—Get a Naloxone Kit to Treat an Opioid Overdose
There has been a lot of news about opioid overdoses recently. Opioids, such as oxycodone and morphine, are medications used to treat pain. You can suffer an opioid overdose even when the medication...

October 31, 2017: The Second Victim: Sharing the Journey toward Healing
Healthcare organizations typically take a structured approach to providing care and support to patients and their families when an unintended event results in patient harm. However, healthcare...

October 11, 2017: SafeMedicationUse.ca Newsletter - Keep Your Vaccinations Up to Date
Vaccines protect you and those around you from certain diseases, so it is important to keep your vaccinations up to date. Check your immunization record or ask your healthcare provider to make sure...

September 28, 2017: Sink or Swim? Helping Patients and Practitioners to Understand Opioid Potencies and Overdose Risk
Although opioids are often classified as a single group, individual agents differ in relative analgesic potency, as well as the potential risk of harm to patients. Furthermore, the availability of...

September 20, 2017: SafeMedicationUse.ca Newsletter - Talking to Your Pharmacist May Prevent Harm
When you pick up a new medication from the pharmacy, you should try to talk to the pharmacist about it. You may be tempted to skip this step if you're in a hurry, but try to plan for it. Most...

September 6, 2017: Health Canada: INVOKANA (canagliflozin) and INVOKAMET (canagliflozin & metformin) – Risk of Lower Limb Amputation


August 30, 2017: Med Safety Exchange Webinars
The goal of the Med Safety Exchange webinar series is to facilitate shared learning from medication incident data analyses. It is intended to be a national, practitioner-driven online platform,...

August 30, 2017: Medication Incident Data in Canada: A Strategy for More Effective Sharing and Learning
Most healthcare organizations providing patient care in Canada independently collect and analyze medication incident data; and many of these organizations develop and implement recommendations...

August 30, 2017: Take With Questions
This year's Canadian Patient Safety Week (CPSW) campaign, Take With Questions , is all about medication safety. Here’s what you can do to prepare for CPSW (Oct. 30 to Nov. 3,...

August 30, 2017: Unrealized Exposure to Heparin
In a recent newsletter, ISMP (US) discussed the problem of unrealized exposure of patients to heparin-coated medical devices. These devices are most often used during surgery or other...

August 16, 2017: SafeMedicationUse.ca Newsletter - Do You Know Your Medication Allergies?
Medications can sometimes cause an allergic reaction. You might get hives, a rash, or some swelling, or you might have trouble breathing. The reaction can be different from one person to another. A...

July 27, 2017: SafeMedicationUse.ca Newsletter - Opioids – Be an Informed Consumer
Opioids, also known as narcotic medications, are strong painkillers. They can treat some kinds of pain, but they do not work for every type of pain. You and your doctor or nurse practitioner may...

July 3, 2017: Health Canada: Gentamicin Injection – Potential for Adverse Reactions with 12 Lots Contaminated with Histamine


June 29, 2017: Epinephrine Use for Anaphylaxis – A Multi-Incident Analysis
Anaphylaxis is an acute, life-threatening, systemic allergic reaction associated with various triggers, clinical presentations, and levels of severity. Epinephrine is the only life-saving...

June 29, 2017: Health Canada Seeking Feedback on Mandatory Reporting of Serious Adverse Drug Reactions and Medical Device Incidents
In late June 2017, Health Canada released the consultation paper "Mandatory Reporting of Serious Adverse Drug Reactions and Medical Device Incidents by Health Care Institutions" in...

June 29, 2017: Updated Labelling and Packaging Guide Will Make It Easier for Canadians to Use Health Products Safely
A newly revised guide released by Health Canada is expected to improve the safe use of nonprescription and natural health products by making labels easier for consumers to read and understand. In...

May 25, 2017: Death Due to Pharmacy Compounding Error Reinforces Need for Safety Focus
Some patients may require a medication in a dose or dosage form that is not commercially available. Such medications must be specially prepared for the patient in a pharmacy and are referred to as...

June 17, 2017: Health Canada provides information on shortage of injectable sodium bicarbonate products in Canada


June 14, 2017: SafeMedicationUse.ca Newsletter -  Losing Medications Can Spoil Your Vacation
Whenever you go on a vacation, it's important to bring enough medication for the time you will be away. It's also important to take steps to keep your medications safe. Forgetting or losing...

May 25, 2017: WHO's Third Global Patient Safety Challenge: Medication Without Harm
Following on its 2 previous global patient safety challenges, related to infection control and safer surgery, the World Health Organization (WHO) recently announced the launch of its international...

May 18, 2017: Health Canada: Health Product Risk Communication for MIFEGYMISO (mifepristone & misoprostol tablets)


May 10, 2017: SafeMedicationUse.ca Newsletter - Know and Share Your Weight in Kilograms
Some medication doses are based on body weight or on a combination of weight and height. If your doctor is writing a prescription and asks for your weight, would you answer in pounds or in...

April 27, 2017: Acetaminophen: Preventing Harm through Safe Use
Despite its reputation for safety, acetaminophen has been identified as the leading cause of liver failure in Canada. Acetaminophen is a commonly used analgesic that is widely available in either...

April 27, 2017: Updated Paper to Electronic MedRec Implementation Toolkit now available
The Institute for Safe Medication Practices Canada, in collaboration with the Canadian Patient Safety Institute and the University of Victoria and with the support of Canada Health Infoway, is...

April 27, 2017: Updated Medication Reconciliation Getting Started Kits
ISMP Canada is delighted to release 2 newly revised medication reconciliation (MedRec) Getting Started Kits . These new kits highlight the most current evidence, knowledge, and practices in both...

April 27, 2017: More than 100 Endorsements for 5 Questions to Ask about Your Medications
To date, more than 100 organizations have endorsed 5 Questions to Ask about Your Medications , including international, national, and provincial associations and programs. You can request a...

April 24, 2017: NEWS RELEASE - Opioid Safety Information sheet available in pharmacies across Canada
The Institute for Safe Medication Practices Canada, Neighbourhood Pharmacy Association of Canada and Pear Healthcare Solutions Deliver a Collaborative Response to the Opioid Crisis: Opioid...

April 1, 2017: Health Canada: Pfizer Canada recalls two lots of EpiPen / EpiPen Jr auto-injectors due to possible device failure


March 22, 2017: SafeMedicationUse.ca Newsletter - Suddenly Stopping a Medication Can Be Harmful
For different reasons, some medications must be stopped slowly. Suddenly stopping these medications may lead to side effects and potential harm. Antidepressants are one type of medication that must...

March 20, 2017: Health Canada: Keytruda (pembrolizumab) - Risk of Severe Skin Reactions


March 9, 2017: Health Canada: Buckley's syrups recalled due to potential choking hazard


March 8, 2017: Express Levothyroxine Doses in Micrograms not Milligrams
Multiple cases of errors and near misses involving levothyroxine dose conversions from milligrams (mg) to micrograms (mcg) and vice versa have been reported to ISMP Canada and in the literature....

March 8, 2017: Caution: M-Eslon Now Also Available as an Immediate-Release Product
For over 2 decades, healthcare practitioners have associated the name M-Eslon with an extended-release formulation of morphine. With the introduction of M-Eslon IR, an...

March 8, 2017: Call for Expert Reviewers
ISMP Canada Safety Bulletins undergo rigorous multidisciplinary review. Expert review is a critical part of this process and supports the development of recommendations that are relevant and useful...

February 28, 2017: Gaps in Medication Monitoring May Contribute to Death
As part of ongoing collaboration with several provincial offices of the Chief Coroner or Medical Examiner, ISMP Canada received a report about the death of a woman who was taking levothyroxine but...

February 28, 2017: Your Feedback is Requested: Injectable Compounded Product Label Design for Safety
Label content and design have been identified as contributing factors to numerous medication incidents. It is crucial to consider the intended use of the product and the needs of the end user when...

February 28, 2017: Your Opinion Matters: 5 Questions to Ask about your Medications
We would like to invite you to participate in a short survey about your experience using 5 Questions to Ask about your Medications developed collaboratively by Canadian Patient Safety Institute,...

February 8, 2017: SafeMedicationUse.ca Newsletter - Some Medications Don't Mix
Medications are supposed to make you better. However, when certain medications are taken together, serious side effects may occur. When this happens, it's called a drug interaction. The...

