Feedback for Implementation of Continuous Quality Assurance for Medication Safety

1.
Pharmacy Technician  ·  March 31, 2017

I believe the standards of practice allow for continuous quality assurance already but this will be a good supplement to the standard guidelines.

2.
Pharmacist  ·  March 31, 2017

Currently most hospitals have an in-house reporting system for medication incidents or near misses, as well pharmacists art to report to ISMP. Community Pharmacists also report incidents and near misses via ISMP. With OCP reporting, this will be a 3rd report that will need to be completed for one near miss or incident. Moreover, if you are a consultant providing services for a client hospital, there may be a fourth requirement for reporting within your company. Has the college considered a `one-stop' reporting system that will integrate data into ISMP reporting systems? Thank you for providing an opportunity for response and questions.

3.
Pharmacist  ·  March 31, 2017

Good program which would prove beneficial to all pharmacies, without worry of OCP intervention, and via shared info would help provide better patient outcomes, and future error prevention

4.
Pharmacist  ·  March 31, 2017

Have had an in-house reporting form the the last 15 years. I support the development of an anonymous reporting mechanism for both professional and personal reasons. We ask for the public's trust in our services so we must be prepared to show we are committed to providing a safe dispensing system..

Pharmacist  ·  March 31, 2017

I am in favor of improvment of profession. Given the time frame and remuneration loss should be kept in mind. New graduates and practising parhacists over the years it is a challenge.

5.
Pharmacist  ·  March 31, 2017

The program/tool should make entries mandatory. As part of a pharmacist's daily practice, he/she should enter near-misses or errors daily (almost like maintaining a learning portfolio for error prevention). With enough assurances that the information will not be used for undue accusations, pharmacists should also be reminded that it is next to impossible to have a daily practice without a near-miss or an error.

6.
Pharmacist  ·  March 31, 2017

I agree wholeheartedly with the idea that this plan puts forth. However it is asking a lot of the staff in the madhouse that is a pharmacy dispensary to comply with all the technical and clerical suggestions that are mentioned.

7.
Pharmacist  ·  March 31, 2017

There are various med incident/ADR reporting tools out there, some that are much more user-friendly than other. I think that care should be used and feedback elicited while developing a tool that captures relevant data (eg contributing factors, outcome, suggestions, etc) and is also user-friendly. I would recommend submitting a draft of the reporting tool to the volunteer pharmacies and carefully considering feedback from the end-users.

8.
Pharmacist  ·  March 31, 2017

I think it is good idea but should be publish for pharmacy's team to proven same error.

9.
Pharmacist  ·  April 1, 2017

Sharing information on errors or near misses will help prevent such incidents to be repeated. Implementing the proposed program in two steps is a good idea, as report given by pilot pharmacies could be used to monitor and make enhancements to it.

Pharmacist  ·  April 17, 2017

If such sharing of information will "help prevent repetition" then why do they still continue when every case before the Discipline Committee carries a general deterrent component for the profession? I don't believe this for a minute, because it's already in place via reports from Discipline and yet you see the same types of incidents repeat themselves -- often with no increased penalty. The public expects to be protected by the regulatory authority, as it always states that its actions must be "public interest" first. To possibly suggest that by self-reporting a level of "protection" is now instituted does a disservice to the public. Once a type of error is reported to the membership (e.g., via Pharmacy Connection or other means), from that date forward a similar incident occurring should be met with increased consequences, which would send the message that errors are not "something that goes with the turf." We're the gatekeepers -- the last bastion of protection for the patient -- and we're taught to do everything in systems, procedures, etc. to prevent any type of error from occurring.
So let's not suggest that "voluntary reporting" should be allowed to lessen the consequences, especially when a pattern of such behaviour is shown and those reports are not deterring such incidences. That also has to be considered here.

10.
Pharmacist  ·  April 1, 2017

A lot of thought needs to be put into this. What constitutes an error? There are mixups that happen behind the counter in a retail pharmacy that are then caught and never reach the patient. What types of errors must be reported? Will there be a 'severity scale'? Sometimes a patient will call and say "just fill all my meds" without being specific. Most are filled, one is missed. Is that an error? I can uderstand the intent of this - and I agree that error reporting can be helpful, but the committee setting this up will have to be very specific about what needs to be reported and what doesn't.

Pharmacist  ·  April 17, 2017

I agree 100%. In the processing of an order, until it is released to the patient or patient's agent (i.e., out of control of the pharmacist/pharmacy) it is not an error. Why? Because what gets to the patient is, in fact, what is ordered by the prescriber.
Taking your comments one step further, in preparing a prescription and doing calculations (where we're taught to triple check our calcs) if you detect a calculation error initially, this should not be a "near miss" or an "error." Checking is part of the dispensing process, designed to ensure that the accurate preparation is dispensed to the patient. I can't recall any such initial calculation issue being the subject of any complaint or disciplinary process at the College.

11.
Pharmacist  ·  April 1, 2017

Most times errors are due to rush rush rush. Patients do not want to wait longer. Although mandetory reporting is a good idea it is retrospective. It wont stop that particular error. As a pharmacist working in community pharmacy, my say is that there should be AVERAGE limit on number of scripts being checked by pharmacist. Like some US states have, if pharmacy is doing more than 150 scripts in a day (12 hours), pharmacy owner should add additional pharmacist. Its like per prescrption and per patient....how many minutes can a pharmacist spare on average? Too less is a chance of error. Thank you.

