At its September meeting, the College Board approved a motion requiring mandatory anonymous medication incident reporting in all pharmacies.

Over the next several years, the College will work to develop standards and criteria, as well as bylaw and policy changes to enable implementation of a mandatory anonymous Medication Incident Reporting Program by 2022/2023.

The issue was first presented to the Board at its November 2017 meeting by Melissa Sheldrick, a patient safety advocate whose son passed away due to a drug dispensing error in Ontario.

While the Pharmacy Operations and Drug Scheduling Act (PODSA) Bylaws currently outline requirements for pharmacy managers to establish and maintain written quality management policies, there is currently no way to quantify the number and types of medication incidents that are occurring in community pharmacy settings. As well, there is currently no central information system to which community pharmacy staff can report medication incidents. This presents a missed opportunity for the majority of pharmacies and pharmacy professionals in BC to learn from incidents occurring in other pharmacies.

PODSA Bylaws s.24

Community Pharmacy’s Manager – Quality Management

A community pharmacy’s manager must establish and maintain written quality management policies and procedures that

  1. ensure pharmacy staff, equipment, and facilities comply with all legislation, bylaws and policies applicable to the operation of a community pharmacy,
  2. include a process to monitor compliance with the quality management policies and procedures, and
  3. include a process for reporting, documenting and following up on known, alleged and suspected errors, incidents and discrepancies.

As a result, the College began exploring mandatory medication error reporting to an independent third party in November 2017 as part of a broader effort to explore potential alternatives to the College’s existing quality management requirements.

A Leading Cause of Preventable Injury

Medication errors are a leading cause of preventable injuries and result in significant costs to health systems across the world. In 2017/2018 and 2018/2019, the most common complaints received by the College were related to medication dispensing errors by pharmacy professionals.

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

The goal is to allow pharmacies to use any medication incident-reporting platform they choose, provided it is among those that meet the College’s criteria, which has yet to be developed. These criteria include the capability to transfer a minimal data set into a national repository that is administered by an independent third party.

As part of exploring the best path forward for medication incident reporting in BC, the College has been participating in national conversations on the implementation of medication incident reporting systems, including the NAPRA Medication Incident Reporting Working Group. Moving forward, the College will be continuing to work with the NAPRA Working Group to develop medication incident reporting standards and criteria, and establish a single national data repository.

Learn More: ReadLinks -  Mandatory Medication Incident Reporting in all Pharmacies by 2023

© College of Pharmacists of British Columbia. All Rights Reserved