January 31, 2017: Errors Associated with Hospital Discharge Prescriptions: A Multi-Incident Analysis
During a hospital stay, a patient's medication regimen may undergo multiple changes. If these changes are not captured accurately on the patient's discharge prescription, these...

January 31, 2017: Diabetic Ketoacidosis with SGLT2 Inhibitors
Diabetic ketoacidosis (DKA) is a rare medical emergency resulting from insulin deficiency, making it difficult for the body to use glucose for energy. In this situation, fat becomes the energy...

January 31, 2017: Your Feedback is Requested: The Use of Abbreviations on Prescription Health Product Labels in Canada
An abbreviation may have more than one perceived meaning and may be susceptible to isinterpretation—particularly if users are unfamiliar with its intended meaning. To provide consistency and...

January 26, 2017: Health Canada: Methotrexate - Serious dosing errors


January 23, 2017: Health Canada: Fluoroquinolones - Risk of Disabling and Persistent Serious Adverse Reactions


January 11, 2017: SafeMedicationUse.ca Newsletter -  What to Expect if the Pharmacy Makes a Mistake
Although pharmacists do their best, mistakes sometimes happen at the pharmacy. It's important to know what to expect your pharmacist to do after a medication mistake is found....

December 23, 2016: Health Canada reviewing potential negative effects of general anesthetics and sedatives on young children and fetuses


December 20. 2016: Allergy Never Events
"Never events" is a healthcare term used to describe preventable patient safety incidents that, if they do occur, result in serious patient harm or death. Allergy never events can result in...

December 8, 2016: SafeMedicationUse.ca Newsletter - Know Your Medications before Leaving on a "Pass"
A hospital or a long-term care home may allow a "pass" or leave of absence. Passes allow patients or residents to go to appointments or to spend time with family and friends. Before you...

December 7, 2016: Weight-Based Medication Dose Errors
Failure to accurately measure and record a patient's weight can contribute to serious, even fatal, dose errors, especially with high-alert medications such as anticoagulants and...

November 29, 2016: Safer Decisions Save Lives: Key Opioid Prescribing Messages for Community Practitioners
In fall 2015, ISMP Canada brought together a panel of opioid experts from across Canada to identify prescribing and management practices likely to result in better opioid prescribing in the...

November 29, 2016: Eliminate Dangerous Dose Designations—Use a Leading Zero before a Decimal
CBC.ca recently reported a medication incident that resulted in immediate harm and potential long-term complications to a young boy because he ingested a 10-fold overdose of risperidone...

November 16, 2016: The Chronicle Herald: Nova Scotia pharmacies lead in safe medicine practices - CPhIR


November 9, 2016: SafeMedicationUse.ca Newsletter - Be Sure You Know the Meaning of "Take as Needed"
It's important to understand how your doctor wants you to use your medications. Some medications are meant to be taken every day. Other medications should be used only when a specific symptom...

October 26, 2016: Strengthening Medication Reconciliation (MedRec) at Discharge - Ontario Critical Incident Learning Bulletin
Unintentional medication errors at discharge can compromise and effectively "undo" otherwise excellent care. Medication reconciliation (MedRec) is a process that helps healthcare providers...

October 19, 2016: SafeMedicationUse.ca Newsletter - Medications Can Look Like Candy
Have you ever noticed that some medications look like candy? Some medications are even made into gummies and lollipops, which can be very appealing to children. It is important for children to know...

October 5, 2016: Delayed Treatment after Transitions of Care: A Multi-Incident Analysis
Transition of care is a term describing the movement of patients between healthcare locations, providers, or different levels of care within the same location, as their conditions or care needs...

October 5, 2016: Safe Labelling of Compounded Products: Your Input is Requested
The label on a health product communicates key information and is an important aid in product identification, selection and administration. The ability to perform these activities safely is...

September 20, 2016: SafeMedicationUse.ca Newsletter - 5 Questions to Ask about Your Medications
Do you know what questions to ask about your medications? Knowing which medications, if any, have changed and how to take all your medications properly can help you to avoid serious problems. Ask...

September 15, 2016: Health Canada: Updated Labelling Standard for OTC acetaminophen products to help consumers use these products more safely


September 7, 2016: Health Canada reinforces the importance of preventing pregnancy while taking the acne drug isotretinoin to avoid birth defects


August 30, 2016: Accidental Intravenous Infusion of a Heparinized Irrigation in the Operating Room
ISMP Canada received 2 reports describing similar incidents involving the inadvertent intravenous (IV) infusion of a heparinized lactated Ringer's solution intended for topical irrigation....

August 29, 2016: University of Waterloo: Naloxone at pharmacies: what you need to know to combat the opioid crisis


August 16, 2016: Health Canada: Summary Safety Review - Atypical antipsychotics - Assessing the Potential Risk of Sleep Apnoea


August 11, 2016: Understanding Human Over-reliance on Technology
Through the analysis of an incident received from the National System for Incident Reporting (NSIR), this ISMP Canada safety bulletin highlights human over-reliance on technology by introducing...

August 2, 2016: Health Canada: Solu-Cortef 100 mg/ 2 mL Act-O-Vial - Recalled Lots due to Potential for Dosing Error


July 31, 2016: ISMP (US) List of High-Alert Medications in Long-Term Care Settings
 

July 25, 2016: Neighbourhood pharmacies and ISMP Canada provide one-page handout for patients prescribed opioids


July 20, 2016: Summary of 2015 Critical Incident Reporting Analysis - Ontario Critical Incident Learning Bulletin
The Ontario Hospital Critical Incidents Related to Medications or IV Fluids Analysis Report is written annually based on critical incidents that are reported by acute care hospitals. The reporting...

July 15, 2016: Improved labelling and packaging will minimize the risk of confusion and harmful medication mistakes
New guidance released by Health Canada will help improve the safe use of health products by making product labels easier for consumers and health professionals to read and understand. Two new...

July 14, 2016: Beat the Heat: How to Prevent, Recognize, and Manage Heat-Related Illnesses
With summer in full swing, many of us are making the most of the beautiful weather. However, when spending more time outdoors, it's important to be aware of heat-related illnesses,...

June 30, 2016: Health Canada: New industry guidance for health product labels will make it easier for Canadians to use products safely
 

June 28, 2016: Gaps in Transition: Management of Intravenous Vancomycin Therapy in the Home and Community Settings
As a result of changes in healthcare delivery, patients are increasingly receiving medical treatment in the home and community setting, instead of as inpatients in a hospital. Patients receiving...

July 2016 – Newsletter: Misconceptions about Medicines That Could Be Deadly: Part 3 — What Works for Me Will Work for You
SafeMedicationUse.ca, ISMP Canada's consumer–focused website, published a 3–part series highlighting common misconceptions that consumers have about medications. The series is based...

June 2016 – Newsletter: Misconceptions about Medicines That Could Be Deadly: Part 2 — If One Is Good, Two Will Be Better
SafeMedicationUse.ca, ISMP Canada's consumer–focused website, is publishing a 3–part series highlighting common misconceptions that consumers have about medications. The series is...

June 7, 2016: SafeMedicationUse.ca Newsletter - 
Misconceptions about Medicines That Could Be Deadly: Part 3

In this, the final instalment of our series discussing common misconceptions about medicines, we describe a tragic incident in which sharing of a medicine led to a person's death. The...

May 31, 2016: SafeMedicationUse.ca Newsletter - 
Misconceptions about Medicines That Could Be Deadly: Part 2

In the second part of this series, we highlight another misconception that was identified in an ISMP Canada analysis of errors with medicines that resulted in death. Misconception Two: If...

April 26, 2016: Reminder: Contact Lens Cleaning Solutions with Hydrogen Peroxide May Cause Eye Injury
Some contact lens cleaning solutions contain hydrogen peroxide. These cleaning solutions that contain hydrogen peroxide must not be used directly in the eye or as a rinsing solution for lenses. In...

April 21, 2016: Safety Considerations with Newer Inhalation Devices
Over the past few years, several new devices for the administration of inhaled medications have been introduced in Canada. Some of these devices are used to administer newly marketed medications,...

April 21, 2016: Safe Use of Newer Inhalation Devices: Reference Poster
A printable reference poster of the newer inhalation devices is available to practitioners to download.

