ISMP Canada Safety Bulletins

The ISMP Canada Safety Bulletins are designed to disseminate timely, targeted information to reduce the risk of medication incidents. The bulletins are available from this page.

ISMP Canada Publications/Position Statements

• Multiple IV Infusions Project: Mitigating Risks Associated with Multiple IV Infusions
• Error management - Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model
• Optimizing Communication about Medications at Transitions of Care in Ontario
• Joint CAPCA and ISMP Canada Project - Application of TALLman Lettering for Drugs Used in Oncology
• Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model
• Identification of Medication Safety Indicators for Public Reporting
• Pharmaceutical Bar Coding to Improve Patient Safety: Options for Technical Standards in the Canadian Environment
  (Proceedings of a Stakeholder Invitational Roundtable, June 2008)
• Pharmaceutical Bar Coding to Improve Patient Safety - Options for Technical Standards in the Canadian Environment
  (Roundtable Discussion Paper, January 2008)
• Striking a Balance: Facilitating Access to Patient Safety Data While Protecting Privacy Through Creation of a National Harmonized Standard
• Canadian Root Cause Analysis Framework - A tool for identifying and addressing the root causes of critical incidents in healthcare
• ISMP Canada Independent Double Check Usability Test Report
• ISMP Canada Position Paper — Guidelines for Sharing Medication Incident Data in the Era of Ontario's PHIPA and QCIPA
• Drug Safety in Canada — Letter to CMAJ re Bupivacaine
• Is Consent Required For Publication of Medical Errors?
• Medication Errors and Risk Management in Hospitals
• Ontario Pharmacists Can Help Provide a Safer Medication Use System
• Medication Error Reporting Systems: Problems and Solutions

Publications in CACCN Dynamics

The following articles appeared in CACCN Dynamics, a journal published by the Canadian Association of Critical Care Nurses.

• Fall 2011 - Drug name alert: Potential for confusion between Pradax and Plavix
• Spring 2011 - ALERT: Mix-ups between conventional and lipid formulations of amphotericin B can be extremely dangerous
• Fall 2010 - Hospitals report on medication safety in Canada
• Spring 2010 - Hospital-acquired acute hyponatremia and reports of pediatric deaths
• Winter 2009 - National Collaborative: Top five drugs reported as causing harm through medication error in pediatrics
• Fall 2009 - Pharmaceutical bar coding: Moving forward in Canada
• Summer 2009 - ALERT: Revatio is another brand name for Sildenafil
• Spring 2009 - A near miss involving cyclophosphamide
• Winter 2008 - Prefilled syringes of epinephrine and compatibility with intravenous tubing: Learning from an incident
• Fall 2008 - Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols
• Spring 2008 - Preventing substitution errors involving high-concentration heparin products
• Winter 2007 - Enhancing safety with potassium phosphates injection
• Fall 2007 - Epidural medications given intravenously may result in death
• Spring 2007 - Neuromuscular blocking agents: Enhancing safety by reducing the risk of accidental administration
• Winter 2006 - Secondary lines require "primary" attention
• Fall 2006 - To Err is Human,To Share is Divine
• Spring 2006 - Communication of medication orders by telephone – “Writing it right”
• Winter 2005 - The challenge: Balancing competency and error management
• Fall 2005 - Dangerous abbreviations: “U” can make a difference!
• Spring 2005 - Meperidine (Demerol^®) safety issues
• Winter 2004 - Reports of epidural infusion errors
• Fall 2004 - Preventing narcotic adverse events in critical care units
• Spring 2004 - High alert: Preventing insulin errors

Publications in Healthcare Quarterly

Abstracts of articles that appeared in Healthcare Quarterly.

• 2010 Vol. 13 Special Issue - Community Pharmacy Incident Reporting: A New Tool for Community Pharmacies in Canada
• 2010 Vol. 13 Special Issue — Identification of Medication Safety Indicators in Acute Care Settings for Public Reporting in Ontario
• 2008 Vol. 11 Special Issue — Development of Canadian Safety Indicators for Medication Use
• 2008 Vol. 11 Special Issue — Using Human Factors Methods to Evaluate the Labelling of Injectable Drugs
• 2008 Vol. 11 Special Issue — Medication Safety in Operating Room: Teaming Up to Improve Patient Safety
• 2008 Vol. 11 Special Issue — Using ISMP Canada's Framework for Failure Mode Effect Analysis: A Tale of Two FMEAs
• 2006 Vol. 8 Special Issue — Implementing System Safeguards to Prevent Error-Induced Injury
  with Opioids (Narcotics): An ISMP Canada Collaborative
• 2005 Vol. 8 Special Issue — An Effective Tool to Enhance a Culture of Patient Safety
  and Assess the Risks of Medication Use Systems
• 2005 Vol. 8 No. 4 — Is Consent Required For Publication of Medical Errors?

Publications in Pharmacy Connection

Pharmacy Connection is the official publication of the Ontario College of Pharmacists.

• Fall 2011 — Medication Safety in Pediatrics
• July-August 2010 — Medication Safety in Community Pharmacies
• March-April 2010 — Enhancing MedsCheck, improving outcomes
• November-December 2009 — Hands-on learning key to co-op students
• September-October 2008 — Medication Incidents Reported to OCP: A Review by ISMP Canada
• November-December 2007 — New Medication Safety Assessment Program for LongTerm Care
• May-June 2005 — The Role and Impact of the Institute for Safe Medication Practices Canada

Publications in the Canadian Pharmacists Journal (CPJ)

Canadian Pharmacists Journal is the official publication of the Canadian Pharmacists Association. The following articles appeared in the SAFETY FIRST column.

