In November 2018, the College decided to begin exploring the implementation of mandatory medication error reporting to an independent third party.

This comes after Melissa Sheldrick – a patient safety advocate whose son passed away due to a drug dispensing error in Ontario – requested that the College consider the implementation of mandatory medication error reporting.

The second most common complaint received at the College are those regarding medication dispensing errors made by registrants.

Exploring Implementation

The implementation of mandatory medication error reporting aligns with the College’s duty to protect the public, as well as its vision of “Better health through excellence in pharmacy,” and Code of Ethics. 

Data analysis of medication errors has the potential to improve public safety nationally and provincially. Mandatory anonymous medication error reporting provides data that can be analyzed to help identify trends in errors that are occurring and provide opportunities to learn from mistakes, improve practice and better protect the public. 

Although sections 24(1) and 29(1) of the Pharmacy Operations and Drug Scheduling Act Bylaws currently require pharmacy managers of community and hospital pharmacies to develop, document and implement an ongoing quality management program, the specific requirements of the program are left to the discretion of the pharmacy manager, and the College does not assess the adequacy of the program.

Several provinces in Canada have also implemented, or are in the process of implementing, new quality management requirements that include mandatory medication error reporting to an independent third party.

The College is now in the process of developing a briefing package with options for a plan to move forward and a recommendation for a decision at the September 2019 Board Meeting. 

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