Medication mistakes can happen. Doctors, nurses, pharmacy team, caregivers and patients can make mistakes. To Err is Human is a book published in 1999 that led the movement towards increasing patient safety from all medical errors. It focused on a systems reform and helped to change our thinking. We are not to blame humans, but to re-examine the workflow systems that contribute to errors.
As a result, health systems have implemented many safeguards over the years to improve safety. However, because changes are constantly introduced in the health care field, it is hard to keep ahead. For example, health care technology, while being a strategy to minimize errors (e.g., e-prescribing can reduce handwriting misinterpretations), can introduce new errors (e.g. Doctor picks the wrong strength from drop-down box).
All pharmacies have double check and quality processes in place, but occasionally errors happen. Patient and caregivers are key players in identifying a mistake. Always call or go see the Pharmacist if you suspect a mistake. They will review and address why something is different or confirm the mistake and get this resolved.
After a mistake is confirmed a few things happen:
- the pharmacist will assess and advise the patient/caregiver if medical attention is required. The physician will be notified if needed.
- the mistake will be fixed.
- the pharmacy manager will review the mistake with the pharmacy team. Together they identify what contributed to the mistake and discuss and implement strategies or processes to prevent it from happening again.
- the mistake (also called a medication incident) is entered into a provincial database (don’t worry, no patient specific details are entered). The incidents are examined collectively by an expert group to identify trends across the province. Reports are produced quarterly to suggest system improvements for pharmacies to consider.
It is now mandatory for all pharmacies in Ontario to document the medication incident in a provincial database. This is a change that was led by a mother, Melissa Sheldrick, whose son died as a result of a medication incident. Check out her website for her story and advocacy efforts. https://www.melissasheldrick.ca/
Standardizing reporting and analysis are key safety strategies to prevent similar mistakes from reoccurring.
Patients and caregivers are also encouraged to report medication incidents through a government funded medication incident database on the https://safemedicationuse.ca/ website. Click on Report Now.
Let’s all support each other to stay safe from medication mistakes.
