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 Canadian Medication Incident Reporting and Prevention System. The goal of this national program is to collect medication incidents and near misses from healthcare practitioners and institutions in Canada so adverse medications events can be investigated, analyzed and information for error prevention strategy can be disseminated to the Canadian Healthcare System. The data collected will be invaluable in learning, conducting trending analysis and facilitating research on patient safety.
- ISMP Canada's first Medication Safety Support System project 'Removal of Concentrated Potassium Chloride (KCl) from Patient Care Areas in Ontario Hospitals' was very successful. Majority of Ontario hospitals have removed concentrated potassium chloride from their patient care areas as a result of this initiative. ISMP Canada continues to support the KCl initiative. For more information please go to the 'KCl Support' section.
- A three-day Coroner’s inquest was completed on February 12, 2004 in Peterborough to investigate the death of a hospital patient who died on January 21, 2002 after receiving concentrated potassium chloride by direct intravenous injection. The jury’s primary recommendation stressed the need for the complete removal of concentrated potassium chloride from patient care areas in hospitals. A second key recommendation was that the manufacturers of concentrated potassium chloride should package their products in a format highly distinguishable from other drug products, using packages with clear and obvious warning labels. The lawyers representing all parties, including the deceased patient’s son, agreed with all the recommendations presented by the expert witness, David U, President and CEO of ISMP Canada. A detailed list of these recommendations will be posted on the ISMP Canada website once officially released by the coroner’s office.
- Joining Ontario, the following provinces including Nova Scotia, Manitoba, and Saskatchewan have established formal collaborations with ISMP Canada who will provide medication safety services. These services include: participation in the Medication Safety Self Assessment (MSSA) program, the ISMP Newsletter and the Canadian Safety Bulletins. ISMP Canada would welcome the opportunity to work with the Ministry and Department of Health in the other provinces.
- The Medication Safety Self Assessment (MSSA) is a tool to assist hospitals in reviewing their current processes and determining areas for improvement. The Canadian Council on Health Services Accreditation has endorsed the use of this self assessment tool as reflected in their new standard guideline 14.5. The best approach is to have participating hospitals from within the same province complete the MSSA to allow aggregate data to be compared from within their own province. For more information please see the MSSA page.
- Analyze-ERR® is a medication error reporting and analysis software program available to Canadian hospitals. This program allows hospitals to input medication incidents and analyze contributing factors to ensure a proactive approach to medication safety and to facilitate a culture of safety. Additional information can be accessed from the Analyze-ERR page.
- ISMP Canada welcomes their first Fellow, Julie Greenall. Julie has taken a one year leave of absence from her position as Manager, Pharmacy at the North Simcoe Hospital Alliance (Midland/Penetanguishene) to acquire more in depth knowledge of medication safety issues with the goal of improving patient safety.
- ISMP Canada undertook the Infusion Pump Survey project in 2003 and the preliminary results in graphical representation are posted on the Infusion Pump Survey page.
