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Publication Type: Safety Bulletin
Single or Multiple Incident: Multiple
Date: 10/15/2020 12:00:00 AM
Country: Canada

This safety bulleting discusses the real and potential patient safety incidents that have occurred when cleaning products such as sanitizers are repackaged into bottles previously containing distilled water and not appropriately labelled. To combat the spread of COVID-19 through enhanced surface cleaning and disinfection, community pharmacies have been purchasing and storing larger-than-usual quantities of cleaning products, including sanitizers and disinfectants (referred to collectively as “cleaning products” in this bulletin). As a result, some of these products may be purchased in bulk containers and then decanted into other, smaller containers, for ease of handling. This bulletin is shared to alert all pharmacy staff to the potentially harmful outcomes of this practice. One incident is described. A child was given the first dose of an antibiotic suspension that had been reconstituted and dispensed by a community pharmacy. After ingesting the first dose, the child gagged and vomited. Shortly afterward, the pharmacist called the child’s parents and asked them to smell the antibiotic liquid. The parents reported that it smelled like vinegar. The pharmacy then acknowledged that vinegar, instead of distilled water, had likely been used, in error, to reconstitute the medication. The bulletin provides a number of recommendations to mitigate the risk of similar incidents.

Additional Details


ALERT: Risk of Inadvertent Reconstitution of Medications with Cleaning Products