Feedback for Implementation of Continuous Quality Assurance for Medication Safety

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.

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