AIMS (Assurance and Improvement in Medication Safety)

The Assurance and Improvement in Medication Safety (AIMS) Program supports continuous quality improvement and puts in place a mandatory consistent standard for medication safety for all pharmacies in the province. Its goal is to reduce the risk of patient harm caused by medication incidents in, or involving, Ontario pharmacies.

The program builds on the College’s existing expectation that pharmacies and pharmacy professionals are engaging in safe medication practices and continuous quality improvement, as described in in the supplemental Standard of Practice. This includes a requirement to anonymously report all medication incidents and good catches (near misses), document details, analyze and share learnings.

The purpose of the AIMS program is to identify trends and develop quality improvement solutions and recommendations to assist pharmacy professionals in reducing the risk of patient harm caused by medication incidents. To do this, AIMS requires that pharmacy professionals anonymously record data about medication safety incidents – including information about how and why those incidents occurred – into the AIMS Pharmapod platform. The tools and resources available through the AIMS Pharmapod platform are designed to support pharmacies in meeting supplemental Standard of Practice expectations in a consistent and standardized manner across the province.

Every community pharmacy has access to its own data, as well as provincial trends. The College publicly reports aggregated and de-identified data collected through the program, but does not have access to information related to specific pharmacies or pharmacy professionals

An AIMS Safety Insights Group (SIG) group comprising pharmacy professionals and data analysis experts was formed in 2021 to work with the College and the Ontario Drug Policy Research Network (ODPRN) to provide guidance and actionable recommendations for pharmacy teams, the pharmacy sector, and other health system stakeholders on how to improve medication safety. The AIMS SIG group is responsible for identifying recommendations based on data analysis, including key findings and proposed actions. Their first report is expected in 2024.

By recording medication incidents and good catches (near misses), and by using the continuous quality improvement tools and resources available in the AIMS Pharmapod platform, pharmacy professionals can proactively develop strategies to prevent future reoccurrences.

In addition, aggregated and de-identified data that is made available by Pharmapod is analyzed by the AIMS Safety Insights Group (SIG) group, in conjunction with the College and the Ontario Drug Policy Research Network (ODPRN), to provide guidance and actionable recommendations to improve medication safety.

Hundreds of thousands of prescriptions are dispensed every day in community pharmacies across the province and patients and the public should feel assured that pharmacy professionals are making patient safety the number one priority at all times. It’s important that patients and the public know that there is a medication safety program in place in pharmacies across Ontario to promote continuous quality improvement and enhance the safety of pharmacy care for all patients.

It’s also important for patients and the public to know that the information the College gathers through this program is anonymous and does not include personal health information. This program does not replace the College’s regulatory responsibility to respond to concerns about the conduct or safety of individual pharmacies or pharmacy professionals.

A core component of the program is the anonymous recording of incidents and good catches (near misses) via an incident-recording platform administered by a third party. Only aggregate, de-identified provincial level information on medication incidents and good catches recorded by pharmacies is available on the College’s website and shared across the pharmacy sector to support continuous quality improvement to improve patient safety.

Medication incidents can and do happen; however, it’s difficult to improve what we can’t measure. Understanding why these incidents happened, the outcomes, and how they can be prevented requires analysis and interpretation of the data into practice recommendations.

This is the first structured program in Ontario specific to community pharmacies that will lead to an improved understanding of the number, type, frequency, impact and cause of medication events in, or involving, Ontario’s pharmacies. It will establish clear expectations related to quality improvement and identify system-wide recommendations to reduce the risk of medication incidents across the province.

The information collected through the AIMS Program helps the College, together with its health system partners, to identify trends and develop recommendations to assist pharmacy professionals in reducing the risk of patient harm caused by medication incidents

No, the information reported through the AIMS Pharmapod platform is completely anonymous to the College and will not be used to launch an investigation. This is a fundamental component of creating a safety culture in healthcare. Health professionals are encouraged to record incidents and good catches (near misses) and should feel empowered to discuss them openly with their peers and colleagues without feel of punitive action. The goal is to share learnings and preventative measures and ultimately improve patient safety. The adoption of a safety culture in other parts of the health system has helped to improve patient safety, and the intent of this program is to help foster a similar safety culture within pharmacy.

In keeping with these well-established principles and best practices, the College will not be able to identify individual pharmacies or pharmacy professionals through the AIMS Program, which remains separate and distinct from our investigation functions.

While AIMS is an important new requirement that aligns with the College’s mandate to serve and protect the public, it is just one component of the College’s quality assurance initiatives, which include practice assessments, pharmacy assessments and the ongoing development of strategies and standards aimed at promoting safe, quality pharmacy care in the province.