Pharmacist  ·  April 17, 2017

Another point well made. For years, the concern about a "ratio" has been made and yet it has not been brought to bear within the profession. Now, they look to place more documentation requirements on pharmacists without having implemented the ratio safecheck. Why?

12.
Pharmacist  ·  April 1, 2017

The CQI/CQA will not standardize the practice but will also bring consistence. The major benefit will be tabletting the results across different practice landscapes and perhaps identifying trends. Practitioners would however need to treat each error/near miss seriously and review all contributing factors and develop systems that would minimise of prevent the safety/quality issue. Regular communication between DM and the staff would be key to the success of this program. DM need to sell MSSA and accountability given that the current belief is that of blame and punishment

13.
Pharmacist  ·  April 1, 2017

Community Pharmacies do have an in-house form for medication incidents or near misses ( OCP Tools ) ISMP reporting system is also available for Community Pharmacies OCP should consider setting up a ' one-stop ' reporting system to facilitate the process of reporting Thanks

14.
Pharmacist  ·  April 1, 2017

Great idea on third party reporting and learning from trends and wide-spread practice issues. CQI/CQA programs are not a new idea. I worry about the reality of putting theory into practice. Just in the last 2 years, there have been a lot more administrative and bureaucratic downloading to pharmacy managers, pharmacists and pharmacy staff. Is the pendulum swinging too far to the other end without true consideration on the impact and consequences to developing a stronger profession and higher level of quality real-time patient care? As a pharmacist for over 3 decades, I have seen numerous changes that have not resulted in better and true value-add patient care but, on the contrary, more transaction, self-promoting and self-preservation fueled actions and outcomes. It is deeply concerning to see what has and is still happening to the profession and thereby patient-care. Unfortunately, the matter of patient safety is much broader than CQA and requires us to have a completely different mindset on changing how interprofessional and pharmacist-patient interactions occur in daily real-time practice to solve the real and complex health care issues today. I also think that the influencers, leaders and people with authority need to look at the puzzle and think very differently, thereby flipping the model upside down and even sideways if need be. Outcomes have a big part to play in driving an individual's actions.

15.
Pharmacist  ·  April 1, 2017

Mandatory reporting will certainly help identify opportunities that exist and sharing of best practices. With that said, mandatory should not necessarily be time consuming. I am hoping a secure web-form that is easy to fill out will be implemented.

16.
Pharmacist  ·  April 1, 2017

It's fantastic to implement this program but shouldn't we first make handwritten prescriptions obsolete? Med errors can come from misinterpretation of a poorly written or worded hand written prescription, yet we're still stuck decifering them every single day. Calling dr's to confirm what they've written, yet the dr is gone, unreachable, etc. Anyone who works in quality control would be astonished at the fact that we're still decifering these prescriptions. This should be the first step. The lack of quality control in pharmacy is appalling

17.
Public  ·  April 2, 2017

Please implement all the recommendations of the Task Force in full, urgently and permanently with no foot dragging.

18.
Public  ·  April 2, 2017

I support the need for this quality control mechanism as I have been given the wrong medication and have been given the wrong format that included ingredients that I am allergic to despite reviewing my allergies and them being on file.

19.
Pharmacy Technician  ·  April 2, 2017

I look forward to the implementation of standardized reporting. It sounds like it will be more consistent for everyone and best for patient safety.

20.
Pharmacist  ·  April 2, 2017

Advantage of this process is numerous. Other than what is stated in the OCP site, it will lead to data mining and will lay the foundation of development of AI. This will not work if data is not good, so the importance should be laid out to all and accumulated data should not be a property of third party and must be public.

However voluntary reporting will not work unless an incentive is provided that the insurance cost will go down once a pharmacy complies. This is what we see in the financial sector.

21.
Pharmacist  ·  April 2, 2017

I am a hospital pharmacist working in an outpatient clinic, but I have a lot of previous experience working in community. I'd like to suggest 2 things:

1) Community pharmacists when reporting an error should/must also be able to document details of their shift, e.g. working 16 hour days, no breaks, no lunch, etc. I don't know why we are exempt from labour laws requiring employees to have breaks, but I hope we don't wait til a poor exhausted pharmacist working back to back 16 hour shifts makes a mistake that kills a patient and the media goes on witchhunt after pharmacists, until something is done....but that's probably what's going to happen.

2) I'd like to be able to report mistakes that other pharmacists have made. I see it all the time in my outpatient practice, and I would like be able to provide this feedback in case it helps prevent similar errors in the future.

Pharmacist  ·  April 17, 2017

Re your comments in 2): as part of the renewing of individual certificates of registration this year, one has to attest to having read and understanding the Code of Ethics.
As such, sections 2.18 and 4.10 are worth reviewing, as they address the specific point you are discussing.

22.
Pharmacist  ·  April 3, 2017

A lot of thought needs to be put into this. What constitutes an error? There are mixups that happen behind the counter in a retail pharmacy that are then caught and never reach the patient. What types of errors must be reported? Will there be a 'severity scale'? Sometimes a patient will call and say "just fill all my meds" without being specific. Most are filled, one is missed. Is that an error? I can uderstand the intent of this - and I agree that error reporting can be helpful, but the committee setting this up will have to be very specific about what needs to be reported and what doesn't.

23.
Pharmacist  ·  April 3, 2017

It is a very good program,however all prescriptions issued by doctors and other health care professionals should be written electronically and reviewed thoroughly. Narcotic prescriptions should be designed specifically for Narcotics, controlled and targetted substances and to be written electronically. Too many errors are due to hand written prescriptions or the doctor didn't review what he wrote.

