Deaths Associated with Medication Incidents: Learning from Collaborative Work with Provincial Offices of the Chief Coroner and Chief Medical Examiner — (ISMP Canada Safety Bulletin)

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ISMP Canada Safety Bulletin

August 28, 2013

Each Canadian province and territory has an Office of the Chief Coroner or Chief Medical Examiner responsible for investigating deaths from unexplained, unexpected, or unnatural causes. Within the scope of these investigations are deaths associated with medication incidents. In-depth analysis of information from these cases offers unique opportunities to identify underlying factors and generate recommendations to reduce the chances of similar incidents in the future.

Methods and Findings

An analysis team from ISMP Canada, consisting of 3 pharmacists, a registered nurse, and a physician with experience as a coroner, reviewed 523 death cases (from the years 2007 to 2012) in which a medication incident was potentially associated with the death.  Of these, 122 cases were determined to have involved a medication incident and were abstracted into the ISMP Canada database for further analysis. In 115 of the 122 cases analyzed, the medication incident met the criteria for a category I incident (defined as an incident that may have contributed to or resulted i

Medications Involved

The medication classes most commonly involved in incidents associated with death were opioids, psychotherapeutic agents (e.g., benzodiazepines, antidepressants, neuroleptics), anticoagulants, cardiovascular agents, and insulin (Table 1).

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Table 1: Medication classes most commonly involved in incidents associated with death

Medication Class No.   (%) of Incidents *
Total no. of   category I cases 115   (100%)

115   (100%)


54 (47%)

Psychotherapeutic agents

28 (24%)


24 (21%)

Cardiovascular   agents

11 (10%)


8 (7%)

*Some incidents involved more than one  medication class.

A surprising finding that emerged from this analysis was that psychotherapeutic medications (e.g., benzodiazepines, antidepressants, neuroleptics) constituted the second most common drug class involved in medication incidents associated with death… Given their side effect and adverse effect profiles, these medications have known potential to cause harm, either alone or through interaction with another medication,  8,9 and the frequency with which these medications were associated with incidents causing death warrants continued attention.