AIMS, Fall 2018

Foundations of Safety: Supplemental Standard of Practice and Standards of Operation Help Pharmacies Promote a Constructive, Collaborative and Open Patient Safety Culture

Supplemental Standard of Practice banner
Share this:

Last September, College Council approved the supplemental Standard of Practice (sSOP) to provide clearer expectations surrounding medication safety to pharmacy professionals as the College moved forward with the implementation of the AIMS (Assurance and Improvement in Medication Safety) Program in Ontario. Specifically, the sSOP builds on the NAPRA Model Standards of Practice related to safety and quality and provides additional detail for professionals, including the Designated Manager (DM), on what is expected of Ontario pharmacy professionals under the AIMS Program.


Pharmacy owners and DMs are required to create a safety culture that is conducive to all components of the AIMS Program and supports shared accountability. 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 and supporting meaningful and sustainable change at the pharmacy level and, eventually, across the health system.

Mandatory Requirements of Medication Safety

Pharmacy professionals must meet all of the following requirements of the mandatory AIMS Program; pharmacies (i.e. DMs and owners) must enable and support pharmacy professionals in meeting these requirements:

Report Icon

REPORT: Anonymous recording of all medication incidents and near misses by pharmacy professionals to a specified independent, objective third-party organization to support quality improvement within the pharmacy, and for population of an aggregate incident database to facilitate anonymous reporting that will identify issues and incident trends to support shared learnings.

Document Icon

DOCUMENT: Pharmacy professionals document appropriate details of medication incidents and near misses in a timely manner to support accuracy. Continuous quality improvement (CQI) plans and outcomes of staff communications and quality improvements implemented are also documented.

Analyze Icon

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 Icon

SHARE LEARNING: There should be prompt communication to all staff of appropriate details of a medication incident or near miss, including causal factors and actions taken as a result. 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.

Continuous Quality Improvement in Pharmacy – A Foundational Element of the Supplemental Standard of Practice

One of the goals of the AIMS Program is to improve patient safety through the identification of medication incident trends and workflow issues leading to medication incidents, in order to support continuous quality improvement (CQI) in pharmacy practice. CQI involves an ongoing and systematic examination of an organization’s work processes to identify and address the root causes of quality issues and implement corresponding changes.

Effective CQI programs focus on the implementation of quality improvements resulting from both proactive review of work processes to identify areas of risk, and retrospective review of specific medication incidents. The objective of CQI is to ensure that all pharmacy professionals learn from medication incidents, and review and enhance their policies and procedures to reduce the chances of recurrence, thereby improving patient safety.

To achieve safer care for patients, CQI must focus on both system improvements as well as the tasks that individual practitioners perform. CQI principles support shared accountability and holds pharmacy owners and managers accountable for creating a work culture that supports staff engagement in CQI activities and holds pharmacy professionals accountable for the quality of their choices. To enable a culture that supports learning and accountability over blame and punishment, individuals must be comfortable to discuss medication incidents without fear of punitive outcomes.

A critical element in safe medication practices is the sharing of lessons learned from medication incidents through recording of medication incidents and near misses, to support sustainable changes in practice.

Standards of Operation – Enabling Safe Pharmacy Practice

At its September meeting, College Council also approved new Standards of Operation.

The purpose of the Standards of Operation is to facilitate the creation of the optimal environment for the safe and effective practice of pharmacy and enable the supplemental Standard of Practice (sSOP) to be met. The Standards of Operation also reflect changes in minimum library requirements that allow pharmacy professionals to determine what additional references and resources are required to support their practice.

Learn more about the Standards of Operation on the College’s website under Regulations and Standards.

What this means for pharmacy professionals and DMs

  • DMs in both community and hospital pharmacies are responsible for cultivating and fostering a safety culture grounded in continuous quality improvement and shared learning and for promoting open and honest discussions about incidents. They are expected to become familiar with the requirements under the sSOP and Standards of Operation and educate staff in their pharmacies.
  • DMs in community pharmacies should also ensure that staff complete the required training through web-based modules as their pharmacies are onboarded to the AIMS Program and Pharmapod’s recording platform.
  • All pharmacists and pharmacy technicians should make sure that they understand their obligations under the sSOP and actively participate in facilitating the integration of the four medication safety program and quality improvement requirements in the pharmacy.


Have questions about the AIMS Program or how the Supplemental Standard of Practice or Standards of Operation apply to you? Email us at or visit the AIMS Section of the College’s website under Regulations and Standards.

Share this: