Continuous Quality Assurance for Medication Safety

As part of its mandate to serve and protect the public, the College is evolving its expectations around how pharmacy professionals and pharmacies respond when a medication incident occurs, including introducing a requirement for the anonymous reporting of medication incident data to a third party.

The College has developed a standardized continuous quality assurance program (CQA) that will support ongoing continuous quality improvement (CQI) and put in place a mandatory consistent standard for all pharmacies in the province. CQI enables practitioners to learn from medication incidents, and better understand why they happen and how they can be prevented. Utilizing both a preventative approach through proactive reviews of work processes to identify areas of risk and retrospective reviews of specific medication incidents, pharmacy professionals can identify learnings that will help prevent incidents and enhance patient safety.

The standardized CQA program:

  • requires shared accountability between pharmacies, for the systems they design and how they respond to staff behaviour, and pharmacy professionals, for the quality of their choices and for reporting their errors;
  • emphasizes learning and accountability, through a culture where individuals are comfortable bringing forward medication incidents without fear of punitive outcomes; and
  • enables sharing of lessons learned from medication incidents through reporting, resulting in ongoing process improvements to minimize errors and maximize health outcomes.

Anonymous medication error reporting to an independent third party is a critical component of CQA as it provides data to support improvements within pharmacies as well as aggregate reviews of national trends. This reporting is distinct from College processes, and information regarding individual medication incidents will not be received by the College.

Through data obtained by reporting, the College will be able to identify areas of risk and provide appropriate guidance to pharmacy professionals. Driven by our collective commitment to put patients first and support high quality and safe patient care, pharmacies will also be required to do more to ensure they are learning from medication incidents and reducing the chance of recurrence.

The College is committed to patient safety and to enhancing the safe, effective and ethical delivery of pharmacy services in Ontario. Moving forward with a formal quality assurance program will lead to standardized, accurate and complete tracking of medication incident information across the province and help provide a better understanding of errors and how they can be prevented to better protect patients.

Learn more about the CQA model in the Summer edition of Pharmacy Connection: "A Continuous Quality Assurance Program for Medication Safety: Fostering a Culture of Patient Safety."


Next Steps

The College is committed to working as quickly, and as responsibly, as possible on the development and implementation of the CQA program. The program will begin to be implemented in late fall 2017 with approximately 100 pharmacies, with the goal of having the program commence full implemention among all community pharmacies in Ontario by the end of 2018.

Pharmapod Ltd. was selected as the CQA program vendor in October 2017. The College is currently working with Pharmapod to develop all aspects of the medication incident reporting platform and put in place comprehensive training for the initial 100 volunteer pharmacies.


Recent Updates

October 26 - Ontario College of Pharmacists selects Pharmapod to implement medication error reporting system for Ontario pharmacies

June 21 - Council Approves Implementation of the Continuous Quality Assurance Program for Medication Safety

March 30 - Statement from the College on Continuous Quality Assurance for Medication Safety


Background

In the fall of 2016, the College reviewed how medication incident reporting is addressed in practice and what resources are available to improve and strengthen existing measures. The College’s current approach is to rely on policies and Standards of Practice for designated managers and pharmacy professionals regarding management of medication errors to improve patient safety. The College provides additional guidance to pharmacy professionals through multiple communication channels (e.g. articles, practice tools, practice advisors).

In December 2016, Council assigned a task force comprised of public, patient advocate and pharmacy members to develop a model for a standardized continuous quality assurance program. The College consulted with the Nova Scotia College of Pharmacists and the Saskatchewan College of Pharmacy Professionals to gather information on their respective standardized programs, SafetyNET-Rx and COMPASS.

Both jurisdictions stated that mandatory standardized CQA programs have resulted in numerous benefits such as:

  • reduction in blame and fear in discussing medication errors,
  • more open discussions about near misses to prevent similar incidents from reaching a patient,
  • increased practitioner accountability,
  • clearer practice expectations with respect to CQI, and
  • increase in shared learnings and increased awareness of safety issues.

Recommendations from the task force were presented at the March 20, 2017 Council meeting and were unanimously approved, including public consultation to help determine the critical factors that will support a successful rollout. The proposed program was posted online for public and member input from March 31 to May 1, 2017.

Council approved implementation of the CQA program at the June 12, 2017 Council meeting.