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Publication Type: Safety Bulletin
Single or Multiple Incident: Multiple
Date: 5/7/2020 12:00:00 AM
Country: Canada

This Safety Bulletin addresses the safety strategies that should be implemented when prescribing and dispensing verbal medication orders. ISMP Canada encourages the use of written orders, including electronic orders, to prevent medication errors. However, the current pandemic has increased the need for and frequency of telephone and other verbal orders. An incident is described. A community pharmacy reported to ISMP Canada that a miscommunication in a telephone order for hydromorphone led to dispensing of the oral liquid formulation instead of the intended injectable formulation. The oral product was injected by a home care nurse, which resulted in harm to the patient. The bulletin describes a number of contributing factors that may lead to medication errors associated with verbal orders. This bulletin shares recommendations for practitioners to minimize the risk of errors when communicating medication orders verbally.

Additional Details

Medication/Gas/Fluid:
HYDROmorphone
Medication/IV List:
narcotics/opiates, IV, transdermal, and oral (including liquid concentrates, immediate and sustained-release formulations)


Strategies for Safer Telephone and Other Verbal Orders in Defined Circumstances