Safe Medication Practice

Safe prescribing

Prescribing medications can improve health outcomes, quality of life and client experience. However, any medication also has the potential to cause harm. The following general principles apply:

1. Remain familiar with the CMO standards in addition to any local practice/clinic/hospital policies or procedures.
2. Maintain and develop your pharmacology knowledge and identify professional practice resources and clinical tools to support you in your learning and practice.
3. Consider whether you have sufficient information to prescribe safely:
   • Identify and address language or communication barriers to obtaining a client’s health or medication history and understanding their concerns, ideas and priorities.
   • Create and revisit each client’s best possible medication history, including any over the counter medications and supplements.
   • Take into account whether any physical assessments may be necessary, and the mode of consultation you are using (virtual or in person).
4. Utlilize electronic systems or documentation strategies which improve safety, such as an EMR which flags medication interactions or allergies and/or electronic prescriptions, which reduce errors due to legibility. If using written prescription pads, ensure they are personalized and numbered.
5. Consider your abbreviations and dose designations carefully. ISMP Canada has developed a Dangerous Abbreviations, Symbols and Dose Designation list. This list was recently reaffirmed by ISMP Canada and identifies abbreviations and symbols associated with harm or potential for harm.
6. Develop and document a plan for monitoring for therapeutic or adverse effects with the client and adjusting dosages as needed.
7. Document in the client’s chart and report any adverse effects of the medication. Consult as necessary with another health care provider if the drug therapy causes an unanticipated response.
8. If a medication is ordered by another healthcare provider, ensure timely communication of the client’s response to the drug with the prescriber.
9. Ensure the client has a plan for continuing care and monitoring of any medications which will continue after discharge from midwifery care.

While midwives report few medication errors, HIROC notes those that are reported reflect similar trends. Midwives should consider developing a protocol to avoid the risk of adverse drug events by referring to the College’s now rescinded standard on Prescribing and Administering Drugs and their hospital’s policies.

Medication administration

From 2015 to 2020, 7531 harmful medication incidents were voluntarily reported to the ISMP Canada and the Canadian Institute for Health Information’s National System for Incident Reporting (ISMP Canada Safety Bulletin, Vol 20(11) Dec 22, 2020, PDF 2.3 MB). ISMP Canada reported that 86% of these incidents resulted in mild harm. Medications that are most frequently reported in harm incidents across all healthcare settings include morphine and acetaminophen. In obstetrical care, the most common errors relate to oxytocin incidents (PDF 497 KB).  

Various strategies can be adopted by individuals and organizations to mitigate client safety risks related to medication administration.

Low Tech Strategies

•    using the 10 rights of medication administration (HIROC, Risk Profile – Medication Adverse Events);
•    allergy armbands;
•    implementing independent double checks (i.e., another midwife to verify the drug, concentration, dose and route) for drugs with higher risk of adverse outcomes in the event of an error;
•    minimizing interruptions during medication preparation and administration;
•    clear hand-offs at transitions of care;
•    safe, standardized storage and handling of medication according to the manufacturer’s recommendations (e.g., stored separately from specimens, monitoring expiry dates); Refer to the AOM's Template Refrigerator Policy for details (under Infection Prevention & Control);
•    following public health and blood bank guidelines when disposing of unused or expired products; and
•    labeling medications and IV solutions in all settings using consistent, legible labels. 

High Tech Strategies

•    Allergy documentation and alerts in electronic medical record and pharmacy system;
•    pre-use and in-use oxytocin safety checklists;
•    interaction alerts in EMRs; and
•    smart infusion pumps for IV infusions.

Practice resources

Bugs & Drugs: website | Google Play Store | Apple App Store A peer-reviewed, evidence based antimicrobial reference guide for management of infectious diseases and appropriate antimicrobial use. A specific section on infections in pregnancy exists and it is frequently updated. Bugs & Drugs is supported by the Antibiotic Wise program and is funded in BC by the BC Ministry of Health.

Clinical Practice Guidelines & Clinical Treatment Algorithms Developed by the Clinical Knowledge Translation team at the Association of Ontario Midwives.

Drugs Rx App: Google Play Store App | Apple App Store Updated on a regular basis by the Clinical Knowledge Translation team at the Association of Ontario Midwives.

Drugs and Lactation Database (LactMed), National Library of Medicine

Drug Product Database, Health Canada

e-lactancia is a project from the Association for Promotion of and Cultural and Scientific Research into Breastfeeding

ISMP Canada Safety Bulletins: subscribe and learn about strategies to mitigate harm and prevent medication errors. Audio briefs and PDFs available.

Licensed Natural Health Products Database (LNHPD), Government of Canada

Provincial Council for Maternal Child Health Safe Administration of Oxytocin Guidelines and Implementation Toolkit

Clinic posters

ISMP: 5 Questions to Ask (French)

Canadian Association of Midwives: "We can talk about it." (English | Indigenous)

These posters are directed at clients, prompting them to ask questions about their medications and vaccines. They can be posted in your waiting room or in clinic rooms.

Further education

Canadian Association of Midwives offers various webinars and resources regarding vaccines and immunizations, respiratory syncytial virus, medication abortions and IUDs.

ISMP Best Possible Medication History Interview Guide, (PDF 4.5 MB)

ISMP virtual workshops and eLearning including Medication Reconciliation (MedRec) and obtaining a Best Possible Medication History (BPMH) in Primary Care.

McMaster University offers continuing education regarding contraceptive care, STI screening & treatment and medication abortion.

National Abortion Federation of Canada and the Society of Obstetricians and Gynecologists of Canada provide information and training on medical abortion. While midwives require delegation at this time to prescribe medications for the termination of pregnancy, the same medications are used to manage spontaneous losses. Medical management of spontaneous losses is currently within scope.

University of British Columbia Continuing Professional Development eLearning includes courses on the topics of hormonal contraception, STI screening and treatment, immunization practice, labour induction and augmentation and safe prescribing of opioids.

World Health Organization’s 1994 Guide to Good Prescribing: A Practical Manual (PDF 315 KB) lays out a six step framework for prescribing which continues to be used today in medical education.