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Injectable haloperidol is also available in an to confirmation bias, if it was mistakenly Pharmacies, Ambulatory Clinics, and Hospitals about alternative medications and any increases in Institute for Safe Medication Practices Canada
A KEY PARTNER IN
immediate-release formulation (haloperidol USP, as interpreted as meaning "lactate" (the salt present in risk with use of unfamiliar or substitute products.
REPORT MEDICATION INCIDENTS
the lactate salt in a water-based formulation).3 the short-acting formulation).
• Consider how the name of the drug will appear in Compared with haloperidol decanoate, the the pharmacy computer system and on the product Information System Vendors immediate-release formulation has a much faster label with the end user in mind. When expressing a onset and shorter duration of action, which makes it generic name, do not include the salt of the • Ensure that sufficient character spaces are available useful in the treatment of psychiatric emergencies.
chemical unless the medication is available in in drug description fields and in pharmacy label multiple salt formulations.5 formats to display the full generic name of all In Canada, haloperidol is the only antipsychotic With the growing number of marketed products • Add alerts in pharmacy information systems, drugs, including the salt, ester, or other complex, Volume 14 • Issue 11 • December 18, 2014
available in both depot and immediate-release with varied formulations available for selection, electronic prescribing systems, and automated when needed.
formulations. However, another antipsychotic, prescription clarity is becoming increasingly dispensing cabinets for injectable medications that • Ensure that information systems support the use of zuclopenthixol, is available in 2 different depot are available in more than one formulation.
mixed case lettering in drug selection screens and formulations (an acetate ester and a decanoate ester), • Place labels on the shelves where these products are label formats.
A Mix-up between Short- and Long-Acting Medications
with varied durations of action and dosing regimens.
• Consider using the entire name of depot stored to alert practitioners of the availability of the medications, including the salt, ester, or other Administered by Injection: When Does the "Salt" Matter?
complex for medications available in more than • Add depot injectable medications to the one formulation, and state the desired strength; for organization's list of medications requiring an The variation in salts for drugs is clinically important Errors involving mix ups between short- and example, "haloperidol decanoate 100 mg/mL independent double check before administration, in certain situations, such as differentiation between long-acting forms of IM medications can result in long-acting injection (or depot)" instead of where possible. For facilities and other practice short-acting and depot formulations containing the Medications may be formulated as salts or esters 5 mg/mL for injection. The nurse sent the harm. A depot dose is typically much higher than a "haloperidol LA".
settings that carry both short- and long-acting same active medication. Mix-ups between (collectively referred to as "salts"), usually to prescription for "haloperidol LA 25 mg IM monthly" dose of the same drug administered in a short-acting dosage forms of a particular medication, the formulations with different pharmacokinetic improve the properties of the therapeutic moiety (e.g., to the pharmacy. The pharmacist dispensed immediate-release form, because the former is Front-Line Pharmacy and Nursing Staff short-acting form should also require an properties can lead to harm. Communicating drug its stability, bioavailability, or duration of action). In 5 ampoules of the short-acting haloperidol lactate designed to be slowly released into the body over an independent double check. If a second practitioner names with the end user in mind is becoming most cases, the type of salt does not influence how 5 mg/mL to make up the 25 mg dose, which was extended period. If the same high dose of a short- • Contact the prescriber when the presence or is not available to do the check, consider having the increasingly important with the growing number of the drug is therapeutically used. In some cases, subsequently administered to the patient. Following acting formulation is given by mistake, very high absence of a medication name suffix (salt, ester, or patient or a caregiver participate in the checking drugs and the existence of varied formulations. however, the particular salt significantly affects the the injection, the patient's family noticed that he was plasma levels of the drug may result, putting the other complex) fails to align with the prescribed process, in appropriate situations.1 Manufacturers, information system vendors, facilities, drug's pharmacological properties. Depot extremely sedated, was much less alert, and had a patient at significant risk of overdose. As an example, dose. For example, a prescription for "haloperidol • Proactively alert staff about drug shortages and pharmacies, and healthcare practitioners all have a medications are one such group of drugs. These "dazed" look, symptoms that lasted 3 days. symptoms of haloperidol overdose include severe 100 mg" should be questioned, as the salt provide anticipatory guidance about alternative role in preventing incidents related to confusion agents are typically formulated as various salts that Fortunately, the patient recovered without any extrapyramidal side effects, such as akathisia, acute (formulation) is not specified and the dose appears medications and any increases in risk with use of between formulations of the same medication.