The College continues to take its regulatory responsibility to respond to concerns about the conduct or safety of individual pharmacies or pharmacy professionals very seriously. If anyone has a concern about the care provided by a pharmacy or pharmacy professional, they can report information to the College through its existing complaints process.

If a medication incident occurs, it is the College’s expectation that the pharmacy staff act promptly to provide the appropriate support for the patient. They must then anonymously record the incident in the AIMS Pharmapod platform and activate the quality improvement process. This includes documenting what happened, analyzing the incident to determine contributing factors, working to identify how it can be prevented from recurring, and taking the necessary steps to accomplish that goal by applying and sharing quality improvement strategies with their teams.

The same process must also be followed for good catches (near misses), which provide valuable insight into areas of risk, and may indicate where systems can be improved to prevent harm.

The tools and resources available through the AIMS program, including the AIMS Pharmapod platform, are designed to support pharmacies to meet their obligations and to do so in a consistent and standardized manner across the province.

Errors can and do happen anywhere within our healthcare system, and it’s important that healthcare professionals do everything they can to prevent them, including learning from incidents and good catches (near misses) to prevent them from recurring. The recording of incidents and good catches is an important and positive step to enhancing patient safety and making our pharmacy system safer. Active recording indicates that pharmacies are using the AIMS Program as intended, and that pharmacy professionals are committed to patient safety and quality improvement.

Personal health information is not entered into the AIMS Pharmapod platform by pharmacy professionals. The only information entered in the platform that is related to the patient is the patient’s month and year of birth, and gender. The prescription number associated with the medication incident is an optional field, to allow pharmacy professionals working at the pharmacy the ability to cross-reference with the pharmacy’s practice management system (PPMS).

Pharmacies may need to document more information, such as identifiable data (e.g., patient name or details), about the medication event outside of the AIMS Pharmapod platform for internal tracking or as per their own risk management protocols. The College provides a medication incident form template on our website as an example, however the form and method used is a decision of the individual pharmacy.

All Ontario community pharmacies are required to participate in the mandatory, standardized AIMS Program. The ultimate goal of the program is to improve patient safety and reduce the risk of patient harm caused by medication incidents in, or involving, pharmacies. Consistent with the principles of a safety culture, there are four core elements of the medication safety program:

• Report: Medication incidents and near misses are recorded by pharmacy professionals via a third-party platform in order to populate an aggregate incident database to identify issues and trends to support patient safety improvements at the pharmacy and broader system levels.
• Document: Pharmacy professionals will document appropriate details of medication incidents and near misses in a timely manner to support accuracy. Continuous quality improvement (CQI) plans and outcomes of staff communications and quality improvements implemented are also documented.
• Analyze: Pharmacy professionals will analyze the incident in a timely manner for causal factors and commit to taking appropriate steps to minimize the likelihood of recurrence of the incident.
• Share learnings: Pharmacy professionals will ensure prompt communication of appropriate details of a medication incident or near miss, including causal factors and actions taken as a result, to all pharmacy staff.

Please refer to the AIMS Standards and Expectations webpage for more information related to the program.

If a potential error is caught outside of the established processes and procedures at the pharmacy but before the prescription reaches the patient, it should be recorded as a good catch (near miss). Established processes and procedures could include the technical and therapeutic signoffs and/or any other regular process in place to catch errors such as input or DIN errors.

Regardless of when a good catch or medication incident is caught, if you notice that similar errors are re-occurring on a frequent basis, this may indicate that the processes and procedures you have implemented into the workflow are not effective and should be reviewed.

The extent to which good catches are recorded will be a professional judgment decision of the Designated Manager in consideration of the nature of the good catch, its implication for patient safety, and the extent to which it is recurring.

The College has access to de-identified, aggregate medication events data for the purpose of reviewing medication trends and to support shared learning and system-based improvements across the province but does not receive information about medication events involving a specific pharmacy or pharmacy professional. The College does have access to data related to individual pharmacies’ engagement with this mandatory program.

The aggregate and de-identified data collected through the program will help the College, together with its health system partners, to identify trends and develop solutions and recommendations that will assist pharmacy professionals in reducing the risk of patient harm caused by medication incidents.

The College shares this information publicly via our website and each pharmacy has access to its own data, as well as aggregated and de-identified data, through the AIMS Pharmapod platform. The analysis and sharing of this data is key in providing helpful, actionable insights to pharmacy professionals and other healthcare stakeholders to reduce medication errors and improve patient safety. The AIMS Safety Insights Group is responsible for identifying recommendations that will be shared through regular reports based on data analysis which will include key findings and proposed actions for pharmacy professionals and other stakeholders. The first report is expected in 2024.