April 21, 2016: Call for Medication Incidents Involving Delayed First Doses
To better understand why first doses of prescribed medication are sometimes delayed, ISMP Canada will be conducting a multi-incident analysis on this type of medication error. All...

April 5, 2016: Critical Incidents – Disclosure to Patients and Families - Ontario Critical Incident Learning Bulletin
Disclosure is an ongoing process that requires transparency, sensitivity, diplomacy, and diligence amongst all affected parties. When a critical incident occurs, the patient, family members, and...

March 30, 2016: Changes in Expression of Strength: Elimination of Ratios on Single-Entity Injectable Products
The standards set by the United States Pharmacopeial Convention, through the United States Pharmacopeia and the National Formulary (USP-NF), are being updated for publication as USP39-NF34....

March 30, 2016: Health Canada’s Action to Improve Acetaminophen Safety: An Update
ISMP Canada continues to support Health Canada’s efforts to improve acetaminophen safety and to minimize the risk of liver damage. A social media campaign has been launched that focuses on...

March 30, 2016: Knowledge Mobilization Tool: Customized Report of Solutions to Help Prevent Medication Errors
When a medication incident occurs, identifying and implementing system-based interventions may prevent recurrence of the error. The online Knowledge Mobilization Tool (KMT) was designed to give...

March 30, 2016: Hospital Medication Safety Self Assessment (MSSA) – Launch of Canadian Version III, 2016
The Hospital Medication Safety Self-Assessment (MSSA), Canadian Version III (2016) was launched in March 2016. This revised version includes substantial new content from the Canadian Medication...

March 30, 2016: SafeMedicationUse.ca Newsletter - Is this Over-the-Counter Medicine Safe for Me?
Over-the-counter (OTC) medicines are drugs that are sold without a prescription in pharmacies and other locations. Because OTC medicines are so readily available, people may think these...

March 9, 2016: NEWS RELEASE - Making sense of your medications
Toronto, Canada —  Our healthcare system can be an incredibly complex place, even for someone who works in pharmacy. Like many of us, Ms. Emily Musing, who is the Executive...

February 18, 2016: Infantile Hemangioma Treated with Propranolol - Learning Opportunities from an Infant Death
Infantile hemangioma (sometimes called a "strawberry birthmark") is a benign vascular, soft-tissue tumour that affects 4% to 10% of infants. Most infantile hemangiomas resolve...

February 18, 2016: 5 Questions to Ask about Your Medications
Patients are at high risk of medication errors due to fragmented care at transitions. In collaboration with the Canadian Patient Safety Institute, Patients for Patient Safety Canada, the Canadian...

February 8, 2016: Update on Health Canada's Action to Improve Acetaminophen Safety
Health Canada is continuing efforts to improve acetaminophen safety and minimize the risk of liver damage. A Steering Committee of stakeholders, co-chaired by Health Canada and ISMP Canada, has...

January 31, 2016: High-Alert Medications Need Multiple Safeguards - Ontario Critical Incident Learning Bulletin
High-alert medications (e.g., opioids, insulin, and anticoagulants) may not be inherently more likely to be involved in medication errors, but they carry an elevated risk of more serious harm...

January 25, 2016: Practicum in Medication Safety for International Practitioners
ISMP Canada is pleased to announce it is now offering a Practicum in Medication Safety for International Practitioners. This program will be of interest to practicing nurses, pharmacists,...

January 18, 2016: SafeMedicationUse.ca Newsletter - 
Misconceptions about Medicines That Could Be Deadly: Part 1

This is the first in a series of newsletters that will discuss three common misconceptions about medicines. These misconceptions were identified in an ISMP Canada analysis that looked at errors...

December 30, 2015: Medication Incidents that Increase the Risk of Falls: A Multi-Incident Analysis
Falls remain the leading cause of injury-related hospital admissions among Canadian seniors, with 20% to 30% of this age group falling each year. Psychotropic medications and polypharmacy are...

December 30, 2015: Join the Conversation! New Ontario MedRec Network
The MedRec Ontario Network is a pan-Ontario network developed with input from community healthcare providers. It is led by ISMP Canada and supported by Health Quality Ontario. The network is a...

December 17, 2015: Knowledge and Monitoring Deficits Contribute to Hospital-Acquired Hyponatremia
Hospital-acquired hyponatremia is associated with poor outcomes, including higher in-hospital mortality, increased length of stay, and higher likelihood of discharge to a facility relative...

December 11, 2015: Multiple IV Infusion Safety education modules, developed by HumanEra (University Health Network), now available from the ISMP Canada eLearning Portal
The eLearning modules on Multiple IV Infusion Safety , developed by HumanEra (University Health Network) with funding from Health Quality Ontario, are now available from ISMP Canada‘s...

December 2, 2015: ISMP Canada launches eLearning portal
ISMP Canada's eLearning portal provides online educational modules to advance patient safety. These interactive courses can be taken anytime and anywhere from a computer with an Internet...

December 2, 2015: SafeMedicationUse.ca Newsletter - Make Sure You Are Heard by Your Healthcare Providers
It can be daunting to ask healthcare providers questions about your care. This is especially true when you are sick or when you are in a hospital. You may feel overwhelmed by everything that is...

November 18, 2015: Errors Continue with Amphotericin B - Ontario Critical Incident Learning Bulletin
Amphotericin B is an antimicrobial drug used in the treatment of severe fungal infections. It is available in 3 formulations for intravenous use in Canada: "conventional" amphotericin B...

November 4, 2015: SafeMedicationUse.ca Newsletter - Incident Reported with Cold and Flu Product
Choosing a nonprescription medicine can be complicated. Many different products are available to treat similar symptoms. Some products contain more than one ingredient, and some products even...

October 30, 2015: Application of TALLman Lettering for Selected High-Alert Drugs in Canada
TALLman lettering is a method of applying uppercase lettering to sections of look-alike, sound-alike (LASA) drug names to bring attention to their points of dissimilarity. By accentuating...

October 30, 2015: Health Canada Communication Regarding Outdated Labelling of Vincristine Injection
Health Canada recently issued a Dear Healthcare Professional Letter regarding the presence of outdated safety information on the inner and outer labels, as well as the package insert, of certain...

October 30, 2015: Preventing Medication Errors with New High-Concentration Insulins
Until very recently, all insulin products for human use in Canada were available in only one concentration: 100 units/mL. In 2015, Health Canada authorized 2 new high-concentration insulin...

October 21, 2015: SafeMedicationUse.ca Newsletter - Tips to Prevent Medication Errors with Your Blister Pack
Blister packs, also known as compliance packs or bubble packs, can help people to keep track of their medicines. Blister packs contain designated sealed compartments, or spaces for medicines to be...

September 30, 2015: Severe Harm and Deaths Associated with Incidents Involving Low-Dose Methotrexate
For patients with the autoimmune disease rheumatoid arthritis (RA), oral or parenteral methotrexate is the preferred disease-modifying antirheumatic drug with respect to efficacy and safety,...

September 30, 2015: Health Canada Releases a Safety Advisory Regarding BD Syringes
Last week Health Canada released a safety advisory about the use of Becton-Dickinson (BD) sterile disposable plastic syringes for the purposes of storing compounded or repackaged medications....

September 16, 2015: SafeMedicationUse.ca Newsletter - Illegible Prescriptions Can Lead to Errors
SafeMedicationUse.ca recently received a report that highlights just how dangerous bad handwriting on prescriptions can be. The handwriting on a child's prescription for the medicine...

September 9, 2015: ALERT - Methylene Blue Interaction Leads to Serotonin Syndrome
Indigo carmine, a marker dye often used in cystoscopy and in ureteral and other operative procedures, was recently discontinued. Some Canadian healthcare facilities have started to use methylene...

August 26, 2015: Selection of Incorrect Medication Pump Leads to Chemotherapy Overdose
ISMP Canada received a report about an ambulatory patient who received a chemotherapy drug that was administered more rapidly than prescribed via an elastomeric infusion pump (a type of pump that...

August 19, 2015: SafeMedicationUse.ca Newsletter - Oral Chemotherapy: Not Just an Ordinary Pill
Oral chemotherapy is cancer medicine that is taken by mouth. These medicines come as tablets, capsules, or liquids that can be swallowed. As a result, oral chemotherapy can be taken at home. For...

