Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
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

Medication/Gas/Fluid:
antibiotic

Environment / Equipment
  1. Dedicate space within the dispensary to store distilled water intended for prescription processing.
Communication
  1. Ensure that updated WHMIS training is provided for all pharmacy employees; there are labelling requirements for cleaning solutions.
Rules / Policies / Procedures
  1. Do not use distilled water containers to store anything other than distilled water
  2. Do not store cleaning products (including sanitizers, disinfectants, or other products not intended for ingestion) in repurposed empty containers. Purchase and use empty, unlabelled containers for repackaging such products.
  3. Whenever cleaning products are repackaged, immediately label all sides of the new container and include a warning message (e.g., “for CLEANING”) or affix auxiliary warning labels (e.g., “For External Use Only, Not to Be Taken by Mouth”).
  4. Store all cleaning products in a specific location outside the dispensary area and return them to this storage location after use.

ALERT: Risk of Inadvertent Reconstitution of Medications with Cleaning Products