Pharmacies to implement mandatory reporting of medication errors

Ontario pharmacies will soon have to report medication errors to an independent third party, a move that is being applauded by the mother of a boy who died after a medication mistake.

The council of the Ontario College of Pharmacists voted unanimously at a recent meeting to approve a standardized quality assurance program for all pharmacies in the province, which will start to be implemented in the fall.

One morning in March 2016, eight-year-old Andrew Sheldrick didn’t wake up. His mother, Melissa Sheldrick said a police investigation revealed her son died as a result of an overdose of a muscle relaxant that was in his pill container instead of medication to help him sleep.

“It was a substitution error. They grabbed the wrong medication,” Sheldrick said. “It was a refill. Just a refill.”

She met with Ontario Health Minister Eric Hoskins, who pointed her in the direction of the pharmacists’ college for a remedy going forward. Shortly thereafter the college formed a task force that included Sheldrick, who provided a patient’s perspective.

Andrew would have turned 10 years old Monday, Sheldrick said.

“He was full of life and energy and he loved his Xbox, he loved his swims, he loved soccer,” she said. “He was really kind and caring. He’d be the kid in the park who would say, ‘Let’s go play.’ ”

Nova Scotia is currently the only province that requires mandatory reporting of medication errors by pharmacists to an independent body. The Ontario pharmacists’ college said it also looked at Saskatchewan and New Brunswick, which are in the early stages of bringing in a similar program.

The Ontario college hopes to have 100 pharmacies signed up to the new reporting program by the end of the year and all pharmacies by the end of 2018.

The components of the program will include reporting to an independent third party that captures both errors that reach the patient and near misses that are caught beforehand, according to the college, as well as an analysis of that data to understand what happened in order to prevent future mistakes.

“You can’t eliminate human error, but you can minimize it,” Sheldrick said.

“One good thing has come out of this horrible, horrible situation .... People say to me, ‘You’re so strong to do this,’ but really it’s about finding one good thing and it’s about my grieving process and it also gave me a sense of being productive in a situation I couldn’t control.”

It was a substitution error. They grabbed the wrong medication. It was a refill. Just a refill.