Pharmacists in Ontario will be required to report medication errors to an independent third party following the March 2016 death of an 8-year-old Mississauga boy who was allegedly administered the wrong drug.The Ontario College of Pharmacists unanimously approved the program at its June 12 council meeting. It will apply to all pharmacies in the province and include mandatory and anonymous “medication incident” reporting to a third party.Under the plan, both errors and “near misses” must be documented and reported by pharmacy workers in a timely manner, to be included in a provincewide incident database. Pharmacy workers must also analyze the causes of errors and take steps to reduce the likelihood that they will happen again.The move comes after Andrew Sheldrick, 8, died last year of a toxic overdose of baclofen, a muscle relaxant drug, according to a coroner’s report. Andrew had a diagnosed sleeping disorder and was on a regular prescription for tryptophan, a drug that helped regulate his sleep cycle and which his mother, Melissa, thought she had picked up from a Mississauga pharmacy.But the coroner’s report concluded “logic would dictate that baclofen was substituted for tryptophan at the compounding pharmacy in error.”The family’s lawsuit against the pharmacy is ongoing.“Medication errors can have tragic consequences for patients and families … They are also preventable,” Todd Leach, a spokesperson for the college, said in an email. “Understanding why errors happen can help reduce the risk of recurrence, prevent incidents including near misses, and ultimately advance patient safety.”The program requires incidents of error, including causal factors and actions taken in response, to be shared among all pharmacy staff.Melissa Sheldrick called the college’s move “a huge step” for patient safety in Ontario.“Of course, it’s very bitte ...
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