July 22, 2015: Death Associated with Inadequate Reassessment of Venous Thromboembolism Prophylaxis at and after Hospital Discharge
Venous thromboembolism (VTE) prophylaxis is recommended for acutely ill, hospitalized medical patients at risk of thrombosis. As part of ongoing collaboration with a provincial death investigation...

July 22, 2015: Important Information from Health Canada about Acetaminophen Safety
Health Canada has announced new action to improve acetaminophen safety and minimize the risk of liver damage. This action is in light of a Health Canada review that assessed acetaminophen and liver...

July 22, 2015: New Toolkit for Healthcare Providers: Hospital to Home—Facilitating Medication Safety at Transitions
ISMP Canada recently developed a new resource for acute care: a toolkit to support the safe transition of patients and their medications from hospital to home. Hospital discharge is a critical...

July 21, 2015: Resources to Sustain Incident Learning - Ontario Critical Incident Learning Bulletin
ISMP Canada recently developed 2 NEW resources for acute care: a toolkit to support the safe transition of patients and their medications from hospital to home; and a checklist to assess the safety...

July 6, 2015: Dr. Ruth Wilson appointed to the Order of Canada
Dr. Ruth Wilson, ISMP Canada Board Chair, has been appointed to the Order of Canada, the highest and a very prestigious award in Canada for her contributions on improving primary care in...

June 26, 2015: RNAO webinar on June 29 - Multiple IV Infusion Safety and Nursing Education Implications
This webinar is intended for nurses, nursing students and educators who manage multiple IV infusions administered in clinical settings such as critical care, medical and paediatric units. The...

June 18, 2015: SafeMedicationUse.ca Newsletter - Navigating Safely Through a Sea of Health Information
Have you felt overwhelmed by the copious and sometimes conflicting health advice provided by news sources and the Internet? The increasing availability of health information has pros and cons....

June 3, 2015: Missed Doses of Allergen Extracts Contribute to Serious Reaction
Allergen immunotherapy involves the administration of gradually increasing doses of selected allergens to a patient to treat stinging insect hypersensitivity, allergic rhinitis or conjunctivitis,...

Aprl 22, 2015: Analysis of Incidents Involving Oral Chemotherapy Agents
SafeMedicationUse.ca received a report about an older adult who took the osteoporosis medication The past few years have seen the introduction of many oral chemotherapy agents. These agents can be...

April 22, 2015: Computerized Prescriber Order Entry for Systemic Treatment - Best Practice Guideline to Support the Safe Delivery of Chemotherapy
In 2012, Cancer Care Ontario released its best practice guideline on Computerized Prescriber Order Entry (CPOE) for Systemic Treatment. This guideline for systemic chemotherapy focuses on the...

March 31, 2015: ALERT: Shortage of Topical Epinephrine 1:1000 Poses Safety Risks
Since early 2015, there has been shortage of epinephrine 1 mg/mL (1:1000) 30 mL vials for topical use and epinephrine 1 mg/mL (1:1000) 30 mL vials for injection. At the time of writing, the only...

March 31, 2015: Announcing the Draft Good Label and Package Practices Guide
Health Canada and ISMP Canada are pleased to announce the release of the draft Good Label and Package Practices Guide for stakeholder consultation. The purpose of the guide is to provide...

March 31, 2015: SafeMedicationUse.ca Newsletter - Caution: Not All Medicines Are Taken Every Day
Although many medicines are taken every day, other medicines are taken less frequently. SafeMedicationUse.ca received a report about a mix-up between 2 medicines that were meant to be taken...

March 18, 2015: SafeMedicationUse.ca Newsletter - Beware: Medicine Names May Sound Alike, but the Medicines May Be Very Different
Some medicines have names that look or sound like the names of other medicines, even though their ingredients are very different. Medicines with similar names can have entirely different uses,...

March 5, 2015: Wrong-Route Incident Involving Insulin and Dextrose Prescribed for Hyperkalemia
ISMP Canada recently received a report of a serious incident that involved the prescribing and administration of salbutamol, dextrose, and insulin to treat hyperkalemia (elevated serum potassium)....

February 19, 2015: Fluid Management  - Ontario Critical Incident Learning Bulletin
Most patients who are receiving inpatient care require fluid and electrolyte management, a process that is often thought of as simple and routine. However, evaluation of fluid status and...

February 5, 2015: Change in Methadone Concentration Results in an Overdose in a Post-Partum Patient
Methadone is a potent synthetic opioid analgesic that has been used for decades, in conjunction with supportive psychological and social services, to manage and treat addiction to other opioids....

February 5, 2015: Methadone Medication Incidents in Community Pharmacy
ISMP Canada’s Community Pharmacy Incident Reporting (CPhIR) Program is a voluntary program used by community pharmacies across Canada to analyze underlying process and system...

February 5, 2015: Drug Labelling and the Application of TALLman Lettering for Select High Alert Drugs
A notable theme in qualitative analyses has been medication mix-ups due to look-alike/sound-alike drug names. TALLman lettering involves the application of UPPER CASE lettering to...

January 14, 2015: SafeMedicationUse.ca Newsletter - Confusion with a Baby’s Dose of Medicine
When it comes to infants, we must be extra careful with the dose of any medicine administered. SafeMedicationUse.ca has received a report from a consumer whose 1-month-old baby received...

December 18, 2014:
A Mix-up between Short- and Long-Acting Medications Administered by Injection: When Does the “Salt” Matter?

Medications may be formulated as salts or esters (collectively referred to as “salts”), usually to improve the properties of the therapeutic moiety (e.g., its stability,...

December 18, 2014:
SafeMedicationUse.ca Newsletter Synopsis - Medication Appearance and Markings Support Safety

Consumers need to be familiar with the identification marks and general appearance of each of their medications and any medications they administer to others. SafeMedicationUse.ca received an...

December 18, 2014:
Invitation to Participate in a Delphi Method Survey on Medication Safety Pictograms for Healthcare Workers

We would like to invite healthcare professionals to participate in the development of a set of pictograms for medication safety. In this first phase, we are seeking assistance to identify the top...

December 10, 2014: An Opioid-Related Death in a Small Community Hospital
Pain management is a complex process that can involve a number of pharmacologic treatment modalities, including traditional pain medications (e.g., non-opioids and opioids) and adjunctive...

December 10, 2014: SafeMedicationUse.ca Newsletter Synopsis - Know When to Stop Your Medicine
Consumers can play a key role in making sure they take their medication for the correct length of time and no longer. A report received recently by SafeMedicationUse.ca highlights the challenges of...

December 10, 2014: Doc Mike Evans Video on Medication Safety Now Available
Practitioners are encouraged to talk to their patients about keeping a list of all their medicines and how they take them. Patients are advised to keep the list with them at all times and to show...

December 8, 2014: Multiple IV Infusions - Risks and Recommendations
Despite growing awareness of the factors that lead to errors in programming a single intravenous (IV) infusion, minimal research has been conducted into the errors that can result from...

November 20, 2014: Decimal Point in New Strength of HYDROmorph Contin Leads to an Opioid Overdose
ISMP Canada received a report of a critical incident involving the high-alert medication HYDROmorph Contin (HYDROmorphone hydrochloride controlled-release capsules). In this incident, a...

November 20, 2014: Deaths Associated with Opioids - Highlights of a Multi-Incident Analysis
Opioid medications continue to be among the top medication classes associated with harmful incidents voluntarily reported to ISMP Canada. As a priority focus of a collaborative project between ISMP...

November 20, 2014: Drug Shortage Safety and Tenecteplase (TNKase®)
ISMP Canada has developed a Drug Shortage Safety Knowledge Exchange site to assist healthcare practitioners and organizations to prepare for and manage select medication shortages. Various...

November 20, 2014: SafeMedicationUse.ca Newsletter: Sharing Opioid Medicines Can Be Deadly
Sharing any prescription medication can be dangerous, but even a single dose of an opioid can cause death in someone who has never taken it before. Through recent work with Offices of Chief...

November 5, 2014: Opportunity with ISMP Canada
Job Category Medication Safety Specialist Location Toronto, Ontario Application Deadline Nov 20, 2014 The Institute for Safe Medication Practices Canada (ISMP Canada)...