Pharmacy Assistant  ·  April 4, 2017

During my community placement, one technician tried so hard to know the doctor's handwriting, then I said why not ask the doctor, she replied:" Doctors do not like pharmacy asking for their handwriting. " It is so true, the basic reason I went to pharmacy technician program is to learn the meaning of my family doctor great Rx writing.

24.
Pharmacist  ·  April 3, 2017

There is already a national incident reporting system through ISMP (especially useful for hospitals) which reports back national issues with suggestions for altering current practice. ISMP also uses these incidents to improve QA with respect to hospital accreditation standards. Please review this method of furthering your goals so as not to duplicate reporting programs. Thanks,

Pharmacist  ·  April 17, 2017

Should consideration, if this is to be rolled out, not be given to such incidents being required to be reported by practitioners (as this definition is broadening)? Physicians, dentists, veterinarians, nurse practitioners, etc. when they create a "medication incident"? There, too, it's voluntary reporting and why make it mandatory for one profession and not others?

25.
Pharmacist  ·  April 3, 2017

I think reporting to a third party will be nice, if it will replace reporting to the collage, gathering the info for database is a good idea. as long as it is not another form, if the form going to the third party can be accessed by the collage that will help minimizing the paperwork.

26.
Pharmacist  ·  April 4, 2017

I think implementing it in two phases is the smartest thing to do. It is hard to think of all the issues without a test phase. Interesting the we will have anonymous reporting but not anonymous comments for the college. I think reporting is always fine

27.
Pharmacist  ·  April 4, 2017

Continuous Quality Assurance and Improvement is critical. Any mandatory reporting framework must be user-friendly and be able to integrate easily into the daily workflow of a busy pharmacist. A new system must avoid duplication and build off of learnings and best practices from other jurisdictions.

28.
Pharmacist  ·  April 4, 2017

I certainly applaud the College taking a lead on implementing mandatory medication incident reporting.

The majority of my pharmacist career has been spent as a “third party” observer, as I have primarily worked in ambulatory care (dialysis), home care, LTC consultant and as a consultant pharmacist for medication safety projects.

During this time, I have discovered many medication errors. I have dialogued with their community pharmacists – sometimes with good results – other times, pharmacists not accepting accountability or even concern for the patient.
In particular, I have been very disappointed with some independent pharmacist, who are the owner/manager/staff pharmacist, who shrug off an incident with “I’ll have to be more careful next time”. How will mandatory reporting be enforced for sole practitioners? How will this happen? “pharmacies will also be required to do more to ensure they are learning from medication incidents and reducing the chance of recurrence”

Due the nature of my jobs, many of these errors have stemmed from a hospital discharge prescription. An opportunity exists to collate regional data, to share back with local hospitals on how they can improve transitions, wrt to medications.

SO my points to consider: Ensure data fields are available to collect items such as source of Rx, handwritten vs computer generated vs e-prescribed, # of Rxs on prescription, received timely from source, patient or caregiver engagement, near miss (intervention prevented it getting to patient – that is such a positive metric to collect), related to technology etc. Great review just released http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2017/Mar;14(1)/Pages/01.aspx Clearly define what is a medication incident, so that everyone is on the same page – I’m assuming that the definition on ISMP Canada’s page will be used? https://www.ismp-canada.org/definitions.htm • Example: Pharmacy dispenses new Spiriva Respimat in original box – does not assemble prior to dispensing. Patient receives and does not understand how to assemble so does not use • Fragmin is ordered at 15000 units sc daily. Pharmacy does not have any weight on file and does not verify dose – thereby facilitating a patient to be overmedicated leading to bleeding • Methotrexate 10mg orally weekly by the rheumatologist. No one makes the association that the patient is being followed by a kidney specialist and has renal issues – despite the med profile suggesting it (calcitriol, replavite – Rx’s from nephrologist). No attempt is made to verify serum creatinine prior to dispensing (and this example also goes for the new anticoagulants and oral/injectable hypoglycemic etc.) Lastly, please incorporate the pharmacists who are working in clinical roles throughout the system (FHT, home care, chemo clinics, dialysis, diabetes clinics, hospital admission etc.) When they discover errors, how can they report? If they have to depend on the community pharmacist to report on their behalf, I fear that it will not be done.

Thank you for your time.

29.
Pharmacist  ·  April 5, 2017

I think it would be a good source of information. It would allow myself to see what kind of errors or near misses others had encountered and what were the contributing factors. It would be good to know which medications frequents the list or which medication is trending. How can the college help? There should be at least a minimum training requirement for pharmacy assistants before they are allowed to work in the dispensary. Managers should be required to bring properly trained staff and not just anyone whom they can pay minimum wage. Otherwise you don't have a assistant , instead you have someone that you assists to do thier job. Sometimes errors happened when there are too many errors happening. You are good at catching it but sometimes one slips away.

30.
Pharmacist  ·  April 5, 2017

Please clarify the responsibility of hospital pharmacies as in house reporting for medication errors are reported by phramacy staff as well as non pharmacy staff clinicians.

31.
Pharmacist  ·  April 5, 2017

It is great idea to implement this program and Share these informations would help to minimize errors. Pharmacist has to report incidents to ISMP . Keep a copy of the report in the Company and implement action plan for error prevention .

32.
Pharmacist  ·  April 5, 2017

ensuring high practice quality standard translate to better safety practice and reduce dispensing errors.

33.
Pharmacist  ·  April 6, 2017

The program will help in sharing information and learning among pharmacists and will help the college and other bodies to have access important data about errors. They can create from the data important outcomes that can help in error prevention, improving patient outcomes and enhance public trust.

