New pharmacy program to prevent medication mistakes

Click to play video: 'New pharmacy program to prevent medication mistakes' New pharmacy program to prevent medication mistakes
Most of us have visited a pharmacy to pick up a prescription. For one Ontario woman, a fatal error there cost the life of her son. But now, there's a new program being launched in Saskatchewan to help prevent that from happening here. Jules Knox reports – Nov 2, 2017

Eight-year-old Andrew Sheldrick suddenly died last year with no warning.

“Not knowing why he died was a state of numbness, a state of questions. We worried about our daughter, we worried that maybe there was something we didn’t know,” Andrew’s mother, Melissa Sheldrick, said.

More than four months after her son’s death, police and the Coroner told her that Andrew had been given the wrong medication, she said.

“When we found out, it was traumatizing, and we were so angry,” Sheldrick said. “Just so many questions about how this could possibly happen, and just how and why and who.”

The Ontario woman started researching the situation and realized prescription errors weren’t tracked.

“When I realized that nobody was going to know about what happened to my son, I wasn’t OK with that. I wasn’t OK that these mistakes had been made and nobody was going to know about that,” she said.

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Sheldrick started working with Ontario’s College of Pharmacists to put together a framework for a program that would track pharmacy mistakes.

READ MORE: Ontario pharmacists move towards mandatory reporting of prescription-dispensing errors

Saskatchewan is now expanding its Community Pharmacy Professionals Advancing Safety in Saskatchewan, or Compass, program. It aims to record and prevent medication mistakes in a national database.

“It will basically go at the problem from three different places: by looking at what incidents have already occurred, by identifying the contributing factors, and then being able to resolve those and put processes in places to prevent them from happening again,” Jeanette Sandifor, Compass program’s project lead, said.

“It follows the dispensing process right from the beginning right till the patient gets the medication, so if there are issues around patient safety because of staffing, that will be identified.”

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

During a pilot project, more than 7,000 incidents were reported. Eighty per cent didn’t reach the patient, but one per cent caused harm.

A pharmacy participating in the pilot project said it has already made changes.

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“We self-reflected, we said you know what, any prescription for any child that comes into the pharmacy, we’ll need to obtain the weight and the diagnosis and ensure that it is appropriate,” pharmacist Spiro Kolitsas said.

The program will be mandatory across the province as of December 2017.

As for Sheldrick, her hope is that the program will spare another family from the loss she suffered.

“It’s very bittersweet because I’ve lost my son, which is the worst pain, but I’m pleased that progress is being made.”

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