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

Click to play video: 'Ontario mother’s tragic loss prompts fight for change to practices in Canada’s pharmaceutical industry'
Ontario mother’s tragic loss prompts fight for change to practices in Canada’s pharmaceutical industry
WATCH ABOVE: After the death of her only eight-year-old son due to a pharmaceutical error, his mother, Melissa Sheldrick is lobbying for change. Angie Seth reports – Nov 28, 2016

More than 600 million medical prescriptions were dispensed by Canadian pharmacies last year, but experts say there’s little information about how often Canadians are mistakenly given the wrong medicine and no national tracking system.

Melissa Sheldrick, a mother from Mississauga, Ont., knows the consequences of prescription dispensing errors all too well. Sheldrick lost her eight-year-old son, Andrew, in March after he ingested the wrong medication.

“We had no idea this could even happen,” Sheldrick told Global News earlier this week. “I remember the paramedic holding me up just saying sometimes this just happens with kids and you need to be prepared for that.”

A coroner’s report found that the bottle of medication Sheldrick had picked up from her pharmacy didn’t contain Tryptophan, the sleeping drug her son had been prescribed. The report indicated the boy had taken a toxic dose of Baclofen, a muscle relaxant.

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READ MORE: Ontario mom wants mandatory prescription-error reporting across Canada after son, 8, dies

The Ontario mother is now calling for prescription error reporting systems to be mandatory across Canada.

A report from the University of Toronto found Canadian pharmacies filled roughly 625 million prescriptions in 2015. Medical experts who spoke with Global News say there is very little data examining the issue and how often pharmacies make mistakes in dispending the wrong meds.

 “We know [medication errors] are under reported if they are reported at all,” said Sandi Kossey, senior director at the Canadian Patient Safety Institute. “There needs to be a greater focus on reporting [errors] and using that information to learn and improve.”

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

The Nova Scotia College of Pharmacists implemented SafetyNET-RX, a research and outreach program, in 2010 that requires its pharmacists to report all errors to The Institute for Safe Medication Practices (ISMP) Canada, an independent non-profit.

“We don’t have good data to define how big the problem is yet,” Sylvia Hyland, a senior director with ISMP. “The optimal next step is to see the [Nova Scotia] model spread across Canada so we can get a national picture of prescription error reporting.”
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Saskatchewan’s College of Pharmacists introduced COMPASS, a similar system to SafetyNET, but it’s based on voluntary reporting.

Neil MacKinnon, a member of the team that helped create SafetyNET-RX, said the program was designed to improve safety at community pharmacies.

“[SafetyNET] includes the mandatory anonymous reporting of errors and near misses to ISMP Canada,” MacKinnon said, adding that the roughly 300 pharmacies in N.S. are required to have documented quarterly meetings and a “yearly, comprehensive safety self-assessment.”

A report from ISMP’s Community Pharmacy Incident Reporting program found that between 2010 and June 2016 there have been 103,258 incidents reported from Nova Scotia, Saskatchewan and New Brunswick, including 887 incidents that contributed to harm and two cases may have resulted in deaths.

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MacKinnon said the majority of these errors were reported in Nova Scotia and are considered “near-misses,” meaning the error was caught before a medication was given to a patient.

Ontario Health Minister Dr. Eric Hoskins said the province is looking at the Nova Scotia program and is committed to working with the College of Pharmacists on the issue.

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“Let’s look at different models that do exist in other parts of Canada or indeed the world, that we can put in place; measures to minimize, if not eliminate that risk from happening in the future,” Hoskins told Global News.

Sheldrick described her meeting with Hoskins as “extremely positive ” and said she is taking her campaign nationally and hopes to meet with Prime Minister Justin Trudeau and federal Health Minister Jane Philpott.

A spokesperson for Health Canada said the agency has an going “commitment patient safety” but stopped short of saying whether a mandatory reporting was necessary.

“Health Canada funds and actively participates in the Canadian Medication Incident Reporting and Prevention System (CMIRPS), a voluntary national program whose goal is to reduce and prevent harmful medication errors in Canada,” Andrew Gagnon said in an email. “In Canada, Pharmacies and Pharmacists’ Scope of Practice, including the reporting of dispensing errors, is regulated under provincial/territorial regulatory authorities.”

*With files from Angie Seth

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