Paediatric Opioid Safety

Paediatric healthcare institutions face many unique challenges in the delivery of care - among these challenges is the lack of standardization of paediatric medication dosing and delivery practice.  It is well known that medication errors and adverse events are among the most common patient safety problems in paediatrics and that certain high-risk medications pose particular risks.  Non-standardized practices are a recognized challenge across the majority of child and youth health centres in Canada across the continuum of care.

In 2006 Members of CAPHC’s Patient Safety Collaborative and key partner organizations agreed to work collaboratively to develop a national action plan to address this important issue across the paediatric continuum of care.


Phase 1 – January 2008 – December 2008

As well as participating in a landscape survey of current medication safety practices, CAPHC member organizations provided incident data that was analysed by ISMP Canada.  This led to the identification of the top 5 medications causing harm or potential harm in paediatric population. The decision to focus on opioid medication was made by the National Advisory Committee after a secondary analysis of the data.

Advancing Medication Safety in the Delivery of High Alert Medications in Paediatrics (Phase 1 Report)

ISMP Canada Bulletin Volume 9, Number 6

Phase 2 – January 2009- January 2010

Draft Paediatric Opioid Safety Guidelines were created for Community & Tertiary hospitals based on national consultation and consensus, focus groups and surveys.  Standard concentrations were based on the work of an expert advisory panel that developed strict criteria for inclusion. 

Canadian Paediatric High Alert Medication Delivery: Opioid Safety -Toward a Change in Practice (Phase 2 Report)

Phase 3 – Education, Knowledge Translation and Implementation: Paediatric Opioid Safety Resource Kit                  

A Paediatric Opioid Safety Resource Kit  has been developed and posted to the Knowledge Exchange Network.  It contains the Consensus Guidelines, references and recommended reading, as well as tools and resources shared from participating organizations.  There is an opportunity for individuals to become a member of the Knowledge Exchange Network and begin sharing information as well.  

A strategy for guideline implementation at community hospitals is being developed.   Individual organizations are implementing specific guidelines and reporting back to the larger community with their experience and feedback.  As practice still varies across the country, organizations are in different stages of readiness to move to standard concentrations, smart pump technology, etc. This collaborative approach allows organizations to learn from one another and provide support.  

(Phase 3 Report)

Presentations will be posted on the Knowledge Exchange Network.

CAPHC and ISMP Canada are proud to be recognized by Accreditation Canada in the 2013 Medication Management Standards with a  reference to the CAPHC/ ISMP Canada Paediatric Opioid Safety Resource Kit! 

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