A victory for reporting medication errors in Canada

Melissa Sheldrick and her son, Andrew

Two years ago, a CBC/Marketplace investigation found that an estimated half a billion prescriptions are dispensed in Canada every year by 38,000 pharmacists. In spite of the volume, there was no national tracking system for potentially fatal medical reporting errors. Nova Scotia is the only province with mandatory tracking tools for medication errors — and in three years, more than 75,000 medication errors were reported there.

After her 8-year-old son Andrew died after a toxic dose of a medication that wasn’t meant for him due to a pharmacy error, Melissa Sheldrick of Mississauga, Canada came to Change.org eight months ago to make changes to medication error tracking in Ontario.

Nothing can bring Andrew back to us,” Sheldrick wrote. “However, in his caring spirit, we want the laws to protect all people, and so we are asking that Ontario create a law to enforce the use of error tracking tools for dispensaries…A reporting system would help put in place a vehicle to examine errors and see how training and procedures can be improved to reduce the number and types of errors.”

Recently, Melissa declared victory on her campaign with the support of 21,305 signatures on her petition. The Ontario College of Pharmacists this week confirmed the beginning of a program requiring medication errors to be reported to a third party. “Dr. Hoskins endorsed this program in December and the College swiftly responded and began planning the program. After a public consultation and two council meetings, it has been unanimously decided to go ahead. Now that this is moving in Ontario and a couple of other provinces, we will continue to push all provinces and territories to make incident reporting mandatory across the country.”

An Institute for Safe Medication Practices Canada Bulletin shared across the country shares recommendations learned from Andrew’s death. Melissa hopes that it will help inform all pharmacies evaluate their practices and environment to continue reducing medication errors. “Medication errors can have tragic consequences for patients and families … They are also preventable,” Todd Leach, a spokesperson for the college, told the Toronto Star. “Understanding why errors happen can help reduce the risk of recurrence, prevent incidents including near misses, and ultimately advance patient safety.”

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