Medication Incidents

According to the Canadian Patient Safety Institute, a patient safety incident is an event or circumstance within the healthcare system that could have resulted, or did result, in unnecessary harm to a patient. Medications are responsible for a significant type of patient safety incidents.

CSHP's Position

Pharmacy Practice in Hospitals and Other Collaborative Healthcare Settings: Position Statements


There is great propensity for patient safety incidents within our healthcare system, as increasingly ill patients are being cared for through complex processes in an environment stressed by limited resources. In 2004, the Canadian Adverse Events Study, led by Dr Ross Baker and Dr Peter Norton and funded by the Canadian Institute for Health Information and the Canadian Institutes of Health Research, was published in the Canadian Medical Association Journal. The study reviewed 3745 hospital admissions (patient charts) for the fiscal year 2000 across five provinces. The overall rate of patient safety incidents in 2000 was 7.5 per 100 acute care admissions (95% confidence interval [CI] 5.7–9.3). Amongst the patients who experienced a safety incident, the events were deemed preventable in 36.9% [95% CI 32.0%–41.8%] and death ensued in 20.8% [95% CI 7.8%–33.8%]. The top two types of incidents were related to surgery (34.2%) and medication or fluid (23.6%). Applying these data to the 2.5 million annual similar medical and surgical admissions in Canada, the investigators estimated that 185,000 admissions were associated with a patient safety incident and nearly 70,000 of these were preventable.

Health care professionals strive to continually improve systems and processes to ensure that, where possible, patient safety incidents are prevented. Pharmacists play a pivotal role in the prevention and review of medication incidents and in the improvement of medication use systems.

As the voice of pharmacists providing patient care in hospitals and other collaborative healthcare settings, CSHP is committed to working collaboratively with healthcare leaders and organizations across Canada to improve patient safety by:

  1. Addressing staff shortages within healthcare facilities
  2. Increasing involvement of pharmacists in direct patient care activities
  3. Improving drug distribution systems
  4. Expanding use of technology and automation
  5. Increasing use of computerized prescriber order entry systems
  6. Improving the reporting and analysis of medication incidents
  7. Fostering a collaborative approach to the prevention of patient safety incidents

Key Messages from CSHP

Position Statements


Background Paper

Dilution of Chemotherapy Drugs – 2013

In the spring of 2013, an incident involving cyclophosphamide and gemcitabine was discovered by a pharmacy technician at a hospital in Ontario. The incident resulted in approximately 1200 patients in Ontario and New Brunswick being under-dosed. From the beginning, CSHP and its Ontario Branch responded to the call for a stronger medication system.

What has CSHP done?

  • Participated in the Sub-working Group of the Ad Hoc Federal/Provincial/Territorial Working Group on Admixing and Compounding. (This group was created to explore long-term options for providing clarity regarding the responsibilities for the oversight of certain compounding activities.)
  • Provided background information to news reporters and others to describe various aspects of sterile compounding and outsourcing.
  • Provided feedback as part of the Ontario College of Pharmacists (OCP) consultation process on the inspection criteria
  • Responded to the invitation to comment on 2 new pieces of legislation, which help close regulatory gaps in Ontario:
    • the regulation on obtaining drugs under the Ontario Public Hospitals Act proposed by the Ontario Ministry of Health and Long-Term Care; and
    • the regulation and bylaws amendments regarding drug preparation premises under the Pharmacy Act proposed by OCP.
  • Accepted the invitation from Dr Jake Thiessen, the independent reviewer assigned by the Ontario Minister of Health and Long-Term Care, to meet by telephone and to provide CSHP’s insight on his questions regarding the incident. Following the interview, CSHP shared a number of its position statements and guidelines (e.g., Outsourcing: Guidelines for Pharmacy Services ) of relevance to Dr Thiessen’s report, A Review of the Oncology Under-Dosing Incident .
  • Provided relevant papers and other sources of information to the OCP as it prepares to regulate and inspect drug preparation premises. According to the Ontario Regulation 202/94 under the Pharmacy Act, 1991, the term “drug preparation premises” is defined as “any place where a member engages in drug preparation activities, or where drug preparation activities take place that a member supervises, but does not include,
    (a) a pharmacy in respect of which a valid certificate of accreditation has been issued under the Drug and Pharmacies Regulation Act,
    (b) a premises in respect of which a valid establishment licence has been issued under the Food and Drugs Act (Canada), or
    (c) a hospital or a health or custodial institution approved or licensed under any general or special Act”.

Where do we go from here?

The effects of this incident are far reaching. In keeping with its mission, CSHP will address relevant recommendations in Dr Thiessen’s report, develop guidelines for best pharmacy practice, connect people to help them share their knowledge and experience, and advocate for improvements to the healthcare system.

Adverse Events – 2004


Canadian Adverse Events Study Summary – CSHP, May 25, 2004

Media Release