The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the wrong route administration of an oral drug into a vein.
The HSIB were made aware of a nine-year-old child who inadvertently had
an oral liquid medication injected into a vein. The initial investigation
highlighted steps missing in the preparation, checking and administration of
the prescribed drug. The full investigation will look at the complexity of the
medications process, applying a human factors view to aid learning.
Interim bulletins are released to share further details of each
investigation, including how it’s met HSIB criteria, the history of the event
it relates to, the national context and any identified safety issues.
The HSIB launched its first full investigation in July 2017, and is now carrying out nine full investigations.
Download the bulletin here