Shared Learning, Shared Accountability


Most of the province’s 4,400+ pharmacies have been onboarded to the Assurance and Improvement in Medication Safety (AIMS) Program. The remaining pharmacies will gain access to the medication incident recording platform by fall 2019, marking the culmination of the largest medication safety program for pharmacies of its kind in Canada.


SHARED LEARNING: AN INTEGRAL COMPONENT AT THE PHARMACY

The sharing of learnings resulting from the analysis of medication incidents is one of the four mandatory AIMS Program requirements, along with report, document and analyze. As more pharmacists, pharmacy technicians and pharmacy assistants have onboarded to the AIMS program and have gained access to the incident recording platform over the last year, there has been a strong focus on recording medication incidents and near misses into the platform. While recording events is a fundamental part of the program, it is not the only effort that needs to take place following a medication incident or near miss; recording should lead to analysis and key learnings, which should then lead to quality improvement actions, as appropriate.

To enable and promote effective shared learning within the pharmacy team resulting from a medication incident or near miss, 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 staff and colleagues;
  • regular scheduling of continuous quality improvement communication with pharmacy staff to educate all pharmacy team members on medication safety;
  • encouragement of open dialogue on medication incidents;
  • completion and discussion of a Pharmacy Safety Self-Assessment (PSSA), once available on the platform; and,
  • development and ongoing monitoring of quality improvement plans.

SHARED ACCOUNTABILITY BETWEEN PROFESSIONALS AND PHARMACIES

Designated Managers (DMs), owners and directors play a pivotal role in facilitating the adoption and implementation of the AIMS Program within individual pharmacies. It is part of the expectations of the program and is expressed in the supplemental Standard of Practice and Standards of Operation. The responsibilities of owners/operators, directors and DMs to ensure an effective and appropriate environment for pharmacies and professionals to satisfy operational and professional obligations are also spelled out in the Standards of Operation.

They must ensure that pharmacy professionals have access to the incident recording platform and associated tools and resources, including confirming that the mandatory AIMS Program web-based training has been completed. The DM must also ensure the pharmacy’s operations are conducive to the principles of the AIMS Program and a safety culture, as well as satisfy all of the elements outlined in the associated standards.

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. It’s clear that the adoption of a safety culture in other parts of the health system has helped to improve patient safety and the intent of the AIMS Program is to help foster a similar culture within pharmacy.

Patient safety requires that all participants are engaged and focused on the same goal: preventing harm and enhancing care. By participating and supporting the identification, analysis and sharing of medication incidents, pharmacy professionals, DMs, owners and directors share the responsibility for the successful implementation of the AIMS Program at the pharmacy.


PROVINCE-WIDE LEARNINGS

An important benefit of the AIMS Program is that the data collected through the anonymous recording platform will help the College – together with its health system partners – to identify trends and develop solutions and recommendations that will assist pharmacy professionals in reducing the risk of patient harm caused by medication incidents. A team of pharmacy professionals and patient safety experts is assisting the College by analyzing the de-identified, aggregate data and developing recommendations for the pharmacy sector aimed at reducing the risk of medication incidents and near misses, as well as identifying strategies for continuous quality improvement.

The first set of recommendations will be shared with pharmacy professionals in the very near future – an important step in our collective efforts to prevent medication errors. The College also plans to share aggregate provincial data publicly on our website and make it available directly to pharmacies and health system stakeholders.