Since the College moved forward with plans to fully implement its Assurance and Improvement in Medication Safety (AIMS) Program last November, access to the AIMS platform administered by program partner Pharmapod has been granted to approximately half of Ontario’s 4,400+ pharmacies.
The province-wide rollout followed a nine-month ambassador phase in which the College worked with approximately 100 pharmacies to test and provide feedback on the program. This feedback has been used to support the full implementation of the mandatory medication safety program that, once fully in place in Ontario by mid-2019, will be the largest of its kind in the country.
The AIMS Program supports continuous improvement and establishes a mandatory, consistent standard for medication safety for all community pharmacies across the province. To support an effective implementation and promote a smooth transition as pharmacies adopt the program and integrate it within their daily practice, the College and Pharmapod collaboratively notify pharmacies in advance of their onboarding date and provide details about what to expect during the onboarding process including mandatory e-training for all pharmacy staff.
As pharmacies are oriented to the program and onboarded onto the anonymous incident recording platform, a series of six e-training modules and other resources provided by Pharmapod are designed specifically to help facilitate the required training behind this medication safety program. Each of the modules focus on the following training topics:
- Describing the difference between a medication incident and a near miss and identifying specific information required to ensure good quality recording of medication incidents and near misses
- Understanding the importance of using standardized terminology as part of the AIMS Program and locating these definitions
- Submitting a medication incident and near miss using the Pharmapod system
- Describing what Continuous Quality Improvement is and how it can be implemented within your pharmacy
- Applying a root-cause analysis of medication incidents and near misses
- Generating reports and reviewing data from medication incidents and near misses
INCIDENT RECORDING PLATFORM
Once the e-training is completed, pharmacies are expected to anonymously record all incidents and near misses into the incident recording platform administered by Pharmapod.
WHAT IS A NEAR MISS?
Near misses are defined as events that could have led to inappropriate medication use or patient harm but did not reach 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.
The pharmacy team should 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.
PHARMACY SAFETY SELF-ASSESSMENTS (PSSA)
This summer, a Pharmacy Safety Self-Assessment (PSSA), also available as part of the Pharmapod platform, will be introduced on a pilot basis to all community pharmacies.
Pharmacies should complete a PSSA within the first year of the implementation of the AIMS Program, then at least once every two to three years thereafter. The PSSA can be used as an informative quality-improvement tool, acting as a baseline of the pharmacy’s efforts to enhance patient safety over time. Pharmacy leaders should also take the opportunity to analyze aggregate pharmacy data regularly to help inform the development of quality improvement initiatives.
Pharmacies will learn more about the PSSA through the onboarding process.
ANALYZE AND IDENTIFY TRENDS
As pharmacies are onboarded to the AIMS Program, the College will be able to use aggregate and de-identified data reported through the anonymous incident recording platform 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. 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 College of Pharmacy, University of Michigan)
- Dr. Nancy Waite (Associate Director at the School of Pharmacy, 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 analyzed aggregate data, along with the analysis and recommendations of the Response Team, 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. 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.
To date, the AIMS Program has been focused on community pharmacies; however, the College plans to apply learnings acquired from the community pharmacy implementation and build upon current hospital experiences to facilitate systems-level learning across the sector through the AIMS Program. Engaging hospital professionals throughout 2019 to better understand the operating environment and explore opportunities will help the College determine how to best utilize the AIMS Program to augment and enhance patient safety in hospitals.
Resources are periodically updated on the AIMS section of the website. Visit:
The College appreciates the support of pharmacies to date and their commitment to patient safety and thanks all of those who are already active on the anonymous incident reporting platform.