Pharmacists in Ontario will be required to report medication errors to an independent third party following the March 2016 death of an 8-year-old Mississauga boy who was allegedly administered the wrong drug.

The Ontario College of Pharmacists unanimously approved the program at its June 12 council meeting. It will apply to all pharmacies in the province and include mandatory and anonymous “medication incident” reporting to a third party.

Under the plan, both errors and “near misses” must be documented and reported by pharmacy workers in a timely manner, to be included in a provincewide incident database.

Pharmacy workers must also analyze the causes of errors and take steps to reduce the likelihood that they will happen again.

The move comes after Andrew Sheldrick, 8, died last year of a toxic overdose of baclofen, a muscle relaxant drug, according to a coroner’s report.

Andrew had a diagnosed sleeping disorder and was on a regular prescription for tryptophan, a drug that helped regulate his sleep cycle and which his mother, Melissa, thought she had picked up from a Mississauga pharmacy.

But the coroner’s report concluded “logic would dictate that baclofen was substituted for tryptophan at the compounding pharmacy in error.”

The family’s lawsuit against the pharmacy is ongoing.

“Medication errors can have tragic consequences for patients and families … They are also preventable,” Todd Leach, a spokesperson for the college, said in an email.

“Understanding why errors happen can help reduce the risk of recurrence, prevent incidents including near misses, and ultimately advance patient safety.”

The program requires incidents of error, including causal factors and actions taken in response, to be shared among all pharmacy staff.

Melissa Sheldrick called the college’s move “a huge step” for patient safety in Ontario.

“Of course, it’s very bittersweet from the loss of our boy,” she said, noting Monday would have marked Andrew’s 10th birthday.

“Part of the process for this is eliminating the blame game. We want this to be positive. We want pharmacists to look at this as really a long-term solution at minimizing incidents. It’s not about identifying and pointing fingers. It’s about a community finding solutions and finding the gaps and filling those gaps.”

Sheldrick had advocated for mandatory medication error reporting in Ontario, accumulating more than 20,000 supporters through an online petition.

The family met last fall with Dr. Eric Hoskins, Ontario’s health minister, who committed to improving safety in the pharmacy industry.

“I believe patient advocates like Melissa Sheldrick, a key member of the task force, play a critical role in this type of work, helping to inform the delivery of quality care and make our health-care system more accountable and transparent,” Hoskins said in a statement. “I applaud and thank Melissa for her courageous advocacy in moving these changes forward.”

Nova Scotia is currently the only province where pharmacists must report all errors to the Institute for Safe Medication Practices Canada, a non-profit organization committed to preventing medication errors.

Saskatchewan is set to join Nova Scotia by the end of the year, while other provinces, including New Brunswick and Prince Edward Island, recently completed similar error-reporting pilot programs.

The Ontario program builds on lessons learned from Nova Scotia and Saskatchewan and will be the largest of its kind in the country after its implementation, Leach said.

The first phase will occur over six months starting this fall, with a plan to have 100 pharmacies reporting medication incidents by December.

For four to six months beginning in spring 2018, additional pharmacies will join the program and incorporate changes deemed necessary after review of the first phase. The goal is for all community pharmacies in the province to implement the program by December 2018.

The college hasn’t yet decided which organization will serve as the third party that receives all medication error reports, but David U, president and CEO of the Institute for Safe Medication Practices, said his organization intends to collaborate.

Loading... Loading... Loading... Loading... Loading... Loading...

“This is something we are looking forward to. We want it to be successful,” he said. “I think we’re moving to the right direction. Ontario has over 4,000 stores. It’s a little bit more complex than other smaller provinces in terms of even having everyone on the same page.”

The plan was adopted after consultation with pharmacy workers and organizations, as well as members of the public. There was no opposition to developing such a program, according to the college.

“We’re just grateful to the college for moving so swiftly on this and for taking it really seriously,” Sheldrick said. “For me, if it even just saves one family from heartache, that’s enough.”