On June 12th, the Council of the Ontario College of Pharmacists unanimously approved the College to move forward with implementing Ontario’s first standardized Continuous Quality Assurance for Medication Safety program for community pharmacies, including anonymous mandatory reporting of medication incidents to a third party. The program will begin to be implemented in Fall 2017, with the goal of having the program fully implemented among all community pharmacies in Ontario by the end of 2018.
About the program
Understanding why errors happen can help reduce the risk of recurrence, prevent incidents including near misses, and ultimately advance patient safety.
The CQA program will support continuous quality improvement and put in place a mandatory consistent standard for responding to medication incidents in all pharmacies across the province. In addition to requiring the anonymous reporting of medication incident data (including near misses) to a third party, the CQA program will enable practitioners to learn from medication incidents and better understand why they happen and how they can be prevented. Through data obtained by reporting, the College will also be able to identify areas of risk and provide appropriate guidance to pharmacy professionals.
The program emphasizes the principles of a safety culture within community pharmacies, similar to what exists in other parts of our health system. It promotes accountability and quality improvement, open reporting of incidents, and opportunities to share learnings with other professionals and organizations to inform pharmacy and system wide improvements.
In addition to anonymous mandatory reporting of data to a third party, core elements of the program include:
- Documentation: Requires pharmacy professionals to document appropriate details of medication incidents and near misses in a timely manner. They will also be required to document quality improvement plans and outcomes of quality improvement initiatives.
- Analysis: Requires that when a medication incident occurs, pharmacy professionals must analyze the error in a timely manner for causal factors and commit to taking appropriate steps to minimize the likelihood of recurrence of the incident. It will also require the completion of medication safety self-assessments and the analysis of individual and aggregate data to inform the development of quality improvement initiatives.
- Sharing of Learnings: Requires prompt communication of appropriate details of a medication incident to all pharmacy staff, including causal factors of the error and actions taken to reduce the likelihood of recurrence. This includes ensuring the scheduling of regular quality improvement communication with pharmacy staff to educate pharmacy team members on medication safety, encourage open dialogue on medication incidents, and develop and monitor quality improvement plans.
The program builds on the College’s existing expectation that pharmacies and pharmacy professionals are engaging in safe medication practices and continuous quality improvement, illustrated in the Standards of Practice and policies for pharmacy professionals and designated managers. This includes a requirement to report medication errors internally within their organizations.