The Ontario College of Pharmacists (OCP) welcomes the first independent expert bulletin that provides a preliminary analysis of medication incidents (errors that reach the patient) and near misses (errors that are intercepted before reaching the patient) reported anonymously by Ontario community pharmacies as part of the College’s Assurance and Improvement in Medication Safety (AIMS) Program. The bulletin, released in recognition of World Patient Safety Day proclaimed by the World Health Organization, also includes recommendations that provide important insights aimed at reducing the risk of medication events involving pharmacies throughout the province.
Produced by an independent team of medication safety and pharmacy experts, the Taking AIMS bulletin is based on an initial analysis of 1,801 medication incidents and 2,331 near misses recorded by community pharmacies between Feb. 1, 2018 and May 31, 2019. Community pharmacies continue to be onboarded to the AIMS Program, which is expected to be fully rolled out to all 4,500+ community pharmacies across the province later this fall.
“This is a positive sign that pharmacies are integrating the AIMS Program into their operations and have started to use the platform to record incidents and near misses,” says Nancy Lum-Wilson, CEO and Registrar. “For the first time in Ontario we now have access to this aggregate provincial-level data to help us not just understand the number of medication events involving pharmacies, but what can be done to prevent them from recurring. With access to good information, learnings can be shared within teams and across the system to make patient safety improvements and reduce the risk of medication events. This is a fundamental philosophy behind our AIMS Program.”
The AIMS Program is a mandatory medication safety program that standardizes expectations regarding continuous quality improvement related to medication incidents and near misses involving pharmacies. An important part of the program is the requirement for community pharmacies to anonymously record information about medication incidents and near misses through an online platform administered by Pharmapod Canada Ltd.
The de-identified provincial data collected through the program is analyzed by a team of experts to identify trends, themes and common areas for improvement. Together with recommendations, the data provides pharmacies and other healthcare professionals and stakeholders with valuable information to help them apply and share learnings from medication events to prevent them from recurring. This will lead to more standardized, accurate and complete tracking of medication event information with the ultimate goal of reducing the risk of patient harm caused by medication incidents in Ontario. It also provides the College with aggregate province-wide information to be able to identify trends that will inform the development of resources and guidance and other education tools to help the profession address system-wide opportunities for improvement.
“The reduction of preventable harm is a common theme within many healthcare organizations today. It should be no different for pharmacy,” adds Nancy. “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. The reality is that medication incidents involving pharmacies can and do happen, and they are also preventable. That’s why anonymously reporting this information and benefitting from the learnings from these incidents to reduce the risk of their recurrence is such a significant part of promoting patient safety and supporting ongoing quality improvement, not just in pharmacy but throughout the entire health system.”
Along with the release of the first expert bulletin, the College is also sharing an aggregated summary of medication incidents and near misses which were anonymously reported by community pharmacies as of Aug. 21, 2019. This information is important to helping pharmacies, the public, and the broader health system understand the information that is now being collected to promote patient safety. Further analysis of aggregate AIMS Program data will form part of subsequent bulletins and will be made publicly available.
“We are grateful to the expert team for this important first bulletin which establishes a solid foundation from which to further develop and provide information and recommendations to pharmacy and other health system professionals to enhance patient safety,” says Nancy. “We also recognize the efforts of the thousands of pharmacies and pharmacy professionals who have embraced the AIMS Program and a safety culture that thrives on shared learnings, accountability and a commitment to continuous quality improvement.”
About the Ontario College of Pharmacists
The Ontario College of Pharmacists (OCP), incorporated in 1871, is the registering and regulating body for the profession of pharmacy in Ontario. The College’s mandate is to serve and protect the public and hold Ontario’s pharmacists and pharmacy technicians accountable to the established legislation, standards of practice, code of ethics and policies and guidelines relevant to pharmacy practice. The College also oversees the province’s community and hospital pharmacies and assesses them against prescribed standards of operation. For more information, visit www.ocpinfo.com.
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