34.
Pharmacy Technician  ·  April 6, 2017

It’s always a good idea to improve quality of work. I’m enthusiastic to support improvement. However, the issue is more complicated than just report a mistake and never make it again. We already have ISMP, at our pharmacy we also have internal incidents reporting system. Adding more paperwork or just extra writing will take more of that precious time we already don’t have enough. We don’t make mistakes on purpose! Rush is a major donating source (sometimes dispensary feels like a factory conveyer). Doctors with their terrible handwritings contribute a great deal - calling, faxing, trying to reach them to clarify a prescription takes a lot of time. Medications going on back order “help” as well. And so on, and so forth. Would be very helpful to have one centralized system that includes all the parties, and observes all the factors.

35.
Pharmacist  ·  April 6, 2017
  1. Do you see the CQA program benefiting practice in your own pharmacy?

Not sure, as at Costco we are sharing these kind of proposed details internally and analyzed by our dead office already. Means we have a full system in place to track trends, errors, near miss, etc. On top of that details by whether the error coming from a copied prescription or a new one, lots of details.

  1. What would support successful implementation?

Transparency is the key, once happened report it in full. Again at Costco the consequences of not reporting is far more serious than reporting on time.

  1. How could the College help with the implementation?

Use Costco as an example to educate the pharmacists. Our forms are thorough and the analysis is spectacular far exceeding the industry standards. By the way that is happening in all areas of our practice, we are obliged to do a weekly full narcotic reconciliation!

  1. What are you are already doing in your pharmacy around CQI and continuing quality assurance?

I think I answered that already, each case is fully documented on time and reported to head office. each pharmacist has the full authority to report any error even my own errors- as a pharmacy manager-.

  1. Is it reasonable to implement the CQA program in two phases?

No, one giant step is needed

36.
Luseland Pharmacy Ltd  ·  April 6, 2017

In Saskatchewan SCPP is implementing COMPASS, their acronym for medication incidence reporting and charging community pharmacies an extra $500/year on our permits for the privilege.

37.
Pharmacist  ·  April 6, 2017

I'm glad that our profession continues to focus on quality assurance and better patient healthcare outcomes. We have worked hard to be recognised as valuable healthcare professionals and policies and programs to improve our work are essential to maintain what we have already achieved

38.
Pharmacist  ·  April 7, 2017

preferably on an on-line format to cut down on paper-flow, also linked to pharmacy software programs like kroll etc,security of site to prevent identifiable factors,

39.
Pharmacist  ·  April 7, 2017

A lot of good points have been made that I agree with. I support a mandatory reporting system, and evaluation of these reports that lead to recommendations and change. I think the reports should be made directly to ISMP, as they have a huge amount of expertise in this and have the infrastructure and dissemination means to support this initiative. They will likely need increased funding and staff.

I want to focus my comments on the Ontario Government's role in this. If my calculations are correct, there have been $1.25 billion in cuts to pharmacies in recent years. It is also my understanding that there are 2,000 pharmacists out of work in the province, and wages have plummeted by as much as 40 to 50% in some areas. I personally have been unemployed since being laid off because of the cuts 3 years ago. I've had to leave the province to look for work, which after 8 months I have finally secured a job in a very small town in Alberta, albeit in retail rather than in my specialty field of psychiatry and addictions.

The pharmacy staff that remain after the cuts are understaffed, overworked, overwhelmed and burnt out. It is a small wonder that there are errors. It is high time that the government take responsibility for their major role in this!

40.
Pharmacist  ·  April 8, 2017

I think it is good idea to share information on errors will help prevent any incidents to be repeated. For improvement of our profession.I totally agree with the idea that this plan be implemented.

41.
Public  ·  April 8, 2017

As a parent, I trust and rely on our local pharmacists as an important part of our medical system.

Error reporting could help identify common patterns or errors that occur frequently across locations. This could assist in procedure improvements and/or label changes to support the pharmacy teams.

Pharmacy is a difficult line of work. Anything that can be done to further support the profession should be.

Pharmacist  ·  April 17, 2017

Thank you for contributing your perspective as a member of the public.

Your suggestions are wonderful; but a problem is going to be that since this "incentive" is to be anonymous in terms of reporting, a repeat offender will not be identifiable in order to allow an oversight body to deal with "errors that occur frequently across locations."
That alone defeats the purpose of this exercise if such locations can continue to "comply by reporting" but not be held accountable for repetitive incidents that don't effect prevention!

42.
Pharmacy Technician  ·  April 9, 2017

This is a great step to built quality into the process of dispensing of a drug through quality assurance process in a consistent manner, which will ensure the patient safety. Furthermore, our commitment towards patient safety is unconditional. We are accountable and responsible through social contract to ensure the patient safety. In the bigger picture the outcome will further consolidate the trust of the profession.

43.
Pharmacy Technician  ·  April 10, 2017

It is unclear in the document Continuous Quality Assurance Programs in Pharmacies if it refers to hospital pharmacies as well because the article only mentions communities pharmacies. I am speaking on behalf of hospital pharmacies who are now regulated by OCP. This initiative should include hospital pharmacies. We have been reporting all medication incidents voluntarily to ISMP Canada for about 12 years, which has been tremendously helpful in understanding systems and human contributing factors to errors. I agree it should be mandatory reporting but we have to be careful how to implement this. It is very time consuming to report all incidents including near misses, not to mention the time it takes to do root cause analysis for some critical incidents. Incidents happened in the community are very different from incidents happened in the hospital because there is another complex layer of administration by nurses. Hospitals are already mandated to report critical medication and IV incidents to NSIR for a few years but the system is very too cumbersome and time consuming. We use ISMP Canada's Analyze-ERR tool which is manageable. I suggest in the task force, there needs to be a physician, nurse, and patient rep in addition to pharmacists and technicians, or patient safety related personnel. Perhaps there should be two separate groups for the phase 1 and 2 - community pharmacies vs hospital pharmacies. Perhaps the focus of analysis should start with high-alert incidents before tackling all incidents.

