Academic Day Seminar #6: Medication Safety

Some key points I took away from this session:

  • Safety culture:
    Errors cannot be eliminated, and as shown in the Swiss cheese Model below, there are flaws in each layer of defense and if aligned, can cause an accident to occur. It is important to avoid naming, blaming or shaming and use errors as an opportunity to learn and reflect on the system
  • Speak up about unsafe practices, recognize potential areas of error and make interventions
    • E.g. methadone: 1mg/mL concentration in community –> 2014 = changed 10mg/mL d/t P’care
  • “Patient Safety Reviews” – protected under Section 51
    • Cannot be brought up to court
  • Be familiar with Required Organizational Practices
    • E.g. K+ > 2mmol/L not allowed on units – can cause sudden cardiac death
  • Tools to reduce medication errors:
  • Avoid using ISMP’s unsafe abbreviations (also on top of order sheet)

For my reference in future rotations, steps to adverse reaction reporting:

Canada Vigilance or BC PSLS (forwards to Health Canada):

  • Report: Rx, non-rx, NHP, biologics (e.g. vaccines, human blood, cells, tissues, organs), radiopharmaceuticals (e.g. dyes in CT scans), disinfectants, sanitizers with disinfectant claims
  • Report all clinically significant suspected ADRs, especially:
    • Unexpected (regardless of severity)
    • Serious (expected or not)
    • Recently marketed health products (< 5 years), regardless of their severity
    • Other reportable ARs: abuse, overdose, interactions, unsual lack of therapeutic efficacy, exaggerated response, teratogenic effect
  • Understand differences between an ADR and a serious ADR
    • ADR: noxious and unintended response to a drug which occurs at doses normally used or tested for diagnosis, tx or prevention of disease
    • Serious ADR: noxious and unintended response to a drug that occurs at any dose and requires in-patient hospitalization, causes congenital malformation, resuts in significant or persistent disability or incapacity, life-threatning or results in death, or if they require significant medical intervention to prevent one of the previously listed outcomes
  • Can report to Canada Vigilance Health Canada (easier) or manufacturer
  • Canada Vigilance AR Reporting Form:


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Reporter can also update:

  • In-house hospital information system (e.g. Meditech, Cerner)
  • Pharmanet, Promis, Paris, Community Pharmacy