October 7, 2014: NEW! One Simple Solution for Medication Safety – Doc Mike Evans Video now available!
You can help make your care safer by keeping a list of all your medicines and how you take them. Keep the list with you at all times and show the list to your doctor, nurse, pharmacist or other...

September 12, 2014: NEWS RELEASE - ISMP Canada releases an anonymous, online Community Pharmacy Incident Reporting (CPhIR) program
Toronto, Canada –  Today the Institute for Safe Medication Practices Canada (ISMP Canada) announced the nationwide release of the Community Pharmacy Incident Reporting (CPhIR)...

September 10, 2014: Support for the Safe Use of Insulin
Insulin is a commonly prescribed antihyperglycemic agent that continues to be one of the top high-alert drugs implicated in medication errors, as identified from incidents voluntarily submitted...

July 30, 2014: Development of a National Medication Safety Action Plan for Canada
The Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI) hosted an invitational summit in Toronto on June 18, 2014, to support the...

June 11, 2014: Reported Confusion with Insulin Syringe Labelling
ISMP Canada recently received a near-miss incident report involving an incorrect insulin dose due to confusion related to labelling of insulin syringes. In this incident, a nurse...

May 14, 2014: Get Involved in a Drug-Drug Interactions Pharmaceutical Opinion Program
The Safety Alerts as Drivers for Pharmaceutical Opinion Program is a community pharmacy-based pilot research project conducted by ISMP Canada, with support from the Canadian Foundation...

March 31, 2014: NEWS RELEASE - ISMP Canada warns of the potential for eye injuries with Clear Care contact lens cleaning solution
Toronto, Canada – ISMP Canada is warning consumers and vendors of contact lens solutions of the potential for painful eye injuries if Clear Care contact lens cleaning solution is not used as...

Le 31 mars 2014: Communiqué de presse - Mise en garde sur le risque potentiel de blessures aux yeux liés à l'utilisation de la solution nettoyante et désinfectante pour lentilles cornéennes Clear Care
Toronto, Canada – ISMP Canada désire aviser les consommateurs et les vendeurs de solutions nettoyantes pour lentilles cornéennes du risque potentiel de blessures douloureuses aux yeux (ex.;...

February 18, 2014: Opportunity with ISMP Canada
Job Category Medication Safety Specialist – Labelling and Packaging Job Type Full Time Contract – 1 year Location Toronto, Ontario Application Deadline Monday,...

November 21, 2013: Manufacturer Adds Warning to Cap and Ferrule of a Succinylcholine Product
Neuromuscular blocking (paralyzing) agents are high-alert medications. Substitution errors have led to serious injuries and death. In 2006, to reduce the risk of these types of errors, Canadian...

November 19, 2013: HYDROmorphone Safety Self-Assessment Now Available
ISMP Canada’s HYDROmorphone Safety Self-Assessment is now available. For further information, please contact ISMP Canada by e-mail mssa@ismp-canada.org or by phone...

November 4, 2013: Look-Alike / Sound-Alike ALERT: trastuzumab emtansine (Kadcyla) and trastuzumab (Herceptin)
Health Canada recently approved Kadcyla (generic name: trastuzumab emtansine), as a single agent, for the treatment of patients with HER2-positive, metastatic breast cancer who have received...

November 4, 2013: International Medication Safety Network Releases Position Statement on Naming, Labelling and Packaging of Medicines
The International Medication Safety Network (IMSN) was formed in 2006 and includes representatives from more than 20 countries. The IMSN recently released a position statement with recommendations...

October 29, 2013: News Release - Health Canada funding announced for Medication Incident Prevention Program
Toronto, Canada  - Health Canada funding to support ISMP Canada’s role in the Canadian Medication Incident Reporting and Prevention System was announced today by Mr. Terence...

October 28, 2013: News Release - Medications Can Be Confusing - Patients are encouraged to keep a list of medications to share with healthcare providers
Edmonton, Canada - With so many medications prescribed every year, there is no denying that administering and taking medications can be confusing and overwhelming. The Canadian Patient Safety...

October 2, 2013: Consumers Can Help Prevent Harm From Opioid Use - Video with Subtitles Now Available
ISMP Canada is pleased to announce that the video "Consumers Can Help Prevent Harm from Opioid Use" is now available with subtitles. The subtitles have been added in response to requests...

September 24, 2013: Consumers Can Help Prevent Harm From Opioid Use  - Video with Subtitles Now Available
ISMP Canada is pleased to announce that the video “Consumers Can Help Prevent Harm from Opioid Use” is now available with subtitles. The subtitles have been added in response to...

August 28, 2013: Risk of Look-Alike Arterial Blood Gas Syringes and Parenteral Syringes
ISMP Canada has received a report describing a near-miss incident in which a syringe intended for withdrawal of a sample for arterial blood gas (ABG) testing was nearly used for preparation of...

August 28, 2013: Risk of Look-Alike Arterial Blood Gas Syringes and Parenteral Syringes
ISMP Canada has received a report describing a near-miss incident in which a syringe intended for withdrawal of a sample for arterial blood gas (ABG) testing was nearly used for preparation of...

August 15, 2013: ALERT: Drug Shortages Highlight the Need for Independent Double Checks
ISMP Canada recently received a medication incident report describing errors in the revision of a master formula for total parenteral nutrition (TPN) at a healthcare organization that led to...

July 23, 2013: ImagineNation Challenge Highlights the Impact of Digital Health in Canada
From drug information systems to electronic medication reconciliation, the continued development of digital health is changing the way healthcare providers deliver care  - and...

June 4, 2013: Video now available: Consumers Can Help Prevent Harm from Opioid Use
ISMP Canada is pleased to announce the launch of a patient safety initiative to educate consumers on the safe use of opioids. Opioids are commonly involved in incidents associated with harm that...

May 27, 2013: Another Mix-up Between Bisoprolol and Bisacodyl
A recent ISMP Canada Safety Bulletin reported on the potential for harm with mix-ups between bisoprolol and bisacodyl. Recently, ISMP Canada’s consumer reporting and learning program,...

May 14, 2013: News Release - Canadian healthcare innovation, the MyMedRec app goes global
MyMedRec, one of Canada’s top free iPhone apps to help people and their families keep track of medication use and immunization history, is now available internationally. MyMedRec allows users to...

May 7, 2013: Overfill Needs to be Taken into Account for IV Chemotherapy
More than 1100 Canadian patients may have received lower doses of cyclophosphamide or gemcitabine than intended because of miscommunication between a supplier and several hospitals that utilized...

April 19, 2013: Institute for Safe Medication Practices Canada Partners with Health Quality Ontario (HQO)
The new strategic partnership between ISMP Canada and HQO will help to address preventable adverse events by increasing uptake, quality and consistency of medication reconciliation (commonly...

April 3, 2013: News Release - ISMP Canada Calls for a National Standard for Labelling Cancer Chemotherapy Solutions with Overfill Volumes
Toronto, Canada - April 3, 2013 - An incident involving the management and labelling of cancer chemotherapy medications highlights the need for a national labelling standard. Since March 2012,...

March 27, 2013:
Health Canada Draft Revised Guidance Document for Industry: Review of Drug Names for Look-alike Sound-alike (LASA) Attributes

Health Canada is working to address issues regarding potentially confusable look-alike/sound-alike (LASA) medication names. As part of its effort to provide more detailed direction to...

March 27, 2013:
ALERT: Using Clear Care Contact Lens Solution Without the Special Lens Case Supplied Can Cause Painful Eye Injuries

ISMP Canada continues to receive reports from consumers who experienced pain and burning in the eyes after confusing Clear Care with a regular contact lens solution. Unlike most other contact lens...

March 27, 2013: Dr. John Senders Retires from ISMP Canada Board of Directors
John W. Senders PhD has recently retired from the Board of Directors of ISMP Canada. It was Dr. Senders’ ongoing research and promotion of failure mode and effects analysis (FMEA) and its...

January 12, 2013: Change to Handwritten Prescription Leads to Dose Misinterpretation
A physician wrote a medication order for a patient who needed analgesia for pain. After writing the prescription for “morphine 1 mg ”, the physician changed the order by writing...

January 12, 2013: Brand Name Change for Dabigatran: Pradax Is Now Pradaxa
In 2011, ISMP Canada published a safety alert (based on voluntary reports received) to highlight the potential for confusion between the brand names Pradax (dabigatran etexilate) and Plavix...