• May/June 2007 -- Failure mode and effects analysis: A tool for identifying risk in community pharmacies
• Sep/Oct 2006 — Take a proactive approach with the Medication Safety Self-Assessment
• May/June 2006 — Using root cause analysis to determine the system-based causes of error
• Sep/Oct 2005 — Overdose a risk of transdermal patch in diverse settings

Publications in CPSO Dialogue

Dialogue is a bi-monthly publication by The College of Physicians & Surgeons of Ontario.

• September 2006 — Screening for Inappropriate Medications in the Elderly
• March 2006 — Sharing of Information among Health-Care Professional Is Critical to Patient Safety

Publications in Pharmacy Practice

• September 2007 — Prescription for Safety

Publications in the Canadian Journal of Hospital Pharmacy

The following articles were published in a regular column that appears in the Canadian Journal of Hospital Pharmacy (CJHP).

Publications in Hospital News

The following articles were published in a regular column that appears in Hospital News.

Presentations

• CMIRPS Presentations for Virutal Forum, November 2, 2011
• Medication Safety 101 - April 2010
• Canadian Medication Incident Reporting and Analysis - April 2010
• Solution Development: Examining Possible Interventions - August 2010
• Medication Safety Self Assessment for Community/Ambulatory Pharmacy - May 2011
• SHRTN Communities of Practice on Medication Safety in LTC webinars:
  • Part 1: The Changing Culture in Healthcare, September 22, 2011 (slide presentation)
  • Part 2: Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety, October 20, 2011 (slide presentation | view recording)
  • Part 3: How MedsCheck for Long-Term Care Can Improve Medication Management in Long-Term Care Homes, November 17, 2011 (slide presentation | view recording)
  • Part 4: An Update from Accreditation Canada on Medication Reconciliation in Long-Term Care, February 16, 2012 (slide presentation | view recording)
  • Part 5: Contemporary Issues in the Use of Psychotropic Medications in Long-Term Care, March 21, 2012 (slide presentation | view recording)
• ISMP Canada Presentation for ORNAO Conference, April 27, 2010
• Canadian Medication Incident Reporting and Analysis, ISMP Canada Medication Safety Conference (Long Term Care), Ottawa, March 11, 2009, slide presentation
• ISMP Canada Mental Health and Patient Safety OHA Conference, September 19, 2008.
• Medication Safety Panel Discussion: Oncology Medication Safety, October 19, 2008.
• ISMP Canada Anticoagulant Project Fall 07 with Carmine Stumpo (Toronto East General Hospital, Toronto).
• ISMP Canada Anticoagulant Project Fall 07 with Judy Chong (Royal Victoria Hospital, Barrie).
• ISMP Canada Anticoagulant Project Fall 07 with Ming Lee (York Central Hospital, Richmond Hill).
• ISMP Canada Anticoagulant Project Fall 07 with Patti Cornish (Sunnybrook Health Sciences Centre, Toronto).
• April 18, 2007 Conference for Ontario Healthcare Facilities, Toronto, Ontario
  On April 18, 2007 ISMP Canada held a Medication Safety Conference for Ontario Healthcare Facilities. This conference was attended by over 250 healthcare practitioners from Ontario. To access the conference proceedings in audio and video format please click on the link above. (Registration is required)
  
• MOHLTC - ISMP Canada's Medication Safety Support Service (MSSS) Initiatives for 2007/2008.
• 2007 CSHP Professional Practice Conference Workshop Slide Presentation
  Medication Reconciliation for Safer Health Care: Where Are We Now?
• Medication Safety: Lessons Learned, CINA 30^th Anniversary Conference, October 20, 2005
• Human Factors: From Theory to Critical Care Bedside, CACCN Conference Ottawa 2005
• Medication and System Safety in Long Term Care slide presentation 2005
• ISMP Canada Failure Modes and Effects Analysis (FMEA) slide presentation 2005
• Medication Safety: What You Cannot Afford to Ignore, CACCN Nursing Conference Banff, October 2004, slide presentation
• Medication Safety: The Important Role of Pharmacy Technicians, CAPT - Alberta Pharmacy Technician Conference 2004, slide presentation
• Patient Safety: Preventing Adverse Events, OHA Conference June 14, 2004, slide presentation
• 2004 CSHP Professional Practice Conference Workshop Slide Presentations
  "Applying Engineering Principles to Medication Safety – Making Sense of HFE, FMEA and RCA"
• July 2003 Next Step Meeting Slide Presentations

Posters

• Extending Hospital-Based Medication Incident Reporting to Enhance Medication Safety and Continuous Quality Assurance in Pharmacy Practice - February 2012
• Analysis of Medication Incidents in Community Pharmacy - July 2011
• Identification of Medication Safety Indicators in Acute Care Settings for Public Reporting in Ontario - March 2011
• Medication Incidents Involving Psychotropic Drugs: An Aggregate Analysis - January 2011
• Canadian Pharmaceutical Bar Coding Project Conference Poster - January 2010
• Analysis of Medication Incidents in Ontario - January 2010
• Conducting a Best Possible Medication History and Resolving Medication Discrepancies in the Community - October 2009
• Aggregate Analysis of Medication Incidents in Community Pharmacy - May 2009

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