College Oversight of Hospital Pharmacies

Revised: August 27, 2020


In 2013, there was an incident of chemotherapy under-dosing in four Ontario hospitals and one hospital in New Brunswick. In response, the Ministry of Health and Long-Term Care of Ontario commissioned Dr. Jake Thiessen to do an independent review and produce a report on the incident.

Dr. Thiessen made several recommendations in his report, including one suggesting that the Ontario College of Pharmacists license and inspect all pharmacies operating within Ontario’s clinics or hospitals.

New Legislation

In response to Dr. Thiessen’s recommendation, the government introduced legislation that would ultimately provide the College with the authority to license and inspect hospital pharmacies throughout Ontario.

Specifically Bill 21: Safeguarding Health Care Integrity Act, 2014:

  • Provides the Ontario College of Pharmacists with the authority to license and inspect pharmacies within public and private hospitals, in the same manner it currently licenses and inspects community pharmacies
  • Provides the College with the ability to enforce licensing requirements with regard to hospital pharmacies
  • Allows the College to make regulations to establish the requirements and standards for licensing, operation and inspection of hospital pharmacies
  • Provides government with the ability to extend the College’s oversight to other institutional pharmacy locations in the future, as appropriate

Although Bill 21 passed in the legislature in December, 2014, provisions relating to the College’s oversight of hospital pharmacies did not come into effect until the required amendments to the Drug and Pharmacies Act (DPRA) regulation were approved by government on August 1, 2016.

Learn more about the new DPRA regulation.

Supporting By-laws

To support the new DPRA regulation, the College proposed changes to the by-laws to include fees for the issuance and renewal of Certificates of Accreditation for hospital pharmacies.

The proposed by-laws were circulated for a 60-day public consultation between September 21 and November 20, 2015. The majority of feedback received during the consultation expressed disagreement with the proposed fee structure for hospital pharmacy accreditation. Therefore, before approving the new by-laws at their December 2015 meeting, Council recommended a reduction to fees for hospital pharmacies.

The new by-laws relating to hospital pharmacy fees (included in College By-law No. 4) have been approved by Council and came into effect on August 1, 2016 upon the proclamation of the new DPRA regulation.


The College took several steps toward developing the accreditation process for hospital pharmacies in advance of the proclamation of the amended DPRA regulation. This included:

Developing Assessment Criteria

The hospital pharmacy assessment criteria was developed through a comprehensive collaborative process involving the review of relevant practice standards and accreditation processes (provincially, nationally and internationally) with ongoing input from practicing hospital pharmacists and pharmacy technicians.

The criteria is not meant to duplicate, but rather compliment and enhance criteria that already exists from other organizations such as Accreditation Canada, the Canadian Society for Hospital Pharmacists (CSHP) and the International Pharmaceutical Federation (FIP).

There are three main types of assessment criteria — standards which already exist, standards that are emerging and organizational standards. Pharmacies are evaluated as either meeting the standards, partially meeting the standards, not meeting the standards, or not applicable.

The final Hospital Assessment Criteria document is available on the College website.

Conducting Baseline Assessments

Throughout 2015, hospital practice advisors conducted baseline assessments of all hospital pharmacies in Ontario. Read more about how hospital pharmacies benefitted from the baseline assessments in the Summer 2015 Pharmacy Connection article.

During the baseline assessments, if any concerns in the pharmacy or medication management system arose, the practice advisor (now called operations advisor) worked with the hospital pharmacy team to provide appropriate recommendations or actions to rectify the concerns as soon as possible. If appropriate, the operations advisor worked with the pharmacies that needed to improve on any of the existing, emerging or organizational standards to create realistic action plans for continuous quality improvement.

Learn more about the baseline assessments and an analysis of common findings in the Hospital and Other Healthcare Facilities Progress Report to Council.

Next Steps

With the proclamation of the new DPRA regulations on August 1, 2016 the College now has official oversight of hospital pharmacies. Having successfully completed a baseline assessment by the College in 2015 hospital pharmacies have been issued a certificate of accreditation.

Pharmacies are required to renew their certification on an annual basis and are subject to routine assessments by the College. A listing of hospital pharmacies including the date and status/outcome of assessments after August 1, 2016, can be found on Find a Pharmacy or Pharmacy Professional.