Patient safety and protecting patients from the harm associated with medication incidents is a priority that patients, pharmacy professionals and the College share. Recognizing that we can always do more to protect patients, College Council approved a mandatory medication safety program for all of Ontario’s community pharmacies in 2017.
The medication safety program
There has always been an expectation that pharmacies are engaging in continuous quality improvement, illustrated in the NAPRA Model Standards of Practice (see Safety and Quality Standards), the College’s pharmacy assessment process and policies for pharmacy professionals and designated managers (see DM Policy - Professional Supervision of Pharmacy Personnel). Moving forward with Ontario's new medication safety program will lead to more standardized, accurate and complete tracking of this information across the province and help provide a better understanding of medication incidents in pharmacies and how they can be prevented. It also clarifies the College’s expectations of how pharmacies engage in continuous quality improvement.
While the anonymous recording of incidents to a third party (Pharmapod, the College’s chosen vendor) via an online reporting platform may be the biggest change for pharmacy professionals under this program, the other elements of the program are equally as important to ensure that all pharmacy professionals in the pharmacy learn from incidents and review and enhance their policies and procedures to reduce the risk of recurrence. Additionally, the program addresses both incidents that reach the patient and those that are detected before reaching the patient (near misses) in order to maximize the learning opportunities.
Pharmacies must achieve all of the following four elements as part of the program:
Report. Anonymous reporting of medication incidents and near misses by pharmacy professionals to Pharmapod, via an online platform, in order to populate an aggregate incident database to identify issues and trends to support patient safety improvements.
Document. Pharmacy professionals document appropriate details of medication incidents and near misses in a timely manner to support accurateness. Continuous quality improvement (CQI) plans and outcomes of staff communications and quality improvements implemented are also documented.
Analyze. When a medication incident or near miss occurs, pharmacy professionals analyze the incident in a timely manner for causal factors and commit to taking appropriate steps to minimize the likelihood of recurrence of the incident. Pharmacies must complete a Pharmacy Safety Self-Assessment (PSSA), which will be available as part of the Pharmapod reporting platform to facilitate use, within the first year of the implementation of the program, then at least once every two to three years, but it may be done more frequently depending on any significant changes in the pharmacy. Pharmacy management should also take the opportunity to analyze aggregate pharmacy data regularly to help inform the development of quality improvement initiatives.
Share Learnings. 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 all staff. The development and monitoring of CQI plans and outcomes should be supported. Pharmacies should have regular CQI communication with pharmacy staff to educate all pharmacy team members on medication safety, encourage open dialogue on medication incidents, complete a PSSA, and develop and monitor quality improvement plans.
Preparing for implementation
It is the College’s expectation that community pharmacies are currently preparing for implementation of the program by familiarizing themselves with the program requirements (as listed above) and educating staff about the program, including how it will help to improve patient safety and outcomes.
Recognizing that many aspects of the Document, Analyze and Share Learnings components of the program (as described above) are already occurring in accordance with the Standards of Practice, the College expects pharmacies and pharmacy professionals to focus on putting these elements in place ahead of getting access to the Pharmapod recording platform.
Onboarding to the online Pharmapod platform will commence in late December 2018, using a phased approach through to mid-2019. Pharmacies will be contacted directly by Pharmapod to organize access to the platform.
The participation and cooperation of pharmacies and pharmacy professionals is integral to the success of the program. In the coming months, both the College and Pharmapod may contact pharmacies regarding necessary training or other activities – it is an expectation of the College that pharmacies will respond promptly to these communications.
The College has posted Frequently Asked Question on the Medication Safety Program to assist pharmacy professionals in understanding and preparing for the program.
Any preventable event that may cause or lead to inappropriate medication use or patient harm. Medication incidents may be related to professional practice, drug products, procedures, or systems, and include prescribing, order communication, product labelling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
An event 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.
Knowledge is power
The medication safety program is built upon the principles of a just culture, very similar to what exists in other parts of the health system. A just culture recognizes that mistakes will be made, but that they must be harnessed to improve the system as a whole. It helps promote open recording of incidents, leading to opportunities to learn from them and to share those learnings with others to help prevent similar incidents from occurring across the system. It also encourages pharmacy professionals to come forward and share opportunities for learning without fear of punishment for admitting a mistake. The focus is not on individual blame, but on system opportunities.
While the medication safety program requires the anonymous recording of medication incidents, including near misses, in a third party platform, the program is much more than this; it promotes continuous quality improvement within individual pharmacies and sets stronger expectations related to prevention and learning. Additionally, the program requires shared accountability between pharmacies, for the systems they design and how they support and respond to staff behaviour, and pharmacy professionals, for the quality of their choices and for recording incidents and identifying possible system vulnerabilities.
It is important to note that any incident and pharmacy level data that is recorded in the platform will not be accessible by the College and will not be used in any complaint, discipline or other College process. All data that the College receives will be in an aggregate, non-identifiable format and will be used to identify general areas of risk and provide appropriate guidance for all pharmacy professionals.
The fundamental purpose of the program is to help protect patients and improve the care that they receive – a goal that the College, pharmacies and pharmacy professionals all share.
An Update on the Ambassador Sites
Late last year, the College identified 100 community pharmacy ambassador sites to be the first to participate in the medication safety program, providing beneficial feedback to inform the development of the program before it is fully rolled out across the province. These sites have been working with Pharmapod to train staff and onboard them to the reporting platform. As of the beginning of May, more than 127 individuals are using the system and have logged over 160 incidents and near misses.
Throughout the summer, the ambassador sites will participate in a formal evaluation, providing the College with qualitative feedback and data to support province-wide roll-out and change management.