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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 medication regimen that included both clozapine and fluvoxamine. A supply shortage of fluvoxamine led to a cascade of events that resulted in the individual's decompensated psychosis. This bulletin shares identified opportunities and related recommendations to avoid similar tragedies. Listen to the Synopsis ...  |   Read more ...