are used differently from their short-acting dystonia, and parkinsonian symptoms.3 Also possible to align with the depot formulation.4 unfamiliar or substitute products.
counterparts. ISMP Canada recently received a report are increases in the risks of electrical disturbances of • When multiple vials or ampoules or • Provide education for staff in psychiatric clinics of an incident in which a short-acting (immediate- the heart, hypotension, hypokalemia, seizures, larger-than-anticipated volumes are needed for a and other settings where these products are used. release) intramuscular (IM) form of an antipsychotic respiratory depression, and coma.3 given dose, healthcare professionals should Address the various formulations of antipsychotic ISMP Canada gratefully acknowledges the following was administered by injection to a patient instead of Depot antipsychotics are commonly used in mental question whether the correct product has been medications and the differences between the individuals for their expert review of this bulletin the prescribed long-acting (depot) formulation. This health care settings, for example, for maintenance In this incident, in which short-acting haloperidol was supplied. In the incident described in this bulletin, formulations, including pharmacokinetic properties (in alphabetical order): bulletin is shared to increase awareness of the various treatment of schizophrenia. Their main advantage is given instead of the long-acting formulation, several five 1 mL ampoules of haloperidol lactate 5 mg/mL and therapeutic uses.
salt formulations of these drugs and to offer low frequency of administration (every 1 to 4 weeks), possible contributing factors were identified: were needed for the prescribed dose of 25 mg; this Lynne Duquette BScPhm, Clinical Pharmacist, system-based changes to prevent these types of which facilitates adherence with treatment.1 necessitated 2 IM injections to deliver the total Manufacturers and Distributors Waypoint Centre for Mental Health Care, incidents from recurring.
• A drug shortage meant that the usual supply of 5 mL volume. In contrast, the decanoate Penetanguishene, ON; James Karagianis MD In most depot formulations of antipsychotics, the haloperidol decanoate was unavailable in the clinic.
formulation for depot administration is available in • Improve labelling on product packaging with the FRCPC, Associate Professor of Psychiatry, Medication Incident
active ingredient is available as the decanoate or • Healthcare professionals were unfamiliar with the concentrations of 50 mg/mL and 100 mg/mL, and end user in mind. A new Good Label and Package University of Toronto, Psychiatrist in Chief, palmitate ester, which is dissolved in a vehicle such differences between the 2 formulations and did not the intended product would have required Practices Guide is being developed by Health Waypoint Centre for Mental Health Care, An older patient had been receiving IM haloperidol as sesame oil.2 These formulations are designed to be understand that they are not interchangeable. Such administration of less than 1 mL total volume.
Canada and ISMP Canada to provide guidance Penatanguishene, ON; Nancy Kwast BSN RPN, decanoate 25 mg every month for many years. deposited via deep IM injection to provide prolonged misconceptions may occur because for many • If the viscosity of the medication seems unusual regarding safe packaging and labelling of these Community Nurse, Vancouver Adult Mental Health Because of a medication shortage, this product was therapeutic action as the drug is slowly absorbed medications, the particular salt of the drug does not compared with previous doses when aspirating products. The guide will include recommendations Intake, Vancouver Coastal Health, Vancouver, BC; not available at the patient's ambulatory health from its oily "depot" within the muscle into the influence its properties and has no clinical medication into the syringe, verify that the correct about how to accurately communicate the drug Helen McGee RN MN CPMHN(C), Advanced centre, so a nurse called several pharmacies in the bloodstream. Haloperidol decanoate is one such drug, formulation is being prepared. Depot medications name to practitioners.
Practice Nurse, Complex Mental Illness Program, area in an attempt to procure the drug. Staff at one and it is typically administered every 4 weeks.3 • The abbreviation "LA", which was used in the are typically more viscous then their short-acting • Proactively alert pharmacies and prescribers about Centre for Addition and Mental Health, Toronto, ON.
pharmacy suggested using haloperidol lactate prescription to mean "long-acting", might have led drug shortages and provide anticipatory guidance ISMP Canada Safety Bulletin
Injectable haloperidol is also available in an to confirmation bias, if it was mistakenly Pharmacies, Ambulatory Clinics, and Hospitals about alternative medications and any increases in immediate-release formulation (haloperidol USP, as interpreted as meaning "lactate" (the salt present in risk with use of unfamiliar or substitute products.
the lactate salt in a water-based formulation).3 the short-acting formulation).
