Preventing Medication Errors and the ISMP

One evening in late October of this year I sat down with a rep from a compounding pharmacy supply company to discuss how our compounding business was going.

One of the first topics he brought up was a story of a young Mississauga boy, Andrew, who had died from an apparent mix-up with a compounded medication.

The boy died of an overdose of baclofen after taking a prescription that was alleged to contain tryptophan for sleep. It was the first I had heard of the tragic story.

It is a scenario that mimics the worst possible case in the back of our heads each time we as pharmacists go to work each day.

As fallible human beings I consider us the strongest and weakest link in the chain of what has largely become an automated day—automated with humans that are capable of a momentary lapse of attention that can kill someone.

It not only focuses directly on errors but on almost any conceivable reason for them occurring

Almost exactly a month later, I am reading in Halifax’s Chronicle Herald of Ontario’s Health Minister Eric Hoskins desire to tighten the safety of his province’s pharmacy dispensing in the wake of this tragedy.

As part of that process he’s looking at how Nova Scotia has dealt with this issue (, namely through an initiative called SafetyNET-Rx. (

This story, of course, grabbed my attention, not only because I am a community pharmacist, but also because I also compound and live and practice in Nova Scotia.

I am further pulled into this story because the SafetyNET-Rx initiative mentioned was started at a former alma mater (St. Francis Xavier University in Antigonish, Nova Scotia), in part by a former classmate of mine from Dalhousie University College of Pharmacy (now Dean Neil MacKinnon at U of Cincinnati Winkle College of Pharmacy).

As a practising Nova Scotia pharmacist, I am fully involved with SafetyNET-Rx. Our pharmacy in Baddeck was part of the pilot project in 2010.

The Nova Scotia College of Pharmacists’ Standards of Practice ( ) now outline that every pharmacy in the province must have a Continuous Quality Improvement (CQI) plan in place.

This is a requirement in the Practice Regulations to the Pharmacy Act of Nova Scotia.  For the first time we now have a monitored, effective QCI process that tracks quality related events (QREs).  It is the SafetyNet-Rx model we use now.

So what does this involve in our day-to-day work in the pharmacy? Mainly, anytime there is a QRE, we note it in a scribbler to be entered later into an online recording system.

These errors encompass everything that can go wrong, such as a prescription handed out for the wrong drug or directions or doctor (even if it exactly follows the actual prescription but was an unintended change).

Most of the recorded errors include mistakes made before the prescription actually gets to the patient’s hands. Every time we enter the wrong doctor, drug, strength or directions, it gets marked down. In a busy day we do the best we can to record these events but in reality some do get fixed and aren’t recorded.

These events are formally recorded online on the Community Pharmacy Incident Reporting site—ISMP (Institute for Safe Medication Practices).

Each pharmacy has its own username and login and can search based on several metrics the types of errors that occur, the days of the week they occur the most, who detected the error, contributing factors, degree of harm from the incident and what the error was—both for your pharmacy and combined aggregate of all pharmacies on the system.

It’s quite interesting to see these comparisons. All of this data is invaluable in helping to prevent future errors. Quarterly staff meetings are required and helpful in sharing this information.

Through this reporting system, we are keenly aware now of the most common source for errors, who is most likely to catch the error, why the error occurred and even when it is most likely to occur.

This allows us to plan staffing and make corrections that we would have normally made after a mistake is made; except now we can do it before the incident occurs.

We can see how we compare with all other community pharmacies and if a discrepancy occurs we can immediately make changes.

Knowing the most common errors prompts one to be extra careful in that field. For example, if you know your store has an inordinately high number of errors that involve number of doses dispensed compared to the aggregate, it becomes a focus until it is normalized.

If we find that many errors occur with incorrectly written prescriptions at the physician level, we would have that conversation with the physicians.

Along with this reporting system, there are several other checks in place.  Many of these are done by any other pharmacy in the country.  Staff emergency contacts are recorded, as are the numbers for all services used by the store from police and fire down to insurance, electrician, plumber, computer data and storage in case they are needed by any staff member.

Regular audits are done that range from removing outdated stock, adverse drug reaction reporting, monthly narcotic drug inventory reconciliation, equipment and facilities certification, adherence to standards of practice are recorded and annual staff performances.

Confidentiality agreements are signed, pandemic planning is completed, robbery and break-in procedures are made and reviewed and emergency response plans of all types are done (staff and customer accidents, fire, leaks, toxic spills and power outages).

For our pharmacy in Baddeck there were a few changes we made as a direct response from all of this monitoring.  We determined the time of day and day(s) of week that we were most likely to see an error and we adjusted staffing levels to be heavier at those times.

We also determined a certain physician that had a higher probability of making an error when writing a continuation prescription for a drug that the patient was already on. This alerted us to pay extra attention to this occurring with this physician.

We also added another satellite computer in the pharmacy, not only as a reminder to document but to allow easier, daily documentation of events.  When it wasn’t possible to do this we jotted them down for later entry.

Another interesting thing that came out from this was through the stringent narcotic self audits.  We started noticing that a certain brand of medication was short one tablet in each bottle we were getting so these bottles were counted upon opening and the rep was alerted to the problem.

We also realized that the most common “near miss” incidents were incorrect quantity and incorrect dose. Special attention was brought to this during the quarterly meetings so extra attention on filling the script would prevent the problem again.

Future reports of quality assurance demonstrate the effect of these changes, new problem areas are found and new targets are made. Regular Medication Safety Self Assessments are done. This is a valuable tool that assesses the pharmacy’s overall ability to function safely based on many parameters and is done on a regular basis.

It is really an environment full of information that was floating there unharnessed before that monumentally helps to improve the safety of our patients when acted on.

If it seems like a lot of extra work in an environment that has very little down time, then you are correct.  Personally though, I have always found a huge sense of calm knowing something extra was done to double check that a patient got what they were supposed to get when they leave my pharmacy.

The time involved though blends in with our work and is worth it.  Time management is a skill that becomes greater as a result.

Getting back to the original patient we spoke of, Andrew, would this event had occurred if all of this were in place?  It is difficult to speculate as the cause is before the courts right now.

One thing though is for certain, making an error is an opportunity to explore why that error occurred and make corrections so it won’t happen again.

In the December 1989 issue of the CAPSIL (The Canadian Association of Pharmacy Students and Interns), I wrote one of my first public articles (without the internet) on the topic of Medication Errors ( ).

It is a subject that will never completely go away. It is a disservice to our patients to not act on each error as a learning experience. SafetyNET-Rx is an invaluable tool that really turbo charges your incident prevention and kudos to the Nova Scotia College of Pharmacists for implementing this requirement into their standards.

It not only focuses directly on errors but on almost any conceivable reason for them occurring. Hats off to my friend and Colleague Dean Neil MacKinnon for his role in its development.  This standard is a huge leap forward that has caught the attention of the rest of the country.

I had the pleasure of corresponding with Andrew’s Mom earlier this year who contacted me ahead of a meeting with the Ontario College of Pharmacists Task Force where a proposal for medication error reporting was on the agenda. The College also contacted me ahead of this meeting to share ideas on the ISMP and my experience with it. Andrew’s Mom was glad to see movement on this system and its potential introduction in Ontario and thanked me for writing about this topic for the national audience of Canadian Pharmaicsts on the Canadian Healthcare Network. Hopefully some good comes out of this tragedy.





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