44.
Pharmacist  ·  April 10, 2017

The initiative sounds promising and logic theoretically. Practically, the OCP has to work on clarifying when to report and encouraging the reporting in a reassuring not threatening or punishment environment.

45.
Pharmacist  ·  April 12, 2017

Many hospitals already have mandatory reporting systems in place for patient incidents including medication incidents. Integration with existing systems would avoid duplication and improve compliance.

46.
Pharmacist  ·  April 12, 2017

Handwritten prescriptions can lead to errors.Rechecking with MD office is time consuming and delays patient care. Thoroughness should not be compromised for speed,as each prescription requires some amount of therapeutic analysis by the pharmacist.In very busy pharmacies the pharmacist is under tremendous pressure to churn out prescriptions super fast, speed in filling prescriptions is dangerous just like speeding in traffic, unfortunately unlike in traffic there is nobody to monitor if someone is going too fast, on the other hand, the pressure is do even faster. Maybe there should be some kind of reportable time frame established for filling different kind of prescriptions as a quality control measure.

Pharmacist  ·  April 15, 2017

I agree.

Pharmacist  ·  April 17, 2017

Um....deciphering a prescription and ensuring it is accurately filled IS OUR JOB, isn't it? Come on; this argument is becoming tiring to hear as a professional that accepted this responsibility upon entering the profession! If it's taking too long to do the job, then maybe more staff are required. You can't continue to escalate your prescription volumes and then not have adequate staff to do it right/safely. That's trying to suck and blow at the same time. And e-prescriptions already have studies out that show they still contribute to errors. They're not a magic preventative.

47.
Pharmacist  ·  April 12, 2017

I would hope for a reporting tool that is easy to use and not cumbersome (i.e selecting from list of what "error" is) - with the ability to also have a place to describe the errors if necessary.

48.
Pharmacist  ·  April 12, 2017

I am always dismayed that the College of Pharmacy does not include hospital pharmacies in its overall vision - we have had medication incident review channels for years. This makes me feel that retail pharmacy is considered "real" pharmacy and that hospital pharmacies are just a tag-along after-thought. Exams aren't focused on our experience and now this review is reinventing the wheel for "pharmacy" in Ontario when it is already ion place for a viable segment of pharmacy. I don't know whether the College does this deliberately or if this an oversight? I hope that changes in the future include hospital pharmacy from the beginning or at least as a separate but equal entity. If we need more input from the hospital pharmacy segment, then please contact us!

49.
Pharmacist  ·  April 13, 2017

Implementation of Continuous Quality Assurance for Medication Safety This program would definitely benefit any practice; however we already have an organization that has started and implemented such a program. ISMP has a national incident reporting system. To prevent duplication in implementing the CQA program, ISMP should be approached/involved to identify the barriers especially with the retail community. For any program to work, we require:

  1. Concise Guidelines on exactly what should be reported, easy forms to fill (independent, franchise,… to have it on line), reporting system changes
  2. Education “Pharmacists must learn to detect medication errors, actual or potential, to understand their causes, and to propose system wide changes to reduce the risks to patients” David U, ISMP
  3. Accountability. Who is accountable to fill and document errors especially if manager is the owner/ pharmacist on duty and what incentive would be provided to stores to report medical errors?
  4. Support. Overall support from all pharmacists to embrace this program. Support from manager/owner/associate to make changes i.e. scheduling, increase staffs. We are trying to improve our profession with added value to our services i.e. injection, minor ailments,…. and thus adding more administrative and bureaucratic work on pharmacists/technicians/manager. Overstressed and overworked pharmacists will make errors.
  5. Sharing Data collection from third party to provide quality improvements. Sharing process to help understand what mechanism needs to be in place to minimize errors in retail stores or hospitals.

Support, thinking outside the box and culture shift would be required from our College as well as throughout the healthcare community to see this program accepted and succeed.

50.
Pharmacist  ·  April 13, 2017

Currently in hospitals we are required to submit a medication incident into our incident management system (including near misses/close calls). The proposal includes pharmacy reporting of anonymous medication incident data to a third party. Would this be a requirement for hospital pharmacies as well (duplicate reporting). Would we have to enter the information into another database? Would a copy of the hospital form completed by sufficient, or would there be mandatory fields required? Is OCP going to be reaching out to each hospital to take into account current reporting that is occurring to try to streamline current processes with the proposed change?

51.
Pharmacist  ·  April 13, 2017

Important Caveat: If you report to a 3rd party you might cause a lot of lawsuits that are unnecessary. The times when these unfortunate situations occur, management and staff has always gone over procedures etc. for the simple fact that no one wants these situations to occur again.

52.
Pharmacist  ·  April 13, 2017

While it is important to have a measure such as the one proposed in place for data purposes, the College must ensure that the collection of such data will not result in punitive actions to its members. Rather, the outputs that result from the initiative should be for education, quality improvement initiatives, and influence on future legislations. The reportable incidents should not carry direct penalties, accusations, or any sort of punitive actions or it will deter the valuable initiative of reporting and ultimately improving patient care.

