ISMP (US) Contact Us Feedback
     Search:  
   

ISMP Canada News

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 and/or inadvertent injection. This practice has resulted in potentially deadly and preventable medication safety incidents. Continuing concerns related to inadvertent injection of chlorhexidine solution intended for topical application serve as a reminder of the need to review practices in patient care areas such as the operating room, where both topical and injectable solutions are used.   Read more ...

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 Self-Assessment (MSSA) during the months of December 2018 and January 2019. This new assessment program highlights the five pharmaceutical "never events" included in the Never Events for Hospitals in Canada Report as well as safety strategies to prevent other critical incidents with high-alert medications.  Read more ...

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 members, and other caregivers to ask questions about medications or talk about any concerns. SafeMedicationUse.ca received a report about a resident in a long-term care home who was mistakenly started on a medication called trazodone. This sleep medication should have been given to someone else with a similar name. The mistake was found a year later when a medication review took place. Because of the review, the error was noticed, and the medication was stopped.  Read more ...

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 scheduling and documentation, eMAR systems are intended to reduce medication errors through efficient workflow management and elimination of some of the error-prone paper-based processes. However, failure to incorporate human factors principles into the design of such systems, as well as a lack of standardization, can lead to new errors. As part of an ongoing collaboration with a provincial death investigation service, ISMP Canada received a report that highlights opportunities to improve the design and presentation of key information in eMAR systems to prevent similar errors.  Read more...

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 may not get the right dose. Without the right dose, there can be unwanted effects, such as dangerously high blood sugar levels.  Read more ...

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 disease. ISMP Canada conducted a multi-incident analysis of vaccine errors as well as a recent failure modes and effects analysis after observing several community vaccine clinics. The systemic vulnerabilities identified through these analyses have the potential to lead to errors and highlight opportunities for system improvements. This bulletin shares learnings to help inform safe medication practices in vaccine clinics.  Read more ...