Ontario pharmacists move towards mandatory reporting of prescription-dispensing errors

Ontario has taken a major step towards making it mandatory for pharmacies in the province to report medication dispensing errors to a third party.

The Ontario College of Pharmacists announced it has adopted a series of recommendations from a task force looking at mandatory error reporting and will begin public consultations Friday before moving towards a formal implementation of the program.

“Recommendations from the task force to develop a continuous quality assurance model, including third-party mandatory incident reporting, were presented at the March 20, 2017 Council meeting,” said Todd Leach, a spokesperson for the College.  “Council unanimously approved the task force’s recommendations and has authorized the College to begin public consultation to help determine the critical factors to support a successful roll out of the proposed model.”

READ MORE: How widespread are prescription error problems in Canada? We don’t really know

Melissa Sheldrick, whose eight-year-old son died in March 2016 after being given the wrong medication, was invited by the College to participate on the task force and help develop a new provincial regulatory framework aimed at reducing the number of pharmacy dispensing errors.

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Sheldrick has been calling for prescription error reporting systems to be mandatory across Canada after the death of her son Andrew and petitioned Ontario’s Health Minister Eric Hoskins to adopt a mandatory system last October.

“There is no reason that in 2017 all provinces can’t adopt this – that it is an unfortunate piece of healthcare that has been overlooked,” she said. “Now we hear more and more stories that these incidents are happening, there is harm, some incidences are caught before they get to the public, but it is damaging to some people’s quality of life and life in general.”

Tweet This Click to share quote on Twitter: "There is no reason that in 2017 all provinces can't adopt this - that it is an unfortunate piece of healthcare that has been overlooked," she said. "Now we hear more and more stories that these incidents are happening, there is harm, some incidences are caught before they get to the public, but it is damaging to some people's quality of life and life in general."

In Canada, Nova Scotia is the only province with a mandatory requirement for its pharmacies to report errors to an independent organization. In most provinces, pharmacies are held accountable by its governing college and error reports are not readily available to the public.

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And with millions of prescriptions filled every year in Canada, nobody knows exactly how often someone is given the wrong medication. A report from the University of Toronto found Canadian pharmacies filled roughly 625 million prescriptions in 2015.

The Ontario College of Pharmacists began looking at the issue of mandatory reporting after a meeting in December 2016.

Leach said the College is working to implement a model aimed at reducing risk of medication incidents while also helping pharmacies learn from incidents and review and enhance policies to reduce the risk of recurrence.

“An important element of this program is a requirement for mandatory medication incident reporting to a third party which would provide the data required to support systemic review of errors in individual pharmacies as well as an aggregate review of national trends to support ongoing quality improvement initiatives,” he said.

But for Sheldrick this is another important step in grieving the loss of her son.

“Andrew was an incredibly caring kid,” she said. “This is the direction that I know he would be pushing me to go and that’s why I do this, that’s why I work hard for him.”

“It actually helps my grief process. It makes me think that I can actually do something in situation that I can’t do anything about. And it keeps his spirit alive knowing that all of this is for him.”

The College said more details on how and when the mandatory reporting program will be implemented will be confirmed by June 2017.