December 12, 2012:
2012 Guidelines on Reporting and Preventing Medication Incidents Now Available

The 2012 version of Medication Incidents: Guidelines on Reporting and Prevention , co-developed by the Canadian Society of Hospital Pharmacists (CSHP) and the Institute for Safe Medication...

November 22, 2012:
Eliminating Harmful Medication Errors at Transitions:
Medication Reconciliation – A National Priority

Reducing medication-related errors is a priority for advancing safe, high-quality health care in Canada. In early November 2012, Accreditation Canada, the Canadian Institute for Health...

October 30, 2012: Canadian Incident Analysis Framework
(revised version of the Canadian Root Cause Analysis Framework)

ISMP Canada is pleased to announce the release of the Canadian Incident Analysis Framework (previously called the Canadian Root Cause Analysis Framework). This updated framework was collaboratively...

October 30, 2012: Education Announcement: Multi-incident (Aggregate) Analysis
ISMP Canada is pleased to offer a 1-day interactive workshop, designed specifically for risk managers, patient safety officers, medication safety officers, and healthcare professionals seeking...

August 30, 2012: Version II of the Medication Safety Self-Assessment for Long-Term Care Now Available
The Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) Version II is now available for use by long-term care facilities. This self-assessment tool was revised this year under the...

August 30, 2012: Sharing SafeMedicationUse.ca Learning—A Sip of Water May Not Always be Enough
ISMP Canada reminds healthcare practitioners that certain oral medications require administration with an adequate quantity of water or other appropriate fluid. This is an important consideration...

July 31, 2012: Learn More about the National Bar Coding Initiative
The work related to the Canadian Pharmaceutical Bar Coding Project can be found on the ISMP Canada website, with documents available for viewing or download. Joint technical statement...

June 27, 2012: Knowledge is the Best Medicine - New Options Available to Help Patients Keep Track of Their Medications
The Canadian Medical Association, Canadian Nurses Association, Canadian Pharmacists Association, Victorian Order of Nurses, and Best Medicines Coalition have worked in partnership with...

June 27, 2012: HYDROmorphone Knowledge Assessment Survey Results
HYDROmorphone Knowledge Assessment Survey Results:   Key Findings ,   Report  – PDF  

June 20, 2012: News Release – Canada’s leading health care organizations launch new app and electronic initiative to promote the safe and smart use of medicines
Ottawa, Ontario – June 20, 2012  –  Seven of Canada’s leading health care organizations have joined together to launch new electronic tools to help Canadians...

June 5, 2012: Beware of Mix-ups Between CycloSPORINE and Cyclophosphamide
SafeMedicationUse.ca has received a report from a consumer who identified a potentially harmful mix-up between cycloSPORINE and cyclophosphamide. The consumer was discharged from hospital with a...

June 5, 2012: Risk Assessment Program for Oncology
Data Submission Deadline Extended to September 30, 2012

The Institute for Safe Medication Practices (ISMP US), together with ISMP Canada and the International Society of Oncology Pharmacy Practitioners, has launched the "2012 ISMP International...

May 2, 2012: ISMP Canada is an Alliance Partner for the 2012 unSUMMIT for Advancing Use of Barcoding
The unSUMMIT is the premier educational event for hospitals interested in Barcode–enabled Point of Care. Since 2005, The unSUMMIT’s mission has been to bring together those who share...

April 30, 2012: Drug Shortages and Framework for Resource Allocation
An ethical framework intended to provide high-level guidance for ethical decision-making and deliberation within and across health sectors and health institutions, as well as among healthcare...

April 30, 2012: Risk Assessment Program for Oncology Now Available
The Institute for Safe Medication Practices (ISMP US), together with ISMP Canada and the International Society of Oncology Pharmacy Practitioners, has launched the "2012 ISMP International...

April 3, 2012: News Release ~ Now Available – ISMP International Medication Safety Self Assessment® for Oncology
News Release –  Oncology practitioners all over the world can now access a tool that will assist in making drug treatment for cancer even safer for their patients. The Institute...

March 24, 2012:
Health Canada Endorsed Important Safety Information on Morphine Sulfate Injection USP 2 mg/mL, 1 mL ampoule
Urgent – Recall of one lot of Morphine Sulfate Injection USP 2 mg/mL, 1 mL ampoule

Sandoz Canada is voluntarily initiating an immediate recall of a portion of lot CC2824 / exp. 2014–12 of Morphine Sulfate Injection USP 2 mg/mL, 1 mL ampoule (Sandoz Code: 5642). The recall...

March 22, 2012: Health Canada Public Advisory - Sandoz Canada recalling partial lot of 2mg/mL (1mL) Morphine Sulfate Injection
Health Canada is advising Canadians that Sandoz Canada Inc. will be voluntarily recalling a portion of one lot of 2mg/mL (1mL) Morphine Sulfate Injection (Lot CC2824 exp. 2014–12) from the...

March 21, 2012: Health Canada Issued Important Safety Information on Sandoz Morphine Sulfate Injection USP
Urgent Notice – 2mg/mL (1mL) Sandoz Morphine Sulfate Injection USP – Some boxes may contain ampoules labelled as Isoproterenol Hydrochloride Injection in addition to...

December 22, 2011: Health Canada Endorsed Important Information on the Correct Use of EpiPen and EpiPen Jr Auto–Injector
Pfizer Canada Inc. (distributor of EpiPen for Dey Pharma, L.P.) in collaboration with Health Canada, are advising consumers and healthcare professionals of the correct method to remove the blue...

December 21, 2011: Engaging Consumers in the Canadian Medication Incident Reporting and Prevention System (CMIRPS)
Consumers can play a vital role in efforts to enhance medication safety, and incident reporting is an important first step. In light of the growing interest in strengthening the role of consumers...

December 21, 2011: Health Canada is Working with Industry to Address Drug Shortages
Health Canada has recently announced efforts to address drug shortages. Because drug shortages have been identified as possible contributing factors in medication incidents, ISMP Canada is also...

November 15, 2011: New USP Requirement for Drug Vial Caps and Ferrules
The United States Pharmacopeia (USP) has finalized a standard that allows only cautionary statements intended to prevent imminent life-threatening situations to be printed on the cap or ferrule...

November 8, 2011: Health Canada Endorsed Important Safety Information on Pradax and Plavix
Boehringer Ingelheim (Canada) Ltd. and Sanofi-aventis Canada Inc., in consultation with Health Canada, are alerting consumers and healthcare professionals to the risk of medication errors...

October 27, 2011: Canadian Medication Incident Reporting and Prevention System (CMIRPS) Update
To learn more about what is happening with CMIRPS, tune in to Canada’s Virtual Forum on Nov 2, 2011 at 1230 pm ET , when Margaret Zimmerman from Health Canada's Marketed Health Products...

August 8, 2011: CTV News - Group warns of feeding tube and IV line mixups
A medical safety agency has issued a warning after receiving two reports in which hospitalized newborn babies were mistakenly given breast milk through IV lines into their bloodstream. Safety...

September 30, 2011: Medication Reconciliation Update
ISMP Canada is co-leading, with CPSI, the National Medication Reconciliation Strategy and is pleased to support the Canada Health Infoway ImagineNation Outcomes Challenge . Canada Health...

September 30, 2011: Collaborative Failure Mode and Effects Analysis (FMEA) - Reducing the Risk of Inadvertent Injection of Concentrated Epinephrine Intended for Topical Use
Given the high risk of harm or death associated with the inadvertent injection of epinephrine 1 mg/mL, further study of the management of this medication was deemed necessary. An Ontario hospital...

September 30, 2011: Narcotic (Opioid) Medication Safety - Manufacturer Enhances Safety by Changing Vial Closures for Injectables
Sandoz Canada Inc. and ISMP Canada received reports of concerns about “tip-off” closures that were in use for a variety of injectable opioid medications manufactured by this company (see Figure...

July 31, 2011: We are interested in your thoughts and experiences related to the potential for IV administration of breast milk to an infant.
If you or your organization provides enteral feedig to neonates, please take a few minutes to complete our short survey. Although compiled data and survey responses may be used in future...

July 31, 2011: Health Canada’s Role in the Management and Prevention of Harmful Medication Incidents
On June 20, 2011, Health Canada updated its website to provide more information to Canadians about the department’s role in reducing and preventing harmful medication incidents, particularly...

