On March 13, 2016 an Ontario mother woke up to the unimaginable – she had found her 8-year-old son unresponsive at home.
By Andrew Schonbe, BScPhm
The coroner would later report the death to be caused by a prescription suspension containing Baclofen, a muscle relaxant. While the packaging on the bottle stated the regular intended therapy of Tryptophan, an error in the actual contents had been made at the dispensing pharmacy.
The mother has called for a public reporting of pharmacy medication errors. An error registry would regain confidence in the pharmacy system, increase transparency, and ensure accountability. Some outside of the pharmacy field feel it is simply fair access and I fully agree with them.
Nova Scotia has already taken the lead on this and is the only province with legislation requiring a process for pharmacies to anonymously report errors. This is part of Safety-NET Rx, a quality improvement program that also works with stakeholders to improve reporting and learning from medication errors in Canadian community pharmacies. Currently, it is voluntary for the actual reporting of incidents, although uptake has been good in Nova Scotia.
The case of the Ontario child is absolutely tragic. But the tragedy goes even further if nothing is learned from this or other similar incidents. Did many pharmacy owners respond to this story by sharing it with their teams and re-evaluating their own safety procedures to prevent a similar event? In conversations with colleagues and from independent experience it is clear to me that community pharmacy practice tends to be more reactive than proactive when it comes to error management.
Anecdotally, the typical response to an error occurrence in practice is often finger pointing or the “blame game”. Those who weren’t responsible consider themselves fortunate and figure it’s not their problem since someone else made the mistake. The plan of action is often simply “don’t do it again” and ensuring “I’ll be more careful next time”. If this is the status quo in a pharmacy (or any organization for that matter) it is unacceptable. A real plan needs to be in place to prevent the error as simply willing it not to occur is an ineffective blueprint for error prevention.
Errors should be learning opportunities. While there are standard enforced policies in hospital pharmacy practice to respond to errors, consider how likely a community pharmacy is to perform assessment methods, such as a root cause analysis. A clear consistent and fully developed approach is paramount to support the continuous quality improvement (CQI) that is already required in pharmacy scope of practice.
Consider the following social media post that followed a story of the Ontario child:
“My daughter was given my prescription with her name on it. I looked and noticed it was wrong and went back and questioned the pharmacist and he said ‘mistakes happen’. Are you kidding me, buddy? If I had given her that dose of anxiety meds it would have hurt her. We since changed pharmacy, but will forever worry about it and always double check.”
This example isn’t to paint all pharmacists with the same brush, but it does point out an important lesson. It is critical for both to ensure the safety of patients and maintain trust with them to address all errors with the same level of urgency. While it is staggering a pharmacist could possibly be so nonchalant in regards to an error, consider when a patient is simply shorted pills accidentally. Even these perceived “minor” mistakes should be treated with same level of care and seriousness. They are sometimes early markers for additional errors down the road.
Apologize and recognize the error, reassure the patient, and share effective steps that have been taken to prevent reoccurrence. When it comes to health caution must be taken to ensure trust and confidence are never breached.
This is not to ignore the reality that pharmacists face enormous pressure that is only increasing. Pharmacists are perpetually being asked to implement new professional services and additional responsibilities within already finite operations. The strategy of just cramming more into the current system already at capacity is a hotbed for increasing errors in the workplace. Clearly considerations of workflow and the labour model are necessary to support advances in risk reduction and improved safety in community practice.
This year governments, healthcare professionals and public stakeholders will continue the conversation on safety systems such as error reporting. In the meantime, community pharmacies can do their part and should target the new year to optimize safety and error risk reduction.
Top error prevention tips:
#1. Be proactive and perform risk and safety assessments of existing procedures at regular intervals.
#2. Treat near misses as errors and minor mistakes as hints that more serious ones could occur.
#3. Take errors seriously and effectively communicate them with patients, even if the outcome of the event was minor.
#4. Develop a clear plan if an error is made and put steps in place to prevent reoccurrence.
#5. Share both internal and external errors with the entire pharmacy team.
#6. Alert all stakeholders when an error is made (e.g. doctors, nurses, caregivers).
Andrew Schonbe a community pharmacist, former pharmacy owner, corporate manager at a pharmacy chain central office, and pharmacy educator.