Safe handling of cytotoxics: guideline recommendations.

Background: This evidence-based practice guideline was developed to update and address new issues in the handling of cytotoxics, including the use of oral cytotoxics; the selection and use of personal protective equipment; and treatment in diverse settings, including the home setting.

Methods: The guideline was developed primarily from an adaptation and endorsement of an existing guideline and from three systematic reviews. Before publication, the guideline underwent a series of peer and external reviews to gather feedback.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

Background: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood.

Objective: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors.

Methods: The study focused on medication verification and administration in an ambulatory chemotherapy setting.

Using breakthrough series collaborative methodology to improve safe delivery of chemotherapy in Ontario.

Purpose: Chemotherapy delivery is complex, involving multiple providers across settings to deliver safe, effective care. Cancer Care Ontario initiated a provincial breakthrough series collaborative, based on methodology from the Institute for Healthcare Improvement (IHI), to improve the safe delivery of chemotherapy, from ordering through preparation and administration.

Methods: Over the 1-year period of the collaborative, three in-person sessions educated participants on improvement methodology.

Medication reconciliation: the priority that isn't.

Medication reconciliation is a crucial step in safe care, but it is often done inconsistently or inadequately, or missed altogether. This can be dangerous and even deadly for patients, and expensive for the system. In this article, the authors discuss the current status of medication reconciliation in Canada, barriers to its implementation and steps healthcare organizations across the country are taking to introduce medication reconciliation.

Medication reconciliation: a prescription for safer care.

Four national healthcare organizations - Accreditation Canada, the Canadian Institute for Health Information, the Canadian Patient Safety Institute and the Institute for Safe Medication Practices Canada - recently collaborated to better understand and share comprehensive information about medication reconciliation in Canada. This article summarizes the key findings of their joint report titled Medication Reconciliation in Canada: Raising the Bar and profiles innovative approaches and tools for healthcare organizations across Canada.

Multiple Intravenous Infusions Phase 2b: Laboratory Study.

Background: Administering multiple intravenous (IV) infusions to a single patient via infusion pump occurs routinely in health care, but there has been little empirical research examining the risks associated with this practice or ways to mitigate those risks.

Objectives: To identify the risks associated with multiple IV infusions and assess the impact of interventions on nurses' ability to safely administer them.

Data Sources And Review Methods: Forty nurses completed infusion-related tasks in a simulated adult intensive care unit, with and without interventions (i.

Multiple Intravenous Infusions Phase 2a: Ontario Survey.

Background: Research conducted in earlier phases of this study prospectively identified a number of concerns related to the safe administration of multiple intravenous (IV) infusions in Ontario hospitals.

Objective: To investigate the potential prevalence of practices or policies that may contribute to the patient safety risks identified in Phase 1b of this study.

Data Sources And Review Methods: Sixty-four survey responses were analyzed from clinical units where multiple IV infusions may occur (e.

Drug name alert: potential for confusion between pradax and plavix.

In this article, the authors highlight an incident that involved a mix-up between the oral anticoagulant medication Pradax (dabigatran etexilate) and the antiplatelet medication Plavix (clopidogrel). Because critical care nurses may admit or care for patients who are receiving (or have received) one of these medications, it is important that they be aware of the potential for confusion between these two drug names throughout the medication-use process.

ALERT: mix-ups between conventional and lipid formulations of amphotericin B can be extremely dangerous.

In this column, the authors review Amphotericin B incidents reported Although amphotericin B may be less commonly used today because to ISMP Canada. In particular, we focus on incidents reported to have of alternative antifungal agents available, incident reports suggest resulted in patient harm due to mix-ups between the conventional there continues to be a need to alert practitioners to the different (non-lipid)formulation and lipid formulations of amphotericin B. formulations, and to implement system safety strategies.

Identification of medication safety indicators in acute care settings for public reporting in Ontario.

In healthcare settings, indicators are useful tools to assess the structure, process and outcomes of care. Moreover, when used to report to the public, indicators ensure greater transparency for our healthcare system. The purpose of this study was to identify in acute care settings three medication safety indicators that are suitable for public reporting in Ontario.

Community pharmacy incident reporting: a new tool for community pharmacies in Canada.

Incident reporting offers insight into a variety of intricate processes in healthcare. However, it has been found that medication incidents are under reported in the community pharmacy setting. The Community Pharmacy Incident Reporting (CPhIR) program was created by the Institute for Safe Medication Practices Canada specifically for incident reporting in the community pharmacy setting in Canada.

Hospital-acquired acute hyponatremia and reports of pediatric deaths.

Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.

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.

A near miss involving cyclophosphamide.

Reports of near miss incidents offer valuable learning opportunities. In this article, the authors highlight a near miss incident that occurred in an intensive care unit with the cytotoxic medication cyclophosphamide, for a non-oncology indication. The learning from this incident, including recommendations, is shared.

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.

Preventing substitution errors involving high-concentration heparin products.

Critical care practitioners routinely administer heparin for various indications (e.g., treatment of acute coronary syndrome, venous thromboembolism prophylaxis, line maintenance) and by various routes (e.

Medication safety... Your call to make a difference.

Making system improvements for safer medication use in hospitals requires leadership from the top of the organization. We need hospital administrative staff to believe in and support efforts for the promotion of a culture of patient safety. Individual staff in every discipline are also in a position to make significant contributions to safety in the system as a whole.

Epidural medications given intravenously may result in death.

Anesthetics, such as bupivacaine, intended for epidural analgesia can cause severe cardio- and neurotoxicity when inadvertently administered via the intravenous route. This article highlights a case report and the dangers associated with the inadvertent administration of an epidural solution intravenously. Multiple system-based strategies for prevention are provided.

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.

Medication error and patient safety.

A number of barriers to the enhancement of patient safety through a reduction of medication errors have been identified These include a blame culture; lack of leadership;lack of peer-review protection; and the absence of a collaborative voluntary national reporting system. The latter would provide oversight and help healthcare providers avoid recurrence of these adverse drug events stemming from human error.A voluntary practitioners reporting system similar to that promoted by the Institute for Safe Medication Practices Canada (ISMP Canada) has been shown to be successful in the United States in achieving the goal of enhancing patient safety.