In June 2017, the Ontario College of Pharmacists unanimously endorsed implementing a medication safety program for all pharmacies in the province. Till then, Nova Scotia was the only province in Canada to have mandatory pharmaceutical error reporting. But her calls for change are working.
Since her son died in March 2016, Ontario mother Melissa Sheldrick has been working to change the system.Her eight-year-old son Andrew, who suffered from a sleeping disorder, died because of a pharmaceutical error — the wrong medication was put into a bottle labelled in his name with his address on it.He was taking tryptophan. But instead, baclofen, a muscle relaxant for multiple sclerosis (MS) patients, was mixed in his bottle.
Since the death of her son, Sheldrick has been lobbying for Ontario and the rest of the provinces to adopt a mandatory error reporting policy.
One of the core elements of the program would be a requirement for pharmacies and pharmacy professionals to anonymously report medication errors to a third party.
The Ontario College of Pharmacists recently announced that third party will be Pharmapod Ltd. CEO and registrar of the Ontario College of Pharmacists, Nancy Lum-Wilson said, “The Pharmapod system was actually built by pharmacists for pharmacists and they understand the milieu in terms of pharmacy and work that they have to do and the process that needs to be followed, and so, as a result, they came in with a proposal that met all of our needs and exceeded them.”
Lum-Wilson says the first phase of the medication safety program in Ontario is already being implemented at around 100 community pharmacies, with full implementation of the program in the remaining pharmacies on board by late 2018. But she says the whole process is still in the early stages.
Pharmapod will be looking at the data as it comes in, analyze it and then communicate the findings to both the pharmacies and the College.Pharmapod will also be in charge of providing training in the pharmacies and quality improvement processes based on the data collected and conclusion made.
Lum-Wilson said, “The process as we understand it now will include anonymous reporting, so pharmacists and professionals can actually make a report into the system and Pharmapod would be looking at all this data, analyzing it, learning from it and communicating out to both the pharmacies as well as providing aggregate data to the College.”
The Ontario College says that as the program is implemented, they are expecting medication incidents to rise before they decrease as more pharmacy professionals take on the practice of anonymous reporting.
The College also points out accountability in pharmacies and among pharmacists is key and has always been in full practice at the College.
In addition to Ontario, other provinces including Saskatchewan, Manitoba, P.E.I., B.C. and Quebec are working to implement their own mandatory error reporting in pharmacies across the regions.