• Consider how the name of the drug will appear in Compared with haloperidol decanoate, the the pharmacy computer system and on the product Information System Vendors immediate-release formulation has a much faster label with the end user in mind. When expressing a onset and shorter duration of action, which makes it generic name, do not include the salt of the • Ensure that sufficient character spaces are available useful in the treatment of psychiatric emergencies.
chemical unless the medication is available in in drug description fields and in pharmacy label multiple salt formulations.5 formats to display the full generic name of all In Canada, haloperidol is the only antipsychotic With the growing number of marketed products • Add alerts in pharmacy information systems, drugs, including the salt, ester, or other complex, available in both depot and immediate-release with varied formulations available for selection, electronic prescribing systems, and automated when needed.
formulations. However, another antipsychotic, prescription clarity is becoming increasingly dispensing cabinets for injectable medications that • Ensure that information systems support the use of zuclopenthixol, is available in 2 different depot are available in more than one formulation.
mixed case lettering in drug selection screens and formulations (an acetate ester and a decanoate ester), • Place labels on the shelves where these products are label formats.
with varied durations of action and dosing regimens.
• Consider using the entire name of depot stored to alert practitioners of the availability of the medications, including the salt, ester, or other complex for medications available in more than • Add depot injectable medications to the one formulation, and state the desired strength; for organization's list of medications requiring an The variation in salts for drugs is clinically important Errors involving mix ups between short- and example, "haloperidol decanoate 100 mg/mL independent double check before administration, in certain situations, such as differentiation between long-acting forms of IM medications can result in long-acting injection (or depot)" instead of where possible. For facilities and other practice short-acting and depot formulations containing the Medications may be formulated as salts or esters 5 mg/mL for injection. The nurse sent the harm. A depot dose is typically much higher than a "haloperidol LA".
settings that carry both short- and long-acting same active medication. Mix-ups between (collectively referred to as "salts"), usually to prescription for "haloperidol LA 25 mg IM monthly" dose of the same drug administered in a short-acting dosage forms of a particular medication, the formulations with different pharmacokinetic improve the properties of the therapeutic moiety (e.g., to the pharmacy. The pharmacist dispensed immediate-release form, because the former is Front-Line Pharmacy and Nursing Staff short-acting form should also require an properties can lead to harm. Communicating drug its stability, bioavailability, or duration of action). In 5 ampoules of the short-acting haloperidol lactate designed to be slowly released into the body over an independent double check. If a second practitioner names with the end user in mind is becoming most cases, the type of salt does not influence how 5 mg/mL to make up the 25 mg dose, which was extended period. If the same high dose of a short- • Contact the prescriber when the presence or is not available to do the check, consider having the increasingly important with the growing number of the drug is therapeutically used. In some cases, subsequently administered to the patient. Following acting formulation is given by mistake, very high absence of a medication name suffix (salt, ester, or patient or a caregiver participate in the checking drugs and the existence of varied formulations. however, the particular salt significantly affects the the injection, the patient's family noticed that he was plasma levels of the drug may result, putting the other complex) fails to align with the prescribed process, in appropriate situations.1 Manufacturers, information system vendors, facilities, drug's pharmacological properties. Depot extremely sedated, was much less alert, and had a patient at significant risk of overdose. As an example, dose. For example, a prescription for "haloperidol • Proactively alert staff about drug shortages and pharmacies, and healthcare practitioners all have a medications are one such group of drugs. These "dazed" look, symptoms that lasted 3 days. symptoms of haloperidol overdose include severe 100 mg" should be questioned, as the salt provide anticipatory guidance about alternative role in preventing incidents related to confusion agents are typically formulated as various salts that Fortunately, the patient recovered without any extrapyramidal side effects, such as akathisia, acute (formulation) is not specified and the dose appears medications and any increases in risk with use of between formulations of the same medication.
are used differently from their short-acting dystonia, and parkinsonian symptoms.3 Also possible to align with the depot formulation.4 unfamiliar or substitute products.
