Webinar

This one hour interactive webinar is designed to provide healthcare professionals and administrators with an overview of an ISMP Canada initiative to assess knowledge deficits amongst healthcare providers related to the safe and effective use of Hydromorphone.

Learning Objectives:

At the conclusion of this webinar, participants will be able to:

• describe the types of hydromorphone related incidents reported to ISMP Canada,
• recognize some of the contributing factors to errors involving Hydromorphone, and
• understand the purpose of the upcoming ISMP knowledge assessment survey and how individual practice sites and practitioners can participate.

Contact Us: webinars@ismp-canada.org

Speakers

Linda Poloway , BScPharm, FCSHP, Consultant to ISMP Canada Improving the safe use of hydromorphone has special meaning for Linda Poloway, a consultant pharmacist now working with ISMP Canada on this hydromorphone project. While serving as a Regional Director of Pharmacy, a mix up between morphine and hydromorphone resulted in a death of an emergency department patient. Most recently, Linda held a position as the Director, Patient Safety, with the Health Quality Council of Alberta where she led numerous provincial reviews of critical incidents, many of which involved medications. Medication safety continues to figure prominently in her activities as a consultant.

Lori Taylor, RN, BScN, Masters of Nursing Candidate – student placement, ISMP Canada Lori Taylor is a Project Manager in Corporate Nursing at the University Health Network, in Toronto. She has an interest in technology use in nursing practice to improve medication safety. Lori is currently completing a clinical placement at ISMP Canada for her Master of Nursing degree at Ryerson University.

Ian Trimble, BScPhm, ACPR, PharmD, Candidate – student placement, ISMP Canada Ian Trimble is a pharmacist with the Vancouver Island Health Authority who is currently on leave completing his Doctor of Pharmacy degree through the University of Colorado. His interest in medication safety, particularly in safe opioid prescribing and use led him to choose ISMP Canada as one of the sites for his advanced pharmacy practice experiences. Ian’s home position is on a mixed renal/general medicine floor at the Royal Jubilee Hospital and in the past he has worked in drug information, critical care, and orthopedic surgery.

Julie Greenall, RPh, BScPhm, MHSc, FISMPC, Interim Operations Leader, ISMP Canada Julie Greenall joined ISMP Canada in 2004 to complete the first Canadian Fellowship in Safe Medication Management and is now Interim Operations Leader. Her responsibilities include medication system safety reviews and critical incident analysis. Opioids in general, and hydromorphone in particular, are a recurring theme in medication incidents causing harm, including death, that have been voluntarily reported to ISMP Canada.

Background

Hydromorphone has been identified as a medication with a high potential to cause patient harm. It is one of the top 3 medications involved in medication incidents associated with harm voluntarily reported to ISMP Canada, and has been identified by several organizations as an area for improvement. There are many possible contributing factors to these incidents and ISMP Canada has recently undertaken a project to better understand the significance of knowledge deficit amongst healthcare professionals as a contributing factor. This project will build on learning from a collaborative initiative undertaken by ISMP US.

Related Links:

ISMP Canada Safety Bulletins:

• Vol. 6 Issue 9 – Shared Learning – Reported Incidents Involving Hydromorphone
• Vol. 6 Issue 1 – Top 10 Drugs Reported as Causing Harm through Medication Error

• Event Analysis Report: Hydromorphone–Morphine Event

• Demonstration Project Cuts Some Risk From Hydromorphone Use

Contact Information