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.
Full implementation is expected to be complete by mid-2019. Once fully implemented, the program will be the largest medication safety program for pharmacies of its kind in the country.
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:
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.
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):
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.
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.
The AIMS Program establishes clearer expectations related to quality improvement and includes a mandatory requirement to anonymously report medication incidents and near misses via a third-party platform. 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.
Ultimately, through a better understanding of trends associated with recorded incidents and near misses, including how and why they occur, together with health system partners we will be able to identify solutions and recommendations to prevent those incidents from recurring and to share these learnings throughout the province.
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.
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.
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.
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.
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.
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.
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.
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.
Understanding why these events happened, the outcomes of the incidents and how they can be prevented requires fulsome analysis of the data which has not yet been completed. In order to benefit from a more robust, reliable and statistically relevant data set, incident and near-miss data from the preliminary phase will be analyzed together with data recorded by other pharmacies as they onboard to the program over the coming months.
In the meantime, pharmacies will be expected to record, document and analyze the incidents at the local pharmacy level for root causes and contributing factors and apply and share among their teams continuous quality improvement strategies to prevent their recurrence using tools and resources now available through the platform.
While the AIMS Program is an important new requirement that aligns with the College’s mandate to serve and protect the public, the program remains separate and distinct from our Investigations function.
The College continues to take its regulatory responsibility to respond to concerns about the conduct or safety of individual pharmacies or pharmacy professionals very seriously. 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.
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.
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.
The incident data reported through the third-party platform is completely anonymous in order to encourage reporting. The College will not be able to identify individual pharmacies or pharmacy professionals through this program to preserve the well-established principles of a safety culture that are foundational to this initiative.
While the AIMS Program is an important new requirement that aligns with the College’s mandate to serve and protect the public, the program remains separate and distinct from our Investigations function. The College continues to take its regulatory responsibility to respond to concerns about the conduct or safety of individual pharmacies or pharmacy professionals very seriously. 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.
It’s important that patients and the public know that there is a medication safety program for pharmacies in place in Ontario and that its purpose is to promote continuous quality improvement and enhance the safety of pharmacy care for all patients.
It’s also important for patients and the public to know that the program does not replace the College’s regulatory responsibility to respond to concerns about the conduct or safety of individual pharmacies or pharmacy professionals. 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.
Errors can and do happen anywhere within our healthcare system, and it’s important that health professionals do everything they can to prevent them, including learning from incidents to prevent them from recurring. The reduction of preventable harm is becoming a common theme within many healthcare organizations.
Patients should feel confident that their pharmacy professionals are providing safe, high-quality care and that they’re committed to continuous quality improvement. The reporting of incidents and near misses is an important and positive step to enhancing patient safety and making our pharmacy system safer.