counterparts. ISMP Canada recently received a report are increases in the risks of electrical disturbances of • When multiple vials or ampoules or • Provide education for staff in psychiatric clinics of an incident in which a short-acting (immediate- the heart, hypotension, hypokalemia, seizures, larger-than-anticipated volumes are needed for a and other settings where these products are used. release) intramuscular (IM) form of an antipsychotic respiratory depression, and coma.3 given dose, healthcare professionals should Address the various formulations of antipsychotic ISMP Canada gratefully acknowledges the following was administered by injection to a patient instead of Depot antipsychotics are commonly used in mental question whether the correct product has been medications and the differences between the individuals for their expert review of this bulletin the prescribed long-acting (depot) formulation. This health care settings, for example, for maintenance In this incident, in which short-acting haloperidol was supplied. In the incident described in this bulletin, formulations, including pharmacokinetic properties (in alphabetical order): bulletin is shared to increase awareness of the various treatment of schizophrenia. Their main advantage is given instead of the long-acting formulation, several five 1 mL ampoules of haloperidol lactate 5 mg/mL and therapeutic uses.
salt formulations of these drugs and to offer low frequency of administration (every 1 to 4 weeks), possible contributing factors were identified: were needed for the prescribed dose of 25 mg; this Lynne Duquette BScPhm, Clinical Pharmacist, system-based changes to prevent these types of which facilitates adherence with treatment.1 necessitated 2 IM injections to deliver the total Manufacturers and Distributors Waypoint Centre for Mental Health Care, incidents from recurring.
• A drug shortage meant that the usual supply of 5 mL volume. In contrast, the decanoate Penetanguishene, ON; James Karagianis MD In most depot formulations of antipsychotics, the haloperidol decanoate was unavailable in the clinic.
formulation for depot administration is available in • Improve labelling on product packaging with the FRCPC, Associate Professor of Psychiatry, Medication Incident
active ingredient is available as the decanoate or • Healthcare professionals were unfamiliar with the concentrations of 50 mg/mL and 100 mg/mL, and end user in mind. A new Good Label and Package University of Toronto, Psychiatrist in Chief, palmitate ester, which is dissolved in a vehicle such differences between the 2 formulations and did not the intended product would have required Practices Guide is being developed by Health Waypoint Centre for Mental Health Care, An older patient had been receiving IM haloperidol as sesame oil.2 These formulations are designed to be understand that they are not interchangeable. Such administration of less than 1 mL total volume.
Canada and ISMP Canada to provide guidance Penatanguishene, ON; Nancy Kwast BSN RPN, decanoate 25 mg every month for many years. deposited via deep IM injection to provide prolonged misconceptions may occur because for many • If the viscosity of the medication seems unusual regarding safe packaging and labelling of these Community Nurse, Vancouver Adult Mental Health Because of a medication shortage, this product was therapeutic action as the drug is slowly absorbed medications, the particular salt of the drug does not compared with previous doses when aspirating products. The guide will include recommendations Intake, Vancouver Coastal Health, Vancouver, BC; not available at the patient's ambulatory health from its oily "depot" within the muscle into the influence its properties and has no clinical medication into the syringe, verify that the correct about how to accurately communicate the drug Helen McGee RN MN CPMHN(C), Advanced centre, so a nurse called several pharmacies in the bloodstream. Haloperidol decanoate is one such drug, formulation is being prepared. Depot medications name to practitioners.
Practice Nurse, Complex Mental Illness Program, area in an attempt to procure the drug. Staff at one and it is typically administered every 4 weeks.3 • The abbreviation "LA", which was used in the are typically more viscous then their short-acting • Proactively alert pharmacies and prescribers about Centre for Addition and Mental Health, Toronto, ON.
pharmacy suggested using haloperidol lactate prescription to mean "long-acting", might have led drug shortages and provide anticipatory guidance ISMP Canada Safety Bulletin – Volume 14 • Issue 11 • December 18, 2014
Injectable haloperidol is also available in an to confirmation bias, if it was mistakenly Pharmacies, Ambulatory Clinics, and Hospitals about alternative medications and any increases in immediate-release formulation (haloperidol USP, as interpreted as meaning "lactate" (the salt present in risk with use of unfamiliar or substitute products.
the lactate salt in a water-based formulation).3 the short-acting formulation).
