Ontario Critical Incident Learning

To advance the patient safety agenda, in August 2011 the Ontario Ministry of Health and Long-Term Care issued a directive that hospitals must report critical incidents involving medications and intravenous fluids to the Canadian Institute for Health Information National System for Incident Reporting (NSIR). A critical incident is an "unintended event that occurs when a patient receives treatment in the hospital that results in death, or serious disability, injury or harm, and does not result primarily from the patient's underlying medical condition or from a known risk inherent in providing treatment".

ISMP Canada has been identified as the lead organization for analysis of the reported incidents. A multidisciplinary team reviews each submitted critical incident report to ensure effective identification of the contributing factors. In addition, ISMP Canada will periodically conduct aggregate analysis of reported incidents to provide a more in-depth assessment of events involving a particular medication or care setting. On the basis of these analyses, ISMP Canada will develop and disseminate outcome-directed recommendations, with an emphasis on high-leverage actions that take into account human factors engineering principles and the need to design systems with integrated safeguards.

Bulletins:

• Strengthening Medication Reconciliation (MedRec) at Discharge - Iss.18/2016
• Summary of 2015 Critical Incident Reporting Analysis - Iss.17/2016
• Critical Incidents - Disclosure to Patients and Families - Iss.16/2016
• High-Alert Medications Need Multiple Safeguards - Iss.15/2016
• Errors Continue with Amphotericin B - Iss.14/2015
• Resources to Sustain Incident Learning - Iss.13/2015
• Fluid Management - Iss.12/2015
• Multiple IV Infusions: Risks and Recommendations - Iss.11/2014
• Naloxone Saves Lives - Iss.10/2014
• Sharing Insulin Pens is a High-Risk Practice - Iss.9/2014
• Safe Pain Control in the Emergency Department - Iss.8/2014
• Smart Pumps Need Smart Systems - Iss.7/2014
• Monitoring Processes Contribute to Safe Use of Warfarin - Iss.6/2013
• Promoting the Safe Use of Insulin in Hospitals - Iss.5/2013
• Designing Effective Recommendations - Iss.4/2013
• Quality Medication Reconciliation Processes Are Critical - Iss.3/2013
• HYDROmorphone remains a high-alert drug - Iss.2/2013
• Mandatory Reporting—Can We Do Better? - Iss.1/2012

Analysis Reports:

• Ontario Hospital Critical Incidents Related to Medications or IV Fluids Analysis Report - 2015, 2014, 2013, 2012

Knowledge Translation Projects:

• Hospital to Home - Facilitating Safe Medications at Transitions Checklist
• Epidural Label Safety Checklist
• Insulin Use Interventions/Safeguards

Evaluation of ISMP Canada Activities:

• Case Study of the Institute for Safe Medication Practices Canada's Work on HYDROmorphone and Other Opioids

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Collaboration with the Ontario Drug Policy Research Network (ODPRN)

ISMP Canada is collaborating with the Ontario Drug Policy Research Network (ODPRN) to disseminate medication safety-related studies. The ODPRN is a province-wide network of researchers who provide timely, high quality, drug policy relevant research to decision makers. The following ODPRN research minute publications provide summaries of selected medication safety-related studies.

• Ontarians Using Chronic Opioids at Dangerous Doses - 2015
• The Incidence of Neonatal Opioid Syndrome has Increased Dramatically in Ontario in Past 2 Decades - 2015
• Therapeutic Notes have Limited Impact on Physician Prescribing Behaviours for some Drugs - 2014
• Opioid-Related Mortality Leads to Considerable Burden in Ontario - 2014
• High opioid doses associated with risk of road trauma among drivers in Ontario - 2013
• Cholinesterase inhibitors not associated with an increased risk of upper gastrointestinal bleeding - 2013

Webinars

• Supporting Medication System Safety and Preparing for your Accreditation Survey: Applying New Tools for Home and Community Care and Acute Care - 2015/06/23 - (Handouts) (Recording)
• Medication Safety Learning from Ontario Coroners' Cases - Focus on Opioids - 2013/03/06
• Hospital Related Deaths: The Role of the Coroner's Office in Enhancing Patient Safety - 2013/01/31

Frequently Asked Questions

Dangerous abbreviations, symbols and dose designations

• Is there an update to ISMP Canada's Do Not Use Dangerous Abbreviations, Symbols and Dose Designations?
• Can the abbreviation "D/C" be used to indicate "discontinue"?
• Can the abbreviation "OD" be used in patient charts to indicate "overdose"?

TALLman Lettering

• Can our institution add additional drug names to ISMP Canada's TALLman Lettering for Look-Alike/Sound-Alike Drug Names in Canada? Would ISMP Canada consider adding to the current list?

Independent Double Checks

• What is the best way to apply the practice of "independent double checks" for high-risk medications when there is only one nurse working?

Administration of Multiple Doses from a Single Ampoule

• Is it considered a safe practice to administer multiple doses of medication from a single syringe?

Disposal of Fentanyl Patches

• How should fentanyl patches be safely discarded?

Range Dose Orders

• How should nurses handle prescriber orders that give range doses?

Using ISMP Canada publications

• I would like to use an ISMP Canada resource in a publication. Do I need copyright permission?

Rapid Sequence Intubation Kits

• What is the best approach to restricting neuromuscular blocking agents while making them accessible for rapid sequence intubation kits?

Medication Incident Reporting

• How do I report a medication incident to ISMP Canada?