53.
McKesson Canada  ·  April 13, 2017

Good initiative as the anonymity will encourage reporting and the blame mentality will be reduced. This is a good step forward in ensure safe practices and building trust and confidence in the patient population.

Pharmacist  ·  April 17, 2017

Dangerous, however, will be the aspect that in not being "punitive" it creates an acumen that suggests to the public that we accept errors occurring as being part of our professional practice. That should never exist, and so I would state that this process CANNOT BE A FACTOR IF A MEMBER OF THE PUBLIC legitimately pursues their right to file a complaint with the College. You cannot have that process then "temper" the consideration by saying "oh, they self-reported so we have to consider that as a mitigating factor in our decision." If that is going to happen, then this has to be reviewed because for internal "future prevention" purposes/system checks -- ok. But not to influence the complaint process in any way.

54.
Sobeys National Pharmacy Group  ·  April 17, 2017

In responding on behalf of our organization, we commend the action of the Ontario College of Pharmacists to implement a standardized continuous quality assurance program for pharmacies, including the reporting of anonymous medication incident data to a third party.
Our key feedback is a request for clarity around “anonymous” reporting. Would a centralized report submission solution on behalf of our pharmacies be permissible, such that the pharmacy is not required to complete double entry of the same error report information on both our internal platform and a third party platform?

Pharmacist  ·  April 17, 2017

The College should not be seen as "implementing a standardized (CQA)..." That is the responsibility of all pharmacies/pharmacists AND SHOULD ALREADY BE IN PLACE. In the past, the OCP has published suggested forms to use in terms of complaints, error assessments, etc. if they are not being used to date, what assurance does it give that now requiring reporting to a 3rd party is going to ensure that what should already be in place will be enhanced?

55.
Pharmacist  ·  April 17, 2017

Thanks for this consultation.

1) The move to make "errors" appear "a part of doing business" when we are taught that they are unacceptable is concerning. It's one thing to require reporting for statistical purposes; but to even consider there ought not to be consequences is a public disinterest.
Any such reporting cannot, in any way, be tied to assurances that if the complaint process is pursued by a victim of such errors, there will be lessened "penalty" by considering that a reply to the complaint that "I reported it" should lessen the impact of the offence. The systems should already be in place to prevent them from occurring, especially given case after case after case being reported to the membership in the official publication to members.

2) No sense of "nothing can happen to me if I self-report" can become the norm. The "other process" (right to file a complaint) has to be kept SEPARATE AND APART from "ISMP/anonymous reporting". The two cannot be co-mingled ("putting selves into the patient's shoes" is for the complaints process, not the "future prevention" aspect).

3) Publication of errors that proceed to a disciplinary hearing in the panel's findings include what the panel calls "general deterrence" for the profession. If a member practising at the time of publishing these matters doesn't use the case, findings, and penalty as "deterrence" against future such cases, then it's not a deterrence. So -- a future occurrence of similar matters after that time should ESCALATE the penalty...not be the same and not be watered down by the fact that "3rd party reports were made" because that should be the requirement in ALL cases as professionals. It should be "brownie points" if the victim files an official complaint to lessen the due process that the public expects -- because they "know" that errors are now reportable. But they still expect "justice" through the "public interest protection" mechanism afforded via the RHPA -- notwithstanding 3rd party reporting which should "lessen/eliminate" these occurrences according to why it's being required in the first place!

4) There are essentially only two categories justifying reporting: i) near misses (ie, caught before dispensing), and ii) errors (not caught and dispensed). Category ii) can be subdivided into "harm or no harm to the patient."
Who is going to know if "near misses" are not reported? If it's corrected before it's dispensed, it's of no negative impact to the patient. The record of dispensing will be accurate, and so, no trail for an OCP assessor to see will exist if it's not done. Since internal CQI should already be in place, these should be discussed at regular staff meetings and not require reporting to a 3rd party agency -- because if not done consistently, it's missing the intended goal.

5) Since the Code of Ethics that we all now are to have read requires (section 2.3) that "members disclose medical errors and "near misses"...these require definitions (as some have already commented upon) -- [Non-maleficience section].

6) So consider this now: you create a dbase somewhere that such incidents, in an ideal world, all get reported to. The busy pharmacist in today's reality signs on in the morning (or at shift start) and then...WHEN do they go to this user-friendly (ideally) dbase to review it, and WHERE do they go to review it without obstacles in their way?

It should be front and centre on the OCP homepage for achieving the goal of education and future deterrence, and be both public and member accessible since identifiers have been removed.

7) If this dbase will not be used to effect action on regular offenders within a specific location (similar to the MOHLTC not using the drug monitoring dbase to allow dispensers to check on specific locations, etc. unlike PharmNet in BC), then how, if a specific location reads the data but continues to commit errors, is the goal being achieved? Would the "efficacy" of the program not require reconsideration, if it's going to be kept?

Thank you.

56.
Pharmacist  ·  April 18, 2017

2 phases, absolutely. Let's get it right, practical, simple and useful before rolling it out. Otherwise it is just more work for everyone.

57.
Pharmacist  ·  April 19, 2017

In England one pharmacy chain has an inbuilt system in the dispensing software that tracks any cancellation of a processed prescription(filled prescription) by asking for a reason for cancellation eg wrong dose, wrong patient etc. These are then populated as errors/near miss. Building such system into the workflow would positively impact time management. I believe such a system can be developed and can anonymously transmit the data to a third party.