• Consider how the name of the drug will appear in Compared with haloperidol decanoate, the the pharmacy computer system and on the product Information System Vendors immediate-release formulation has a much faster label with the end user in mind. When expressing a onset and shorter duration of action, which makes it generic name, do not include the salt of the • Ensure that sufficient character spaces are available useful in the treatment of psychiatric emergencies.
chemical unless the medication is available in in drug description fields and in pharmacy label multiple salt formulations.5 formats to display the full generic name of all In Canada, haloperidol is the only antipsychotic With the growing number of marketed products • Add alerts in pharmacy information systems, drugs, including the salt, ester, or other complex, available in both depot and immediate-release with varied formulations available for selection, electronic prescribing systems, and automated when needed.
formulations. However, another antipsychotic, prescription clarity is becoming increasingly dispensing cabinets for injectable medications that • Ensure that information systems support the use of zuclopenthixol, is available in 2 different depot are available in more than one formulation.
mixed case lettering in drug selection screens and formulations (an acetate ester and a decanoate ester), • Place labels on the shelves where these products are label formats.
with varied durations of action and dosing regimens.
• Consider using the entire name of depot stored to alert practitioners of the availability of the medications, including the salt, ester, or other complex for medications available in more than • Add depot injectable medications to the one formulation, and state the desired strength; for organization's list of medications requiring an The variation in salts for drugs is clinically important Errors involving mix ups between short- and example, "haloperidol decanoate 100 mg/mL independent double check before administration, in certain situations, such as differentiation between long-acting forms of IM medications can result in long-acting injection (or depot)" instead of where possible. For facilities and other practice short-acting and depot formulations containing the Medications may be formulated as salts or esters 5 mg/mL for injection. The nurse sent the harm. A depot dose is typically much higher than a "haloperidol LA".
settings that carry both short- and long-acting same active medication. Mix-ups between (collectively referred to as "salts"), usually to prescription for "haloperidol LA 25 mg IM monthly" dose of the same drug administered in a short-acting dosage forms of a particular medication, the formulations with different pharmacokinetic improve the properties of the therapeutic moiety (e.g., to the pharmacy. The pharmacist dispensed immediate-release form, because the former is Front-Line Pharmacy and Nursing Staff short-acting form should also require an properties can lead to harm. Communicating drug its stability, bioavailability, or duration of action). In 5 ampoules of the short-acting haloperidol lactate designed to be slowly released into the body over an independent double check. If a second practitioner names with the end user in mind is becoming most cases, the type of salt does not influence how 5 mg/mL to make up the 25 mg dose, which was extended period. If the same high dose of a short- • Contact the prescriber when the presence or is not available to do the check, consider having the increasingly important with the growing number of the drug is therapeutically used. In some cases, subsequently administered to the patient. Following acting formulation is given by mistake, very high absence of a medication name suffix (salt, ester, or patient or a caregiver participate in the checking drugs and the existence of varied formulations. however, the particular salt significantly affects the the injection, the patient's family noticed that he was plasma levels of the drug may result, putting the other complex) fails to align with the prescribed process, in appropriate situations.1 Manufacturers, information system vendors, facilities, drug's pharmacological properties. Depot extremely sedated, was much less alert, and had a patient at significant risk of overdose. As an example, dose. For example, a prescription for "haloperidol • Proactively alert staff about drug shortages and pharmacies, and healthcare practitioners all have a medications are one such group of drugs. These "dazed" look, symptoms that lasted 3 days. symptoms of haloperidol overdose include severe 100 mg" should be questioned, as the salt provide anticipatory guidance about alternative role in preventing incidents related to confusion agents are typically formulated as various salts that Fortunately, the patient recovered without any extrapyramidal side effects, such as akathisia, acute (formulation) is not specified and the dose appears medications and any increases in risk with use of between formulations of the same medication.
are used differently from their short-acting dystonia, and parkinsonian symptoms.3 Also possible to align with the depot formulation.4 unfamiliar or substitute products.
counterparts. ISMP Canada recently received a report are increases in the risks of electrical disturbances of • When multiple vials or ampoules or • Provide education for staff in psychiatric clinics of an incident in which a short-acting (immediate- the heart, hypotension, hypokalemia, seizures, larger-than-anticipated volumes are needed for a and other settings where these products are used. release) intramuscular (IM) form of an antipsychotic respiratory depression, and coma.3 given dose, healthcare professionals should Address the various formulations of antipsychotic ISMP Canada gratefully acknowledges the following was administered by injection to a patient instead of Depot antipsychotics are commonly used in mental question whether the correct product has been medications and the differences between the individuals for their expert review of this bulletin the prescribed long-acting (depot) formulation. This health care settings, for example, for maintenance In this incident, in which short-acting haloperidol was supplied. In the incident described in this bulletin, formulations, including pharmacokinetic properties (in alphabetical order): bulletin is shared to increase awareness of the various treatment of schizophrenia. Their main advantage is given instead of the long-acting formulation, several five 1 mL ampoules of haloperidol lactate 5 mg/mL and therapeutic uses.
