Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach.

Purpose: To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting.

Methods: A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders.

Establishing an international baseline for medication safety in oncology: Findings from the 2012 ISMP International Medication Safety Self Assessment® for Oncology.

Background: In 2012, the Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada) collaborated with an international panel of oncology practitioners to develop the ISMP International Medication Safety Self Assessment® for Oncology. This self-assessment was designed to assist oncology practitioners in hospitals, ambulatory care centers, and office practice settings throughout the world to evaluate safe practices related to medication use in the oncology setting and to identify opportunities for improvement.

Instrument Design: The self-assessment consists of 175 items organized into 10 key elements subdivided into 18 core characteristics of safe medication use.

Hospitals report on medication safety in Canada.

Measurement of safety can be difficult. Given that incident reporting systems rely primarily on voluntary reporting and some types of medication incidents may occur rarely, lack of reports about a particular type of incident cannot be interpreted as evidence that the underlying causes are resolved. Proxy measurements, such as the level of implementation of evidence-based practices known to reduce the risk of a particular incident, may provide an indication of progress toward safer systems.

National collaborative: Top five drugs reported as causing harm through medication error in pediatrics.

The Canadian Association of Paediatric Health Centres (CAPHC) and the Institute for Safe Medication Practices Canada (ISMP Canada) are working collaboratively to enhance the safety of pediatric medication use. Eleven CAPHC member organizations submitted data on more than 4,000 medication incidents to ISMP Canada for the period October 2005 to June 2008, 305 of which were reported as resulting in harm. From this, the top five drugs causing harm through medication error and contributing factors to the incidents were identified.

ALERT: Revatio is another brand name for sildenafil.

In this column, the authors highlight a medication incident that occurred with Revatio (sildenafil), along with the learnings and recommendations from a previously published ISMP Canada Safety Bulletin. It is well-known to health care practitioners that use of nitroglycerin therapy is contraindicated in patients taking sildenafil (commonly known as Viagra). Many health care practitioners may be unaware that sildenafil is also marketed under the brand name Revatio for treatment of primary pulmonary hypertension or pulmonary hypertension secondary to connective tissue disease.

Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.

In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.

Using ISMP Canada's framework for failure mode and effects analysis: a tale of two FMEAs.

Patient safety concerns in healthcare are not new or unexpected, and one goal of all healthcare organizations is to provide the safest possible care for patients and their families. With that goal in mind, Annapolis Valley Health, a rural district health authority in Nova Scotia, identified the need to develop expertise in the use of failure mode and effects analysis (FMEA) as a tool to promote quality processes within the organization. Staff members were aware of the value of this type of analysis but also recognized that real learning would best be achieved through completing an FMEA of an existing process or situation, rather than through a simulation or staff training.

Implementing system safeguards to prevent error-induced injury with opioids (narcotics): an ISMP Canada collaborative.

Institute for Safe Medication Practices Canada (ISMP Canada) is involved in collaborative initiatives focusing on opioid safety in two Canadian provinces: Ontario and Alberta. Baseline survey responses from these provinces indicate opportunities for improvements to the opioid system that might be applicable nationally. Information about the Ontario project and preliminary analysis of follow-up survey results from that province are shared here, to increase awareness and create further national impetus for the enhancement of safeguards in the use and management of opioids.