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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 compounded medications. As part of ongoing collaboration with a provincial death investigation service, ISMP Canada received a report regarding the death of a child who had ingested a prescribed, compounded oral liquid suspension that contained the wrong medication. This bulletin shares some of the contributing factors identified in the case analysis, and provides recommendations to guide pharmacies and other compounding facilities, as well as standards-setting organizations in their efforts to reduce the likelihood of similar errors in the future.  Read more ...