Standards and Expectations

Supplemental Standard of Practice

The supplemental Standard of Practice (sSOP) provides clearer expectations surrounding medication safety to pharmacy professionals as the College moves forward with the implementation of the AIMS (Assurance and Improvement in Medication Safety) Program in Ontario. Specifically, the sSOP builds on the NAPRA Model Standards of Practice related to safety and quality and provides additional detail for professionals, including the Designated Manager (DM), on what is expected of Ontario pharmacy professionals under the AIMS Program.


Standards of Operation – Enabling Safe Pharmacy Practice

At its September 2018 meeting, College Council approved new Standards of Operation. The purpose of the Standards of Operation is to facilitate the creation of the optimal environment for the safe and effective practice of pharmacy and enable the supplemental Standard of Practice (sSOP) to be met. The Standards of Operation also reflect changes in minimum library requirements that allow pharmacy professionals to determine what additional references and resources are required to support their practice.


Expectations of pharmacy professionals and DMs

  • DMs in both community and hospital pharmacies (designated contacts) are responsible for cultivating and fostering a safety culture grounded in continuous quality improvement and shared learning and for promoting open and honest discussions about medication incidents. They are expected to become familiar with the requirements under the sSOP and Standards of Operation and educate staff in their pharmacies.
  • DMs in community pharmacies should also ensure that staff complete the required web-based training on the AIMS program available on the Pharmapod platform once onboarded.
  • All pharmacists and pharmacy technicians should ensure that they understand their obligations under the sSOP and actively participate in facilitating the integration of the four medication safety program and quality improvement requirements in the pharmacy.

Promoting a Safety Culture

Pharmacy owners and DMs are required to create a safety culture that is conducive to all components of the AIMS Program and supports shared accountability. A safety culture enables staff to engage in open, honest discussions about medication incidents and near misses. It also permits staff to identify the causal factors of incidents and share lessons learned with an emphasis on preventing errors from recurring. This is a foundation for supporting meaningful and sustainable change at the pharmacy level and, eventually, across the health system.


Mandatory Requirements of Medication Safety

Pharmacy professionals must meet all of the following requirements of the mandatory AIMS Program; pharmacies (i.e. DMs and owners) must enable and support pharmacy professionals in meeting these requirements:

Report icon Report: Anonymous recording of all medication incidents and near misses by pharmacy professionals to a specified independent, objective third-party organization to support quality improvement within the pharmacy, and for population of an aggregate incident database to facilitate anonymous reporting that will identify issues and incident trends to support shared learnings.
Documen icon

Document: Pharmacy professionals 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 icon Analyze: When a medication incident or near miss occurs, pharmacy professionals 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. Pharmacies must complete a Pharmacy Safety Self-Assessment (PSSA), which will be available as part of the Pharmapod reporting platform to facilitate use, within the first year of the implementation of the program, then at least once every two to three years, but it may be done more frequently depending on any significant changes in the pharmacy. Pharmacy management should also take the opportunity to analyze aggregate pharmacy data regularly to help inform the development of quality improvement initiatives.
Share learning icon Share Learnings: There should be prompt communication of appropriate details of a medication incident or near miss, including causal factors and actions taken as a result, to all staff. The development and monitoring of CQI plans and outcomes should be supported. Pharmacies should have regular CQI communication with pharmacy staff to educate all pharmacy team members on medication safety, encourage open dialogue on medication incidents, complete a PSSA, and develop and monitor quality improvement plans.