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.
“He was given three times the lethal dose for an adult,” Sheldrick said. “So it would have stopped his breathing. It would have just stopped everything in his body… quickly.”
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.
At the time, Nova Scotia was the only province in Canada to have mandatory pharmaceutical error reporting. But her calls for change are working.
In June 2017, the Ontario College of Pharmacists unanimously endorsed implementing a medication safety program for all pharmacies in the province.
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.
VIDEO: Ontario College of Pharmacists to soon implement mandatory error reporting
The Ontario College of Pharmacists recently announced that third party will be Pharmapod Ltd.
“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,” CEO and registrar of the Ontario College of Pharmacists, Nancy Lum-Wilson told Global News.
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.
“There is training that needs to happen, there is a ton of work that needs to happen to get them there but through this process, we can learn and work out any bugs that are there so we have a system when we roll it out across all 4,200-plus pharmacies,” Lum-Wilson said.
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.
“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,” Lum-Wilson explained.
“For example, let’s just say we received all of this aggregate data. We understood there were a number of near-misses that were happening across the board at a number of different pharmacies and there were certain processes and workflow that were in place in these different pharmacies.
“So what would happen now is we would be able to analyze all the data because we could see a trend. Then we would say what is happening with this process and then we could work collaboratively to develop a different approach to this.”
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. “As more pharmacies begin to use the program, we naturally expect to see an increase in the number of reported incidents. We then anticipate seeing the number of medication incidents decrease over time once improvement activities are implemented based on analysis of the data that will now be available due to mandatory reporting”, Todd Leach with the Ontario College of Pharmacists explains.
The College also points out accountability in pharmacies and among pharmacists is key and has always been in full practice at the College.
“When we are looking at this from the patients’ perspective, they will always have the opportunity to make a complaint and the College will always investigate. On the other side of it, when we have the medication safety program that is going to be running in parallel, that then allows us to learn and put systems in place that will actually reduce the overall errors in the system, have us learn from it, and thus have better outcomes for patients,” Lum-Wilson told Global News.
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.
Sheldrick has been working with each of the Colleges, telling her story and offering her own recommendations to ensure the best practices are implemented.
“Andrew was an incredibly caring kid,” Sheldrick told Global News. “It actually helps my grief process. It makes me think that I can actually do something in a situation that I can’t do anything about. And it keeps his spirit alive knowing that all of this is for him.”