June 17, 2011: Ontario Long Term Care Association (OLTCA) – Website aiming to curb adverse medication effects in seniors
List of potentially harmful meds and safer alternatives provided to Caregivers Fourteen Ontario organizations – including the Ontario Long Term Care Association ( OLTCA )...

June 16, 2011: News Release - CMIRPS Web site has been officially launched
Toronto, Canada  – ISMP Canada is pleased to announce that CMIRPS Web site has been officially launched ( www.cmirps-scdpim.ca ). This new Web site is now available with...

June 14, 2011: News Release - Safer medication use highlighted during Seniors’ Month
Website aims to combat adverse drug effects in older persons      Toronto, Canada  – Adverse reactions to prescription drugs among older persons is...

April 30, 2011: Muscle Relaxant Cyclobenzaprine Ordered as “Cycloprine” and Interpreted as Immunosuppressive Agent Cyclosporine
An order for “cycloprine 10 mg po qhs”, which was intended to refer to the muscle relaxant cyclobenzaprine, was entered into a pharmacy system as “cyclosporine 10 mg po...

April 30, 2011: Mix–ups Continue between Conventional Amphotericin B and Lipid–Based Amphotericin B
Amphotericin B, a systemic antifungal medication, is not commonly used, and health care practitioners may be unfamiliar with its various formulations and the potential consequences of mix–ups...

April 20, 2011: MedRec Final Summit Report
On February 10, 2011 the Canadian Patient Safety Institute in partnership with the Institute for Safe Medication Practices Canada and Canada Health Infoway , hosted Canada's first national...

February 23, 2010: Community Pharmacy Incident Reporting Program (CPhIR)
ISMP Canada, with support from the Ontario Ministry of Health and Long-Term Care, developed the Community Pharmacy Incident Reporting ( CPhIR ) Program ( www.cphir.ca ) to allow community...

February 23, 2010: Risk Assessment Program for Medication System Safety in Community Pharmacy
The Medication Safety Self-Assessment (MSSA) for Community/Ambulatory Pharmacy was developed to assist and guide individual community pharmacies in dentifying opportunities to improve their...

February 23, 2010: Evaluation of Services Provided by ISMP Canada through the Canadian Medication Incident Reporting and Prevention System (CMIRPS)
In 2010, ISMP Canada engaged Prairie Research Associates (PRA) Inc. to conduct an evaluation of the work that ISMP Canada has delivered through the CMIRPS program. The evaluation (available from:...

December 10, 2010: Risk Assessment Program for Medication System Safety in the Long–Term Care Setting
The long–term care environment presents unique challenges for the development and implementation of safe medication systems. ISMP Canada developed the Medication Safety...

August 31,2010 : Risk of Inadvertent Injection of Epinephrine Intended for Topical Use
Erfa Canada Inc. recently released Health Canada Endorsed Safety Information regarding the risk of inadvertent injection of the topical / nasal formulation. For additional information,...

June 30, 2010: Anti-infective Guidelines for Community-acquired Infections are Now Available
• Developed by the Anti-infective Review Panel, an interdisciplinary expert review panel; • Evidence-based guidelines published since 1994; • Includes new...

June 9, 2010: News Release

ISMP Canada Urges Patients to Take Steps to Reduce the Chances of a Medication Mistake

One in ten adult Canadians with health problems reported receiving the wrong medication or the wrong dose when filling a prescription or when hospitalized within the last two years The...

May 25, 2010: Neuromuscular Blocking Agents: Another Manufacturer Changes Labelling and Packaging to Increase Safety
In 2006, ISMP Canada described a collaborative initiative involving clinical experts and pharmaceutical manufacturers of neuromuscular blocking agents (in alphabetical order: Abbott Laboratories,...

April 30, 2010: Community Pharmacy Incident Reporting Program
ISMP Canada has developed the Community Pharmacy Incident Reporting ( CPhIR ) Program ( www.cphir.ca ), with support from the Ontario Ministry of Health and Long-Term Care, to allow community...

March 16, 2010: Oncology Medication Safety Self-Assessment
The Institute for Safe Medication Practices Canada (ISMP Canada), the Institute for Safe Medication Practices (ISMP; US), and the International Society of Oncology Pharmacy Practitioners (ISOPP)...

February 3, 2010: News Release - Bar coding for improved medication safety in Canada one step closer
National consensus reached on Joint Technical Statement for drug products Toronto, Canada - A pan-Canadian initiative was announced today that will ultimately have a major impact on...

December 30, 2009: Incidents Reported with Spiriva Capsules and Inhalation Device
As of December 2009, ISMP Canada has received 24 reports of Spiriva (tiotropium bromide monohydrate) being taken orally instead of by inhalation. In addition, there have been 2 reports of...

December 16, 2009: Medication Incident Involving Tamiflu (oseltamivir) at Transition of Care
ISMP Canada received a report about a school-aged child who inadvertently received Tamiflu (oseltamivir) 150 mg orally twice daily, instead of the appropriate weight-based dose of 60 mg twice...

November 2009: Reported Look-Alike Concerns with Labelling for Sodium Chloride 0.9% and Hypertonic Sodium Chloride IV Solutions Lead to Change
ISMP Canada received a near-miss report where sodium chloride 5% was inadvertently used in a pharmacy for admixing a medication instead of the intended sodium chloride 0.9% (i.e., normal saline)....

November 2009: Working with Consumers to Prevent Medication Incidents
ISMP Canada is developing a consumer-focused medication safety website ( www.SafeMedicationUse.ca ) that will provide a mechanism for consumers to report medication incidents. The site will also...

September 2009: FDA Alerts the Healthcare Community About Patient Deaths from Injection of Topical Epinephrine
Full FDA Safety Alert: www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=90#10 Watch the two-minute FDA video:...

ISMP Canada and Canadian Patient Safety Institute Team Up with GS1 Canada to Advance Patient Safety in Canada
Two of Canada’s patient safety organizations – Institute for Safe Medication Practices Canada (ISMP Canada) and Canadian Patient Safety Institute (CPSI) are collaborating with GS1...

August 2009: Report of Incorrect Glucose Tolerance Testing Product Received and Administered
A healthcare organization received bottles of glucose solution containing 75 grams of glucose, rather than solutions containing 100 grams of glucose as ordered from the distributor. The following...

August 2009: A Reported Concern that Xarelto Looks and Sounds Like Xatral
ISMP Canada has received a report of concern about the look-alike, sound-alike potential between the newly marketed Xarelto (brand name for rivaroxaban) and Xatral (brand name for alfuzosin...

Education Announcement: Analyzing Medication Incidents Effectively to Enhance Medication Safety
ISMP Canada, in collaboration with the United States Pharmacopeial Convention (USP), is pleased to offer a one-day interactive program on September 21, 2009, providing vital information on how to...

August 2009: Draft Document Outlines a Strategy for Consumer Involvement in the Canadian Medication Incident Reporting and Prevention System
The Institute for Safe Medication Practices Canada (ISMP Canada) is currently consulting with stakeholders on a strategy to strengthen the involvement of consumers in the Canadian Medication...

May 2009: Automated Identification of Pharmaceutical Products in Canada
The Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI), following broad consultation, jointly endorse the adoption of the GS1 global...

April 21, 2009: Community Pharmacy Medication Safety Assessment Program
The Medication Safety Self-Assessment® (MSSA) for Community/Ambulatory Pharmacy was developed to guide individual community pharmacies in identifying opportunities for medication safety...

March 2009 - NEW: Version 2 of the Operating Room Medication Safety Checklist®
ISMP Canada is pleased to announce the release of Version 2 of the Operating Room Medication Safety Checklist. This checklist facilitates knowledge translation of medication safety principles into...

January 29, 2009: Health Canada Advisory on Cough and Cold Medicine for Children
Health Canada has issued an advisory on the use of cough and cold medications for children. Health Canada is requiring manufacturers to re-label over-the-counter cough and cold medicines that have...

January 23, 2009: Canadian Failure Mode and Effects Analysis Framework Proactively Assessing Risk in Healthcare
ISMP Canada has developed the Canadian Failure Mode and Effects Analysis Framework® - Proactively Assessing Risk in Healthcare with support from Health Canada, through the Canadian Medication...