Pharmacist  ·  April 27, 2017

But please clarify, because it's very relevant: if the pharmacist does a final check, but when doing so discovers that a technician (or other) in the chain inputted something incorrectly (such as something as simple as a typo) and then they have to go back in and re-do it, cancelling it first -- why should that appear/be captured as a "near miss/error" when it's part of the fundamental fill/check process?

58.
Pharmacist  ·  April 21, 2017

Until Big Chains/Franchises allow for more help for pharmacy staff, all this talking won’t help.

The bottom-line that you are striving for……is NOT the same BOTTOM-LINE.

Yes it is business….. yet having been in independent business for 23 years……..business can be done better……not just for Head Office Bosses pockets!!!!

59.
Pharmacist  ·  April 23, 2017

I strongly believe that CQI helps in safe and effective dispensing. Timely reporting can help the Pharmacist to completely focus on safe dispensing. Reporting and discussing within the team would help one to be proactive .

60.
Pharmacy Technician  ·  April 26, 2017

First question ...do doctors and other health professionals have this same sort of initiative coming to their practice or is it just other make work project for pharmcies to take on and consume more of our precious time , leaving us struggle to keep up and focus on the real practice and that is to work in the best interest of the patient . But when the college keeps throwing more and more and MORE . very time consuming policies at us, there is not time left to do the real job anymore and that is to fill the prescription properly. For example...the implementation of scanning..total waste of many precious hours a day, patch for patch ...why are we responsible to police this FOR FREE and again time consuming . we need to get back to BASICS without all this added work and pressure follow policies that rarely have any influence on patient care

61.
Public  ·  April 27, 2017

As someone who has experienced a number of pharmacy errors I applaud this effort and the OCP for taking this project on. One question is once these errors are documented and in the 3rd party hands, how will pharmacists learn from the submitted errors? Given the time pressures identified by many on this page, they will not have time to browse all submitted errors. How will the learning take place? And finally is there a component which is for people like me? How can I learn and support my pharmacist to dispense the correct dose and format, etc?

62.
Pharmacist  ·  April 27, 2017

Working in hospital all incidents and near misses are documented in a software program. We are encouraged to report as much as possible and given recognition for coming forward and bringing to light any situation that may put a patient at risk. Medication incidents are not only reported by pharmacy staff but by other allied health including nursing and physicians. Anyone involved with the medication process from prescribing to dispensing to administration. With pharmacist time stretch thin whether in community or hospital I ask the college to consider this. If an employer already utilizes a software based program to document medication incidents then the employer and software vendor need to develop the means to pull out the required information and forward it to the College mandated Third Party reporting system. If pharmacists are required to report the same incident 2 or 3 different times then the volume and quality of what is reported will perhaps not be as robust due to reporting fatigue. If it is kept simple then not only will medication incidents be documented but near misses will be as well.

63.
Pharmacist  ·  April 27, 2017

I applaud this initiative. I think error reporting is educational. However, it completely ignores what is causing most errors in the first place: exhaustion. So many pharmacies are understaffed, and have pharmacists working 12-16 hours without a break. Head offices continue to push for speedy MedsChecks and other professional services but then base number of pharmacy assistant hours on number on prescriptions processed per hour. Finally, pharmacies are losing so much funding due to government policies. For example, if a patient insists on monthly filling but does not qualify, the PHARMACY must absorb the cost, because the government has specifically forbidden pharmacies from charging the patient or third-party. The OCP has some role to play in this, especially labour standards. Instead, we are now adding MORE paperwork. Also, some education needs to be done on the importance of error reporting. When I report an error, my assistants and even fellow pharmacists get mad because I "wrote them up".

64.
Pharmacist  ·  April 27, 2017

The more the better, we can learn from other cases. we have in-store sharing system already but if we share with more people we can prevent even better.i like the idea of two phases, we can develop the best option.

65.
Canadian Pharmacists Association  ·  April 28, 2017

As a profession, we are experiencing a time of increased scrutiny, which includes a focus on medication errors. I believe this is a good time for OCP to be developing a framework for mandatory error reporting; however, I also believe that we should be taking a national approach, so that there is consistency amongst the provinces. There is a role for NAPRA to develop a set of universal and national standards for mandatory reporting.

66.
Pharmacist  ·  April 28, 2017

the ONLY way to bring errors to near zero is to eliminate multitasking of the pharmacist and to let him concentrate. Currently pharmacists in retail in Canada are cashiers, phone operators, injectors, floor stock boys to direct customers where the diapers are, inventory counters..... , anything but their real job. This can only be achieved by forcing pharmacies to provide enough technicians and staff. If it is not profitable for their "business" they should get out of the "business" and start a fast food outlet! This must be a "profession" not a business. If college can do that (if they really care for people's safety), they have solved the root of the problem.If not, any other action is a minor detail and a waste of time.

67.
Muskoka Algonquin Health Care  ·  April 28, 2017

This initiative is welcomed by Muskoka Algonquin Health Care. There are a few minor comments to be considered: • The document is written as centric to pharmacists and pharmacy practice, and I am not sure that is the most useful, as the medication use circuit involves many different health professionals. • Reporting needs to be easy (downloads from electronic reports) rather than double reporting once to the internal system and then once to the external system will be essential to the success of the program. • Reporting to an independent third party, such as ISMP is important. • Standardized definitions of incidents are important – will it include near miss? Will it include incidents which did not reach the patient.

68.
Pharmacist  ·  April 29, 2017

Most of the retail chain have their own way of reporting an error if occurrd. Pharmacist should not be forced to report the errors because that will make them scared and less productive.

