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A Medication Error Reporting Portal brought to the international healthcare community by the IMSN

The International Medication Safety Network (IMSN) is pleased to launch an international medication error reporting portal for the international healthcare community, to learn from these experiences and be in position to prevent future errors and possible patient harm.

The International Medication Safety Network (IMSN) encourages sharing incidents of medication errors, near misses and hazardous conditions for global learning and action to reduce the risk of patient harm and death. Some jurisdictions also have in-country reporting systems to aggregate and learn from this information nationally. IMSN strongly encourages reporters to continue reporting to the existing local or national reporting and learning systems. Read on...

This portal will enable any healthcare provider worldwide, including physicians, pharmacists, nurses, and other healthcare workers including those in the regulatory and the medical products industry to share their report for international review.


Where applicable, reports will be investigated and reported on the IMSN website by the International Medication Safety Management Fellows at the Institute for Safe Medication Practices (ISMP) in the United States under the supervision of medication safety expert members of the IMSN.


The content of the medication error reports will be handled confidentially: name and location of the reporters will never be shared in public reports. Access to the reporting form

Important information about reported incidents may appear on this website for learning purposes.

2-component vaccines : a new IMSN Global Targeted Medication Safety Best Practice to prevent preparation errors

The International Medication Safety Network (IMSN) releases its fourth Global Targeted Medication Safety Best Practices aimed at preventing errors related to improper preparation of 2-component vaccines

Several vaccines require mixing two components that are supplied by the manufacturer in physically separate containers. For example, a lyophilized powder and a vaccine-specific liquid diluent. Other vaccines may include a powder vial plus a liquid antigen vial or adjuvant component. These powder and liquid containers may be packaged together by the manufacturer or, in some cases, may arrive separately. Preparation of the vaccine for injection must be completed prior to administering the dose.

Unfortunately, errors sometimes occur when proper mixing does not happen and only one component of the two-component vaccine is administered, thus the patient will not be fully immunized. In other cases, an incorrect diluent is used to prepare the lyophilized powder, which may affect stability. Such errors may go undetected thus revaccination does not occur, potentially allowing the development of disease. Among the many opportunities for error, the IMSN has identified different scenarios

In some very dangerous cases, a dangerous substance was accidentally used in place of the vaccine diluent. For example, there have been several incidents where a paralyzing agent (neuromuscular blocker) has been used instead of a liquid diluent: in 2014 fifteen children died in Syria, and more recently in 2018 two others infants died in Samoa.

This 4th Global Targeted Medication Safety Best Practice is in line with the IMSN Position Statement on Safer Design of Vaccines Packaging and Labelling issued in December 2015, that called for greater worldwide attention to the problem of unsafe design of vaccine packaging and labelling. The statement called on pharmaceutical companies, technology vendors, professional organizations, regulatory/standard-setting organizations and health ministries to help improve vaccine safety and efficacy.

In May 2019, the International Medication Safety Network (IMSN) published its first set of Global Targeted Medication Safety Best Practices to identify, inspire, and mobilize widespread international improvement in error prevention.
This international medication safety call to action was aimed at preventing fatalities due to medication errors with concentrated potassium injection, inadvertent intraspinal injection of vincristine, and accidental daily instead of weekly dosing of methotrexate in patients with psoriasis or rheumatoid arthritis.

The IMSN continues its work on labelling and packaging safety and deepens its relationship with pharmacovigilance

 

The International Medication Safety Network (IMSN) hold its 13th Annual Meeting on October 29 and 30, 2018 in Cascais, Portugal, hosted by the Portuguese Association of Hospital Pharmacist (APFH). The meeting focused mainly on 2 topics: drug product labelling and packaging safety and medication error in pharmacovigilance programs.

Targeting International best practice for safe labelling and packaging of prescription medicines

The IMSN members discussed strategies for reducing medication errors related to labelling with representatives of pharmaceutical companies (Abbvie, USA; Baxter, Portugal; BMS, USA; Eli Lilly, UK; Hikma, USA; Janssen, J&J, Netherlands; Novartis, USA; Pfizer, USA; UCB, USA) and medicine agencies (FDA, USA; ANVISA, Brasil; MHRA, UK; Norway Medicine Agency) in the perspective of implementing the recommendations of the June 2018 IMSN / FDA Summit.

Participants agreed on the following best practices:
1. Include both the per mL and the per container quantity, not the per mL quantity alone, when presenting the concentration for injectable; with prominence given to total content per container
2. Use metric units for products and eliminate ratio expressions
3. Eliminate potentially error-prone abbreviations and dose designations on labels, such as U for units, IU for international units, and trailing zeros (e.g., 1.0) to express strength
4. Prominently display cautionary statements on the carton and immediate container labels of NMBs, KCL concentrate injection, methotrexate, and other selected error-prone medications
5. Use contrasting label backgrounds for printing on glass ampules and recommended font size and label orientation to improve readability
6. Physically link or integrate "special" diluents for "specific drugs" with their powder component
7. Increase the adoption of ready to use/ready to administer syringes, premixed IV solutions, unit-dose packaging and other more efficient, safer packaging, while considering the overall cost of implementation
8. Develop product-specific world safety standards; for example, standard packaging for non-oncologic methotrexate to prevent accidental daily use and overdose
9. Include barcodes on primary packages so they can be scanned at the bedside or other locations where medications are dispensed and administered by healthcare practitioners
10. Mention prominently international non-proprietary names (INN) on labels

Participants agreed that an IMSN White Paper targeting International best practice for safe labelling and packaging of prescription medicines should be drafted and about the global need to use barcode in the medication use process for patient safety purpose, that IMSN will undertake a barcode readiness assessment at international level and lobby for European Datamatrix code on unit doses. Read on…

The IMSN promotes integrating Medication Error in Pharmacovigilance Programs

Adverse drug reactions and medication errors are two sides of the same coin: medication safety. The IMSN published almost ten years ago a Position Paper on Pharmacovigilance and Medication Errors. Read on...

Aiming to strengthen the cooperation between pharmacovigilance and medication error or patient safety incident reporting systems, the IMSN invited a panel discussion on medication error in pharmacovigilance programs during its 13thmeeting. The nine countries that presented were: New Zealand, Morocco, United Kingdom, Canada, USA, France, Portugal, Germany and Norway.

There was a consensus view that more attention should be focused on promoting and extending greater involvement of more pharmacovigilance centres in medication error reporting and analysis and that the IMSN should become more active in participating and facilitating in this harmonisation. Specific activities and projects aimed at strengthening the harmonisation, complementarity and integration of pharmacovigilance and medication error were identified and supported by consensus. The IMSN Position Statement on pharmacovigilance and medication errors will be updated accordingly.