AIMS – Assurance and Improvement in Medication Safety FAQs
What is happening?
The Ontario College of Pharmacists is moving forward with the full implementation of its medication safety program (formally known as the AIMS – Assurance and Improvement in Medication Safety – Program) to all 4,300+ community pharmacies starting the week of November 19, 2018. This implementation follows a nine-month preliminary phase in which the College worked with approximately 100 pharmacies to test and provide feedback on the program prior to the province-wide roll out.
What is the AIMS Program?
The AIMS Program is a standardized medication safety program that will support continuous quality improvement and put in place a mandatory consistent standard for medication safety for all pharmacies in the province. Its goal: to reduce the risk of patient harm caused by medication incidents in, or involving, Ontario pharmacies.
The program 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 will be able to identify learnings that will help prevent incidents and enhance patient safety.
The AIMS Program:
- Requires shared accountability between pharmacies, for the systems they design and how they support staff; and pharmacy professionals, for how they manage medication incidents;
- Emphasizes learning and accountability, through a safety 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.
How does this program involve medication incident reporting?
Once onboarded to the program, pharmacies will be required to anonymously report medication incidents and near misses via a third party incident-recording platform managed by our program partner, Pharmapod. This is a critical component of the AIMS Program as it will lead to the collection and analysis of medication incident data to support improvements within pharmacies.
As well, through aggregate data obtained by the reporting, the College will be able to identify trends and areas of risk and provide appropriate guidance to pharmacy professionals across the province.
What are the requirements of the AIMS Program?
The ultimate goal of the program is to 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 (please see the Supplemental Standard of Practice related to the medication safety program for further details):
- Report: Medication incidents and near misses will be 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.
Will the College have access to medication incident data?
The College will receive and have access to de-identified aggregate data only for the purpose of reviewing medication incident trends and to support shared learning and system-based improvements across the province. The College will not receive or have access to information related to a specific pharmacy or pharmacy professional through this program.
Why was it necessary to implement the program in phases?
Starting the week of November 19, 2018, the first of six waves of community pharmacies will begin onboarding to the program. Pharmacies will be notified by the College and its program partner, Pharmapod, as their identified onboarding date approaches, including details about what to expect during the onboarding process. The College expects all community pharmacies to be fully onboarded by mid-2019.
How will the program prevent medication incidents?
Why is having this information so important?
Medication incidents can and do happen; however, it’s difficult to improve what we can’t measure. This is the first structured program in Ontario specific to pharmacy that will lead to an improved understanding of the number, type, frequency, impact and cause of medication incidents in, or involving, Ontario’s pharmacies, establish clear expectations related to quality improvement and identify system-wide recommendations to reduce the risk of medication incidents across the province.
How will the College use and share this information?
Once all of the pharmacies have been onboarded to the program, the College will be able to use aggregate and de-identified data and to work with other partners and experts to analyze and identify trends and provide appropriate guidance and recommendations for quality improvement that will be shared across the province. This information will be shared publicly via our website and made available directly to pharmacies and health system stakeholders.
A Response Team of pharmacy professionals and patient safety experts will assist the College in analyzing the aggregate, de-identified data and develop recommendations on strategies for continuous quality improvement to reduce the risk of patient harm associated with medication incidents. The members of the Response Team are: Dr. Corey Lester (Research Assistant Professor at the University of Michigan), Dr. Nancy Waite (Associate Director at the University of Waterloo), Dr. Lisa Dolovich (Professor, Leslie Dan Faculty of Pharmacy, University of Toronto and Professorship in Pharmacy Practice, Ontario College of Pharmacists), Shelita Dattani (Director, Practice Development and Knowledge Translation, Canadian Pharmacists Association), Alison Bodnar (CEO of the Pharmacy Association of Nova Scotia), Dr. James Barker (Professor and the Herbert S. Lamb Chair in Business Education at the Rowe School of Business, Dalhousie University and Team Lead at SafetyNET-Rx), Deb Saltmarche (Senior Director Professional Affairs, Shoppers Drug Mart), Mark Naunton (Head of Pharmacy, Faculty of Health, University of Canberra, Australia).
The data will be made available directly to pharmacies and health-system stakeholders and will be shared publicly, along with improvement recommendations, on the College’s website on a quarterly basis. The analysis and sharing of this information will be key in providing helpful, actionable insights to pharmacy professionals and other healthcare stakeholders to reduce medication errors and improve patient safety.
What are the obligations of pharmacies regarding reporting incidents?
Pharmacies are expected to record all incidents and near misses into the incident recording platform administered by our program partner Pharmapod, to take prompt and appropriate measures when a near miss or incident is discovered, to document what happened and to analyze the incident in order to determine causal factors, and to implement improvements so that similar incidents can be prevented. The tools and resources available through the program, including the incident recording platform, are designed to support pharmacies to meet these expectations and to do so in a consistent and standardized manner across the province.
What is the definition of an incident and near miss?
Medication incident: Any preventable event or error that reaches a patient and that may cause or lead to inappropriate medication use or patient harm. Medication incidents may be related to professional practice, drug products, procedures, or systems, and include prescribing, order communication, product labelling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
Near miss: An event that could have led to inappropriate medication use or patient harm but that was intercepted before reaching the patient. Near misses provide valuable insight into areas of risk, and may indicate where systems can be improved to prevent harm.
How can I determine when to record a near miss?
If a potential error is caught outside of the established processes and procedures at the pharmacy but before the prescription reaches the patient, then it should be recorded as a 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 near miss or medication incident is caught, if you notice that similar incidents are reoccurring 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 near misses are recorded will be a professional judgment decision of the Designated Manager in consideration of the nature of the near miss, its implication for patient safety and the extent to which it is recurring.
Are pharmacy professionals already using the incident reporting system?
Pharmacies engaged during the preliminary phase have been using the platform to record medication incidents and near misses and to document their learnings and continuous quality improvement activities as they test program components and requirements prior to the provincial roll out. The remaining pharmacies will use the system as they are onboarded to the platform over the next 6-8 months.
Have there been any medication incidents recorded so far?
What does the data tell us about the program thus far?
The experience thus far with the AIMS Program in Ontario is consistent with the experience of other jurisdictions that have moved forward with similar medication safety programs for pharmacies. The Saskatchewan College of Pharmacists’ COMPASS Program for example, as one of the first provinces to implement a program of this kind in Canada, has published a number of reports related to recorded incident data and how pharmacies are using these as learning opportunities to improve.
What does patient harm mean?
The Institute for Safe Medication Practices defines harm as a temporary or permanent impairment in body functions or structures. Includes mental, physical, sensory functions and pain.
What happens with the data that has been already recorded?
How does the medication safety program fit in with the College’s overall regulatory mandate?
There has always been an expectation that pharmacies are engaging in continuous quality improvement, illustrated in the NAPRA Model Standards of Practice, the College’s pharmacy assessment process and policies for pharmacy professionals and designated managers.
Moving forward with the new medication safety program will lead to more standardized, accurate and complete tracking of medication incident information across the province and help provide a better understanding of medication incidents in pharmacies and how they can be prevented. It also clarifies the College’s expectations of how pharmacies manage medication incidents overall and engage in continuous quality improvement as part of their overall commitment to patient safety. These are further expressed in the College’s supplemental Standard of Practice and Standards of Operation.
What if a patient has a concern about an incident, what should he/she do?
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. The College will then follow-up accordingly.
Will the College use or receive information through this program to launch an investigation?
Do patients need to do anything for this program?
Should patients be concerned about incidents being reported through this program?