69.
Pharmacist  ·  April 30, 2017

I believe that mandatory reporting would be beneficial for all pharmacies to prevent errors in others.

70.
Pharmacist  ·  April 30, 2017

I strongly agree with implementing a standardized CQA program. I believe pharmacy staff will work more focused to prevent near misses and/ errors, and if dispensing error happened they can report without fear and owners or head offices will take it serious to review all contributing factors and to improve the area of practice. of course fairness is the key point. All pharmacy staff, owners and head offices support is necessary. for a successful implementation and is more reasonable to implement in 2 phases. I believe the root cause of majority of dispensing errors is Stress, understaffed, overworked and exhaustion which need proper resolution. in my daily practice to overcome these barriers I put all my personal issues and problems back the door, take a deep breath and only focus on my practice and patient care. I fortunately have enough time to check all steps of dispensing a prescription two times. All supplies, stock, files.....are tagged and keeping organized. General information about dispensing error, when,how and where to report is posted at the dispensary as a daily reminder and information purpose, and reporting forms are easily accessible. Near misses/errors notes in the communication note book, and focus is more on improving the quantity and quality of professional services rather than the prescription count. I found these strategies are very effective to prevent dispensing errors. Thanks

71.
Pharmacist  ·  May 1, 2017

Having implemented a similar program in hospital practice, I am sharing a few comments based on experience: - Definitions: it is critical to ensure clarity regarding defintions pertaining to an 'error' vs. 'incident', and to ensure referencing a source that is broadly agreed upon not only in Canada but world-wide - doing so will help not only the practitioners and team members reporting the 'error', but also ensure accuracy in data analysis and reporting so that this is meaningful, and can readily guide interpreting trends, comparing trends, and reporting results;

  • it will be important to have a consistent 'tool' amongst pharmacies - recognize that some may already have a process in place that they developed and is working well for them;

  • provide time to train and education as well as prepare pharmacies for the 'culture' change in making errors transparent;

  • remove the stigma of reporting through a 'no blame and no shame' mentally - we need to report to raise awareness to errors and enable continuous quality improvement - that it is not intended to negatively affect anyone's job/ role or be punitive.

72.
Ontario Hospital Association  ·  May 1, 2017

This response was submitted by the Ontario Hospital Association.

Read the full submission here.

73.
Canadian Society of Hospital Pharmacists - Ontario Branch  ·  May 1, 2017

The Ontario Branch of the Canadian Society of Hospital Pharmacists (CSHP-OB) thanks you for the opportunity to provide feedback on the ‘Implementation of Continuous Quality Assurance for Medication Safety’ Program. The Ontario College of Pharmacists (OCP) should be commended for the efforts to ensure safe, effective and ethical pharmacy services in Ontario.

Read the full submission.

74.
Pharmacist  ·  May 1, 2017

1) Do you see the CQA Program benefiting the practice in your own pharmacy? --> Yes. I believe reflection and analysis of incidents, both near misses and actual ones, is useful, and an important part of continuous quality improvement within a pharmacy. Oftentimes, when an error or near miss occurs, we do not take the time to reflect on how and why it occurred, as well as what we could do on a local/staff level to prevent it from happening again. I think we owe it to our patients to ensure that whenever incidents or near misses are made, that we take thoughtful action and considerations as to how we can ensure that we do our due diligence to improve on and learn from these occurrences. Just as with any intervention in patient care, if it wasn't documented, it did not happen. Likewise, if we do not document our CQA discussions and activities in a consistent or standardized manner, there is no evidence that these endeavours even occurred.

  1. What would support a successful implementation? --> Clear guidelines and details regarding the implementation of such a CQA program, with respect to, but not limited to: what constitutes a medication error and a near miss, what types of errors are to reported on, who should do the reporting/whose responsibility it is to implement the CQA process within the pharmacy, how and when training will be provided, etc. --> Also, a CQA program would not be as effective if there is a negative or blaming culture exists within the workplace. A culture of openness that does not allow for reprisal or blaming must be in place as the foundation for the CQA process to be established, and in order for the staff to fully engage in reporting.

  2. How could the College help with the implementation? --> Set clear, detailed guidelines on what should be reported, who is responsible, how and when the training will be provided to each pharmacy, helpful resources and tools, and encourage a culture of openness within pharmacies. Emphasize that this initiative is for patient care and patient safety, not as a punitive or burdensome activity. --> Set clear and detailed expectations on what the CQA program will entail, what it encompasses, and what each pharmacy should strive to

4) What are you already doing in your pharmacy around CQI and CQA? --> Informal and open staff meetings, alerts and reminders where previous near misses and errors have occurred, encouraging increased documentation to avoid communication gaps that can lead to potential errors, open verbal communication amongst staff regarding ambiguous or problematic situations

5) Is it reasonable to implement the CQA program in two phases? --> Yes. The transition should be gradual, as a CQA program is new and the lessons learned (of what went well and what didn't) can be gleaned and modifications made to improve upon the second phase

75.
Pharmacist  ·  May 2, 2017

We are currently using our incident report sheets to document any discrepancy in the pharmacy, which goes to our head office directly. I think this program encourage pharmacist to report incidents more easily without fear of punishments. Therefore, it can bring more safety and accuracy to pharmacy practice.

76.
United Pharma Group  ·  May 3, 2017

United Pharma Group (UPG) welcomes the opportunity to provide comments on the proposed implementation of a Continuous Quality Assurance (CQA) program for Medication Safety, including the reporting of anonymous medication incident data to a third party.

Read the full submission

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