This week, a study was published that tracked reports from 301 community pharmacies in Nova Scotia over a period of 7 years. The reports that were tracked, were those of medication errors – 98, 000 of them. This seems like a harrowing number but the good news is that 82% of the incidents did not reach the patient. For a bit more perspective, there were 91 million prescriptions filled in the province over those 7 years, so only a small fraction of errors caused some degree of harm to patients, from mild all the way to 2 incidents that caused death. Why do this study and why do we want to know how many patients were harmed? Because data informs practice. How can you get better if you don’t know what is wrong? The key to mandatory reporting and follow up quality improvement programs like AIMS, our program here in Ontario, COMPASS in Saskatchewan, SafetyIQ in Manitoba, and New Brunswick’s incoming program is that they are created and enforced to ensure that the data does not sit and collect dust but that there are plans made to prevent similar incidents from happening again. That’s my point – always. What happened to Andrew and to our family can never happen again.
Thank you to the authors of this study: Certina Ho BScPhm PhD, Adrian Boucher BSc PharmD, Neil MacKinnon MSc(Pharm) PhD, Todd A. Boyle PhD, Andrea Bishop MHSA PhD, Paola Gonzalez MASc PhD, Christopher Hartt PhD and James R. Barker MA PhD for putting your time into this paper. It is a positive step in mitigating potential future harm. The source document for the study is Open Access and readable at http://cmajopen.ca/content/6/4/E651.full.pdf+html?sid=416e6572-7f38-479f-9fc2-f48e0d37d24c