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 e-learning modules about the AIMS Program, which can be accessed from the Pharmapod platform once onboarded or from the College website.
- 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: 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.
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: 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 was due for the first time by December 31, 2021 and should be completed once every two to three years thereafter, or more frequently if there are 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 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.
Mandatory e-Learning Sets the Stage for Success with AIMS
All pharmacy staff must complete the AIMS e-learning modules which are accessible from the Pharmapod platform or the College website. Designated Managers should track and confirm that all staff have completed the e-learning modules.
Effective use of the AIMS Program requires pharmacy staff to have a full understanding of the program and how to use the tools available. The six e-learning modules together take less than an hour to do, with visual slides and a few questions to test understanding. They do not need to be completed at one time – the system will automatically save the place where the user was last.