Feedback for Implementation of Continuous Quality Assurance for Medication Safety

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.

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