salt formulations of these drugs and to offer low frequency of administration (every 1 to 4 weeks), possible contributing factors were identified: were needed for the prescribed dose of 25 mg; this Lynne Duquette BScPhm, Clinical Pharmacist, system-based changes to prevent these types of which facilitates adherence with treatment.1 necessitated 2 IM injections to deliver the total Manufacturers and Distributors Waypoint Centre for Mental Health Care, incidents from recurring.
• A drug shortage meant that the usual supply of 5 mL volume. In contrast, the decanoate Penetanguishene, ON; James Karagianis MD In most depot formulations of antipsychotics, the haloperidol decanoate was unavailable in the clinic.
formulation for depot administration is available in • Improve labelling on product packaging with the FRCPC, Associate Professor of Psychiatry, Medication Incident
active ingredient is available as the decanoate or • Healthcare professionals were unfamiliar with the concentrations of 50 mg/mL and 100 mg/mL, and end user in mind. A new Good Label and Package University of Toronto, Psychiatrist in Chief, palmitate ester, which is dissolved in a vehicle such differences between the 2 formulations and did not the intended product would have required Practices Guide is being developed by Health Waypoint Centre for Mental Health Care, An older patient had been receiving IM haloperidol as sesame oil.2 These formulations are designed to be understand that they are not interchangeable. Such administration of less than 1 mL total volume.
Canada and ISMP Canada to provide guidance Penatanguishene, ON; Nancy Kwast BSN RPN, decanoate 25 mg every month for many years. deposited via deep IM injection to provide prolonged misconceptions may occur because for many • If the viscosity of the medication seems unusual regarding safe packaging and labelling of these Community Nurse, Vancouver Adult Mental Health Because of a medication shortage, this product was therapeutic action as the drug is slowly absorbed medications, the particular salt of the drug does not compared with previous doses when aspirating products. The guide will include recommendations Intake, Vancouver Coastal Health, Vancouver, BC; not available at the patient's ambulatory health from its oily "depot" within the muscle into the influence its properties and has no clinical medication into the syringe, verify that the correct about how to accurately communicate the drug Helen McGee RN MN CPMHN(C), Advanced centre, so a nurse called several pharmacies in the bloodstream. Haloperidol decanoate is one such drug, formulation is being prepared. Depot medications name to practitioners.
Practice Nurse, Complex Mental Illness Program, area in an attempt to procure the drug. Staff at one and it is typically administered every 4 weeks.3 • The abbreviation "LA", which was used in the are typically more viscous then their short-acting • Proactively alert pharmacies and prescribers about Centre for Addition and Mental Health, Toronto, ON.
pharmacy suggested using haloperidol lactate prescription to mean "long-acting", might have led drug shortages and provide anticipatory guidance ISMP Canada Safety Bulletin – Volume 14 • Issue 11 • December 18, 2014
References
1. Feetam C, White J, editors. Guidance on the administration to adults of oil-based depot and other long-acting intramuscular antipsychotic injections. 4th ed. Janssen-Cilag Ltd.; 2014 [cited 2014 Sep 28]. A 2. Taylor D. Psychopharmacology and adverse effects of antipsychotic long-acting injections: a review. Br J Psychiatr Suppl 3. Haloperidol [product monograph]. In: e-CPS [database on Internet]. Ottawa (ON): Canadian Pharmacists Association; [cited 2014 Sep 28]. Available 4. Promoting the safe use of suffixes in prescription drug names: Council recommendations. National Coordinating Council for Medication Error Reporting and Prevention; 2007 Dec 3 [cited 2014 Sep 28]. Available from: 5. Principles of designing a medication label for community and mail order pharmacy prescription packages. Horsham (PA): Institute for Safe Medication Practices. 2010 [cited 2014 Nov 10]. Available from: Invitation to Participate in a Delphi Method Survey on Medication
Safety Pictograms for Healthcare Workers
We would like to invite healthcare professionals to participate in the development of a set of pictograms for medication safety. In this first phase, we are seeking assistance to identify the top issues where the development of a pictogram might provide a visual aid and warning cue to help prevent selected medication errors. Ultimately, the use of a small set of medication safety pictograms could be considered when labelling, dispensing, or administering medications. This collaborative research project is being led by Dr. Regis Vaillancourt, Pharmacy Director at the Children's Hospital of Eastern Ontario, and aims to involve pharmacists, pharmacy technicians, nurses, physicians, and specialists such as anesthesiologists. We have chosen to organize a Delphi consultation by email. The Delphi method is designed as a group communication process which aims to achieve a convergence of opinions on a specific real-world issue. The Delphi consists of three rounds, and each round should take approximately
10-15 minutes of your time to complete. After each round, a summary of the responses will be sent
to an expert group. The first Delphi round will include structured, as well as open-ended questions to facilitate discussion. In addition, new topics provided by responses to the open-ended questions will be disseminated to all Delphi participants in the second round.