July 28, 2008: Pharmaceutical Bar Coding to Improve Patient Safety
On January 24, 2008, a stakeholder invitational roundtable, co-chaired by the Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI), was...

April 8, 2008: World Health Organization Recommendations for Vincristine
Vincristine, a chemotherapy agent, should always be administered intravenously, never by any other route. On July 7, 2007, a 21-year-old woman died in Hong Kong after this drug was inadvertently...

March 2008: ALERT: Recent Change in Rituximab (Rituxan®) Labelling Leads to Reports of Mix-ups
ISMP Canada has received 6 reports regarding the new labelling for rituximab (Rituxan®). Four of these reports involved mix-ups between rituximab and trastuzumab (Herceptin®)...

March 2008: FDA Alert Requests that Prescribing Information for Desmopressin Be Updated with New Information
Following a review of 61 postmarketing cases of hyponatremia-related seizures associated with administration of desmopressin, the US Food and Drug Administration (FDA) issued an alert and asked...

December 2007: Risk Assessment Program for Medication System Safety in the Long-Term Care Setting
A new risk assessment program has been developed by ISMP Canada to assist and guide individual long-term care facilities in identifying opportunities to improve their medication-use systems. The...

December 2007: Positive Response from Manufacturer to Your Reports
A number of facilities have reported concerns about the look-alike labelling and packaging of the following parenteral products (Figure 1): dimenhydrinate 50 mg/mL, 5 mL vial diltiazem 5...

December 2007: Cheers Award Announcement
At the CHEERS Awards Dinner on December 4, 2007, Special Recognition was presented to Robert Lam of ISMP Canada for his tremendous contributions to medication safety. A full list of award...

November 2007: Manufacturer Removes Logo to Enhance Medication Safety
Pharmaceutical Partners of Canada (PPC) recently revised the labelling of its 10 mL format of calcium gluconate. Specifically, the PPC logo has been removed from the label in an effort to make the...

November 2007: Enhanced Labelling of Neuromuscular Blocking Agents Makes a Difference
Ideal features for packaging and labelling of neuromuscular blocking agents were discussed during a collaborative meeting convened by ISMP Canada in 2006. Since then, several manufacturers of...

August 2007: TWO POSTIONS AVAILABLE: Full time medication safety specialist
LOCATION: ISMP Canada, Toronto ON JOB RESPONSIBILITIES: Working as part of an interdisciplinary team, the medication safety specialist will: Lead/support projects related to ISMP...

May 2007: Fluorouracil Root Cause Analysis Report Released
ISMP Canada was contracted by the Alberta Cancer Board to conduct a root cause analysis of a case of fatal fluorouracil overdose. The report of this analysis is now released and available from the...

May 2007: National Survey: Concentrated Potassium Chloride. Deadline Extended until May 25, 2007.
As part of a knowledge translation research project to evaluate the practices for handling concentrated potassium chloride, ISMP Canada in partnership with a patient safety research team, has asked...

May 2007: Second Edition of Medication Errors Textbook Now Available
The expanded 600+ page book, edited by Michael R. Cohen, president of ISMP, brings together experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about...

March 2007: ALERT: Zytram XL Name Looks and Sounds Like Zyban
ISMP Canada has received a report of concern about a newly marketed product with the brand name Zytram XL. Zytram XL is the brand name for tramadol hydrochloride controlled release tablet. Zytram...

December 2006: Look-Alike Product ALERT
Concentrated Potassium Chloride (10mL) and Heparin Lock Flush Solution 10 units/mL (10 mL) ISMP Canada has received two near miss reports describing replenishment of patient care area...

December 2006: ALERT: Generic Fentanyl Patches
A recent report to ISMP Canada raised awareness that drug name and strength are not printed on generic fentanyl patches manufactured by ratiopharm ( Figure 1 ); this information is printed only on...

December 2006: Medication Safety Self-Assessment® (MSSA)
The following medication safety self-assessment programs are available from ISMP Canada: 1. Medication Safety Self-Assessment (MSSA) for Hospitals, Canadian Version II 2. Medication...

October 2006: Collaboration between CSHP and ISMP Canada
The Canadian Society of Hospital Pharmacists (CSHP) and ISMP Canada have signed a Memorandum of Understanding to formally recognize their close working relationship and their mutual commitment to...

October 2006: A Picture Can Be Worth a Thousand Words
ISMP Canada has upgraded the web-based medication incident reporting program for individual practitioners . Practitioners can now upload and submit pictures (e.g., photographs of product packaging...

October 2006: Look-alike/Sound-alike Drug Name Alert
Trosec looks and sounds like Losec and Prozac. ISMP Canada has received three reports of concerns with the newly marketed product trospium chloride (Trosec) 20 mg, an antispasmodic marketed...

August 2006: 12-Month Fellowship on Safe Medication Management
ISMP Canada offers specialty fellowship learning and training in medication safety. The fellowship curriculum includes: orientation to error reporting systems learning about principles...

August 2006: Canadian Anesthesiologists Society Commitment to Sharing Information about Medication Incidents
The Canadian Anesthesiologists Society (CAS) web homepage ( www.cas.ca ) now provides a link to the individual practitioner reporting component of the Canadian Medication Incident Reporting and...

July 2006: 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...

July 2006: 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....

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...

June 2006: 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...

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...

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...

February 2006: Manufacturer Recall of Octreotide Acetate Omega 500 g/mL Labelling Error
Health Canada recently issued a warning relating to the recall of Octreotide Acetate Omega 500 g/mL from lot #5J970. Some vials from this lot may mistakenly contain fluphenazine, an antipsychotic...

December 2005: ISMP Canadas Commitment to Patient Safety Reseach
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...

October 2005
Labelling and Packaging Issues of Pharmaceuticals Meeting with Stakeholders A collaborative meeting of stakeholders, co-led by ISMP Canada and the Canadian Patient Safety Institute...

October 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...

May 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...

April 2005: Safety Alert
Peritoneal Dialysis Solutions with Icodextrin (Extraneal) Can Lead to False Elevations in Blood Glucose Monitor Readings ISMP Canada has received two reports from hospitals, one involving...

May 2004: FMEA Workshops
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...

April 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...

February 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...

September 2003: Look-Alike Product Alert
A hospital has reported a near-miss where magnesium sulfate was almost administered instead of sodium chloride 0.9% as a flush solution. As shown in this issue of the ISMP Canada Safety Bulletin...

August 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...

July 2003
Slide presentations from "The Next Step for Ontario Hospitals" meeting can be viewed here .

June 2003
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...

January 2003
The Ontario Ministry of Health and Long Term Care has recently provided support and funding to ISMP Canada to establish the Medication Safety Support Service for Ontario hospitals. The first...

October 2002
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,...

September 2002: Press Release - Patient safety in hospitals to be enhanced
TORONTO, Sept. 4 /CNW/ - The safety of patients will soon be enhanced with two new, innovative partnerships, announced Health and Long-Term Care Minister Tony Clement. One is a partnership with the...

August 2002: SOUND-ALIKE / LOOK-ALIKE Drug WARNING
ISMP Canada has received correspondence from several health care professionals expressing concern about the name of a recently approved product Pegetron ® . There is potential for confusion...

May 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...

April 2002: Safety Brief Product Look-Alike WARNING
ISMP Canada has received two simultaneous reports of near misses due to the similarities in packaging between (a) the AstraZeneca Xylocaine 4% sterile solution 5mL vial used for retrobulbar...

February 2002
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 .

September 2001
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...

July 2001
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...

April 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.

April 2001
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...

April 2001
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...

March 2001
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...

January 2001
Abboject products from Abbott Laboratory have been available to Canadian hospitals since the middle of December 2000. Now Canadian healthcare professionals have a choice...

November 2000
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...

November 2000
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...

November 2000
Abbott Laboratories has set a timeline for the re-worked Abboject products.

October 2000
ISMP Canada has become aware of a potential problem with using the Abbott Lifeshield product line. Please see the Lifeshield support page

August 2000
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...

June 2000
The On-going working relationship with other healthcare organizations has been updated.

April 2000
The ISMP-Canada web site is published.

March 2000
The organization's vision, mission statement, and goals are formally approved by the board.

January 2, 2020: Auditor's Report Finds That More Can Be Done To Improve Patient Safety In Ontario


January 1, 2020: ECRI and ISMP (US) join forces to create one of the largest patient safety entities in the world