As of 2024, Pharmapod (the medication incident reporting platform) has supplied the College with information on how many times individual pharmacies are reporting medication events over a set period of time, as well as how many team members at each pharmacy have Pharmapod login credentials. This is known as “engagement data” – how often pharmacies are participating in, or engaging with, this mandatory program and how many pharmacy team members have the ability to report incidents and good catches. The College does not have access to identifying data regarding medication events. We do not know which pharmacy or pharmacy professional is connected to reported events. The data related to medication event reporting remain completely anonymous.

The purpose of collecting engagement data is to gauge compliance with this mandatory program and to support targeted outreach to pharmacies with low to no engagement who may be experiencing barriers to participation. With this knowledge, we can help support uptake. Increased engagement means an increased safety culture, which is a primary goal of AIMS.

Pharmapod is the independent third party that was selected by the College following a formal request for proposals process to create and manage the AIMS Program online recording system. All community pharmacies must use this platform to enter medication event data. Pharmapod also provides customer support and responds to questions about the use of the platform.

There are a series of e-learning modules on the College website. A web-based training program is available through the Pharmapod recording platform and can be accessed once pharmacies have onboarded. Completion of the e-learning modules is mandatory. The modules cover the use of the platform for recording incidents and near misses and provide guidance on how to implement continuous quality improvement (CQI) processes within your pharmacy. The modules take under one hour to complete. In addition, you can reach out to Pharmapod directly for one-on-one support as needed.

Pharmacies are expected to analyze the information entered in the platform in order to identify factors that may have caused the incident or good catch (near miss). This analysis can contribute to the identification of potential quality improvement actions at the pharmacy. Designated Managers and pharmacy staff have a shared responsibility to ensure there is prompt communication to all staff of a medication event, its causal factors and any actions taken as a result. It is important to note that the AIMS program is not just about recording medication incidents and good catches in the platform – it is about utilizing that data to prevent recurrence of the incident and enhancing patient safety.

To add users, select the ‘Settings’ tab and then add team members as platform ‘Users.’ You will be prompted to fill out the details of the user—don’t forget to assign access by clicking the ‘Facilities Access’ button and choosing your pharmacy. If you are unable to add a user, please contact [email protected] for support.

Each accredited community pharmacy requires a unique Pharmapod account. Designated Managers have the responsibility to onboard and activate the AIMS pharmacy account for each of their pharmacies.

If you are the Designated Manager at multiple pharmacies, you will use your email address (the email address provided to the College under the registrant profile) to set up AIMS accounts for each of the pharmacies. Once you click the link and set up a password in ONE of the invitation emails received, you will be able to see each of your pharmacies on the ‘Select Facility or Organization’ page on the AIMS Pharmapod platform. Please make sure to click into each of the pharmacy accounts on this page to activate each pharmacy.

The Designated Manager is responsible for adding each pharmacy team member at each pharmacy. If you do not have access, notify your Designated Manager. Users can then log in to all of their pharmacies with the same email address and password. These pharmacies will appear on the ‘Select Facility or Organization’ page on the AIMS platform.

Users are able to provide feedback about the program and platform functionality at their convenience simply by selecting “feedback” located on the left selection menu of the AIMS platform and then accessing the feedback form.

If you have any questions about the AIMS Program standards and expectations, please contact the College at [email protected].

All pharmacy staff members should set up their account with the email address that they have registered with the College. If you have forgotten your password, you can click the forgotten password link on the Pharmapod login page. Alternatively, contact Pharmapod at [email protected] or via the live chat.

The Pharmacy Safety Self-Assessment (PSSA) is an informative quality improvement tool that helps a pharmacy track their efforts to enhance patient safety over time. It can be used to proactively identify areas of potential risk, enabling pharmacy teams to plan improvement activities effectively and demonstrate system improvements. The PSSA can only be accessed by the designated manager (DM) by selecting ‘Assessments’ located on the left selection menu of the Pharmapod platform.

For more details, visit the Pharmacy Safety Self-Assessment web page.

The data recorded by individual pharmacies on the platform are anonymous. Pharmacies have access to details of their own recorded events, but only aggregate, province-level data (stripped of any individual or pharmacy identifiers) are available to those outside of the pharmacy.

The College only has access to anonymous, de-identified, aggregate provincial data, as well as engagement data (which is not connected to specific incidents or good catches).

The College has and will continue to report provincial medication event trends publicly using de-identified data to support patient safety in a transparent manner.