Research ethics board approval was obtained for the study from the Children's Hospital of Eastern Ontario (January 23, 2014). Your privacy and anonymity will be guaranteed and only the project coordinators will have access to the raw information gathered, and to any personal information ISMP Canada Safety Bulletin – Volume 14 • Issue 11 • December 18, 2014
This segment of the bulletin describes a recent SafeMedicationUse.ca publication from ISMP Canada's consumer program. December 2014 – Newsletter
Medication Appearance and Markings Support Safety
Consumers need to be familiar with the identification marks and general appearance of each of their medications and any medications they administer to others. SafeMedicationUse.ca received an incident report about a mix-up that occurred in a community pharmacy between a consumer's prescriptions for 2 medications: the antibiotic ciprofloxacin (to be used in treating a lung infection) and ranitidine (to be used on an as-needed basis for indigestion). The error resulted in the ciprofloxacin tablets being placed in the vial labelled "ranitidine" and the ranitidine tablets in the vial labelled "ciprofloxacin". For 6 days, the consumer took 3 ranitidine tablets a day and did not take any ciprofloxacin. As a result, her infection was not treated properly and lasted longer than expected. Fortunately, the consumer had some awareness of the markings of the ranitidine tablets. This helped her to discover the error, which in turn helped her to eventually get the correct treatment for her infection.
The SafeMedicationUse.ca newsletter advises consumers to take an active role in their health by being familiar with the appearance (e.g., colour, shape, markings) of the medicines they take, by checking their prescriptions before leaving the pharmacy, and by reviewing the details of new prescriptions with the prescriber. Consumers are encouraged to read more about checking To further support the consumer in this role, practitioners are encouraged to spend some time with the consumer at the time of prescription pick-up, opening the vials, reviewing each product's appearance, and informing the consumer of any changes to the medications' appearance.
For additional information about safe practices for consumers and practitioners, read the complete ISMP Canada Safety Bulletin – Volume 14 • Issue 11 • December 18, 2014
Report Medication Incidents
(Including near misses)
The Canadian Medication Incident Reporting and Prevention Phone: 1-866- 544-7672
System (CMIRPS) is a collaborative pan-Canadian program of Health Canada, the Canadian Institute for Health Information ISMP Canada strives to ensure confidentiality (CIHI), the Institute for Safe Medication Practices Canada and security of information received, and (ISMP Canada) and the Canadian Patient Safety Institute respects the wishes of the reporter as to the (CPSI). The goal of CMIRPS is to reduce and prevent harmful level of detail to be included in publications.
medication incidents in Canada.
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The Institute for Safe Medication Practices Canada (ISMP Canada) is an independent national not-for-profit 2014 Institute for Safe Medication Practices Canada. organization committed to the advancement of medication Permission is granted to subscribers to use material from safety in all healthcare settings. ISMP Canada's mandate the ISMP Canada Safety Bulletin for in-house newsletters or other internal communications only. Reproduction by recommendations for the prevention of harmful medication any other process is prohibited without permission from incidents, and facilitating quality improvement initiatives.
ISMP Canada in writing.
ISMP Canada Safety Bulletin – Volume 14 • Issue 11 • December 18, 2014

Source: http://www.ismpcanada.ca/download/safetyBulletins/2014/ISMPCSB2014-11_ShortLongActingMedications.pdf