Medication Safety Resources for Coroners and Medical Examiners

This web page has been developed to provide Coroners and Medical Examiners with useful information regarding death investigation in drug-related cases, including access to a secure, direct, one-way portal for the purpose of sharing information and lessons learned from investigation of medication incident associated deaths.

ISMP Canada has worked with a number of provincial and territorial Coroner's and Medical Examiner's Offices on both a formal and informal basis, including case reviews, committee membership, and providing expert witness testimony for inquests.

Analysis of case data from Coroner and Medical Examiner investigations provides insights into underlying contributing factors and can suggest opportunities for improvement that may be broadly applicable, with the potential to reduce the likelihood of future similar deaths.

Resources for Coroners and Medical Examiners

ISMP Canada Checklist for Investigating Deaths Involving Medication Incidents

• ISMP Canada Checklist - English, French

ISMP Canada Case Review Services Available for Offices of the Chief Coroner and Chief Medical Examiner

• ISMP Canada Case Review Services

ISMP Canada Publications and Resources

Analysis of Data from 2012-13 Health Canada Project:

A collaborative medication safety project was undertaken with 4 provincial Offices of the Chief Coroner and Chief Medical Examiner in 2012-2013, with funding support from Health Canada. This project generated a number of publications and other resources, including the following:

• Deaths Associated with Medication Incidents: Learning from Collaborative Work with Provincial Offices of the Chief Coroner and Chief Medical Examiner
• Deaths Associated with Medication Incidents Occurring Outside Regulated Healthcare Facilities
• Report: Opioid-Related Deaths Associated with Medication Incidents. Findings of a Multi-Incident Analysis - Nov 2014

ISMP Canada Safety Bulletins Related to Analysis of Medication Error Associated Deaths:

• ISMP Canada Safety Bulletins (by drug class)

ISMP Canada Safety Bulletins Related to Analysis of Medication Error Associated Deaths (by drug class)

Anesthetics

• Epidural Medications Given Intravenously May Result in Death - Oct 2006
• System Vulnerabilities across the Spectrum of Care: Another Mix-up between Choral Hydrate and Potassium Chloride - Oct 2005
• Risk of Tragic Error Continues in Operating Rooms - Oct 2004

Anticoagulants

• Death Associated with Inadequate Reassessment of Venous Thromboembolism Prophylaxis at and after Hospital Discharge - July 2015
• Appropriate Anticoagulant Use - A Patient Safety Priority- Dec 2006
• A Need to "Flush" Out High Concentration Heparin Products - Oct 2004

Cardiac Medications

• Infantile Hemangioma Treated with Propranolol: Learning Opportunities from an Infant Death - Feb 2016
• Tragic Error with a Compounded Pediatric Formulation - Shared Learning - Aug 2005
• ALERT: Fatal Outcome after Inadvertent Injection of Epinephrine Intended for Topical Use - Mar 2009
• Tragic Error with a Compounded Pediatric Formulation - Shared Learning - Aug 2005

Chemotherapeutics and biologics

• Severe Harm and Deaths Associated with Incidents Involving Low-Dose Methotrexate - Sep 2015
• Analysis of Incidents Involving Oral Chemotherapy Agents - Apr 2015
• Vulnerabilities of Electronic Prescribing: Height and Weight Mix-up Leads to an Incident with Panitumumab - July 2010
• Incidents of Inadvertent Daily Administration of Methotrexate - Apr 2008
• Fluorouracil Incident Root Cause Analysis: Follow-Up - Aug 2007

Diabetic medications

• Inadvertent Administration of Insulin to a Nondiabetic Patient - Aug 2010
• Unexpected Hypoglycemia: Consider Medication Error in the Differential Diagnosis - Mar 2007

Drug Interactions

• Preventable Death Highlights the Need for Improved Management of Known Drug Interactions - May 2014

Intravenous fluids and Electrolytes

• Hospital-Acquired Acute Hyponatremia: Two Reports of Pediatric Deaths - Oct 2009
• Desmopressin Incidents Identify a Need to Evaluate Monitoring Protocols - Mar 2008
• Concentrated Potassium Chloride: A Recurring Danger - Mar 2004
• More on Potassium Chloride - Nov 2003

Medication delivery devices

• Smart Pumps Need Smart Systems - Feb 2014
• Tunnelled Intrathecal Catheter Mistaken as Central Line - Oct 2005

Opioids

• An Opioid-Related Death in a Small Community Hospital - Dec 2014
• Deaths Associated with Opioids - Highlights of a Multi-Incident Analysis, sidebar in: Decimal Point in New Strength of HYDROmorph Contin Leads to an Opioid Overdose - Nov 2014
• HYDROmorphone remains a high-alert drug - Feb 2013
• Opioid-Related Incident in a Long-Term Care Home - Dec 2012
• Fentanyl Patch Linked to Another Death in Canada - Nov 2007
• Meperidine (Demerol®): Issues in Medication Safety - Aug 2004
• An Omnipresent Risk of Morphine-Hydromorphone Mix-ups - Jun 2004

Other

• Death Due to Pharmacy Compounding Error Reinforces Need for Safety Focus - May 2017
• Gaps in Medication Monitoring May Contribute to Death - February 2017
• ALERT: Interruption of Epoprostenol (Flolan) Infusion Leads to Patient's Death - Mar 2011