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Ontario Pharmacists Can Help Provide a Safer Medication Use System

Medication errors do not just cause injury to patients, they are also costly to the healthcare system. Although Canada does not have statistics on medication errors, extrapolation from the US data suggests an estimate of about 2 percent of hospitalized patients experience a preventable adverse drug event, and an estimate of 700 deaths per year result from medication errors.

Unlike the US, UK and Australia, Canada does not have a national medication error reporting and prevention program. The Institute for Safe Medication Practices Canada (ISMP Canada), however, plans to change this situation. ISMP is a non-profit, independent organization established for the collection and analysis of medication error reports and the development of recommendations for the enhancement of patient safety. Similar to its sister organization, ISMP in the US, ISMP Canada intends to serve as a national resource for promoting safe medication practices throughout the health care community in Canada.

There have been a number of initiatives undertaken by ISMP Canada. One initiative is to collect error and 'near-miss' reports from hospital practitioners, community pharmacists, nurses and physicians. Subsequently, various corrective actions have been recommended to address concerns raised in the reports. Practice-related recommendations have been circulated to practitioners. For product concerns, ISMP Canada has engaged in dialogue with several manufacturers and Health Canada to recommend changes for patient safety. One example, was a collaborative effort with the manufacturer to enhance the labeling of Cipro Oral Liquid. Recommendations related to the labeling of Cipro oral liquid originated with suggestions from community pharmacists. Readers are encouraged to visit ISMP Canada's web site for a description of various initiatives:

ISMP Canada is stressing the importance and need for a healthcare community that has a non-punitive and non-blame culture. This is a necessity if we want practitioners to report and discuss errors and hazardous conditions. ISMP-Canada offers practitioners the opportunity to share information about errors so that the healthcare community can be warned and thereby a repeat error prevented. It is well recognized that human error will always be present. The goal is to search for, and implement improvements within the medication system processes, and the medication prescribing and dispensing systems so that we all help to minimize the risk and potential for an error to occur. Most importantly to reduce opportunity for an adverse event and thereby prevent injury to a patient.

How can Ontario pharmacists get involved? Ontario is the largest province, and without a doubt, has the largest provincial healthcare system. Community drug store owners and supervisors need to take a leadership role in order to develop a non-punitive culture. Staff need to feel comfortable to report and identify potential errors and other hazardous situations, or conditions. Staff need to understand the importance of sharing information related to error or near-miss situations. Managers need to provide adequate opportunities to staff for continuing education related to medication error detection and prevention. For example, ISMP Canada's Safety Alerts identify for pharmacists and technicians the drug names, drug labels and packaging mix-ups which have been reported. These newsletters provide a reminder to dispensing staff that sound-alike names and similarity in packaging continue to be a contributing factor to medication errors.

There are also upcoming conferences dealing with 'Breaking the Silence' which surrounds error and such conference settings provide valuable educational opportunities. Visit our website to find out about upcoming educational events.

The Ontario Pharmacists Association facilitates the organization of workshops. A possible future topic would be to provide a forum for sharing experiences on incidents and to discuss strategies and other methods to prevent them from recurring. Pharmacists are being invited to contribute their ideas and suggestions in various pharmacist's publications. I encourage all members to share information from their practice settings with ISMP Canada so we can learn from each other.

The Ontario College of Pharmacists also has a leading role in reducing medication errors. The College has the responsibility to ensure the safety of the public, and therefore the College needs to ensure that practice standards and performance indicators are in place. Certainly, "punishing" a pharmacist who has made a dispensing error will not effectively make an improvement in patient safety for the long run. Relating errors to competency can also suppress error reporting. Opportunities for system improvements must be addressed and shared when reviewing error reports. Ideally, errors are openly reported so that system and process improvements can be implemented to protect the safety of the public.


Contributed by
David U
President and CEO
Institute for Safe Medication Practices Canada (ISMP Canada)
January 21, 2001