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Exploring Mandatory Medication Error Reporting
At the November 2018 meeting, the College Board directed the Registrar to explore implementation of mandatory medication error reporting to an independent third party.
One of the most common complaints received by the College are related to medication dispensing errors by pharmacy professionals. However, there is currently no way to quantify the overall number and types of medication errors and incidents that are occurring within pharmacies in British Columbia. This is due to the lack of mandatory reporting and a central database in which pharmacy staff can report medication errors and incidents. As a result, there is a missed opportunity for pharmacy professionals to learn from errors occurring in other pharmacies.
What does mandatory medication error reporting typically involve?
Mandatory medication error reporting is just one component of an overall standardized continuous quality improvement (CQI) program. This typically involves:
- Mandatory anonymous reporting of medication incident data (including near misses) to an independent third party organization with expertise in medication incident analyses and commitment to sharing learning from trends and patterns of such incidents
- Tools to help pharmacies self-assess in order to proactively identify areas of concern and monitor the progress of the resulting improvement plan
- Incident reviews and meetings with pharmacy staff to allow open discussion on incidents and root causes, followed by formal documentation of quality improvements made
What are the benefits of mandatory medication error reporting?
Compared to informal methods, a standardized CQI program and mandatory medication error reporting can provide benefits such as:
- Prompt communication and sharing of medication incidents among pharmacy team members, including contributing factors and immediate actions to be taken
- Aggregate data to enable sharing of trends and the ability to learn from incidents and near misses occurring in other pharmacies across BC and nationally
- Analysis, tools and communications from medication safety experts
- Promotion of a culture of safety where individuals are comfortable bringing forward medication incidents without fear of punitive outcomes
What are other provinces doing?
In 2011, Nova Scotia was the first province to fully implement a mandatory standardized community pharmacy CQI program and medication incident reporting through SafetyNET-Rx. Saskatchewan, after pilot phases between 2013 and 2016, made a similar program mandatory in all pharmacies in 2017, called COMPASS (Community Pharmacists Advancing Safety in Saskatchewan). Manitoba, New Brunswick and Ontario are all in the process of fully implementing similar CQI programs which include mandatory medication error reporting.
What should pharmacies do in the meantime?
As the College explores implementation of mandatory medication error reporting, the current requirements in sections 24(1) and 29(1) of the Pharmacy Operations and Drug Scheduling Act Bylaws still apply.
These bylaws require pharmacy managers of community and hospital pharmacies to “develop, document and implement an ongoing quality management program” that “includes a process for reporting, documenting and following up on known, alleged and suspected errors, incidents and discrepancies”.
Although the implementation and details may vary across pharmacies and are currently at the discretion of the pharmacy manager, through the Practice Review Program, the College has seen that some pharmacies still lack a quality management program that meets the above requirements.
We encourage all registrants to examine their practices for medication error reporting and have open discussions about quality improvement.