ISMP (US) Contact Us Feedback

ISMP Canada News

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 misinterpretation of critical information on the label. The practitioner misunderstood the information provided and believed the bag contained 1 mg of HYDROmorphone. As a result, the entire content of the bag (which contained 50 mg of HYDROmorphone) was administered as a bolus. The error was discovered after the patient was found to have an altered level of consciousness; naloxone was given. Listen to the Synopsis ...  |  Read more ...