By Ian Stewart R.Ph, B.Sc.Phm. CALCULATION ERRORS Pediatric patients often require individualized doses of medications based on the child’s age, weight, the indication for use and the recommended dosage regimen of the medication. The determination of individualized doses usually requires the use of calculations which introduces an additional source of error and an increased risk of patient harm. Pharmacists must therefore use extra care when assessing and calculating the appropriate dosages in high risk populations…
Close-Up on Complaints explores incidents reported to the College that have occurred in the provision of patient care and which present learning opportunities. Ideally, pharmacists and pharmacy technicians will be able to identify areas of potential concern within their own practice, and plan and implement measures to help avoid similar incidents from occurring in the future. Summary of the Incident This incident occurred when a patient at a pharmacy noticed that there were documents and…
In late 2016, the Ontario College of Pharmacists embarked on a journey that would result in the introduction of the largest medication safety program of its kind among Canadian pharmacies. An advocate behind this critical work is elementary school teacher Melissa Sheldrick, who lost her son Andrew, 8, to a medication error. Melissa was invited to be a part of the College’s Medication Safety Task Force as it reviewed options related to medication error reporting…
Adrian Boucher, BSc, PharmD Student 1,2Sonya Dhanjal, BSc, PharmD Student 2,3Jim H. Kong, RPh, BSc, PharmD 2Certina Ho, RPh, BScPhm, MISt, MEd, PhD 1,2,3 1 Leslie Dan Faculty of Pharmacy, University of Toronto2 Institute for Safe Medication Practices Canada3 School of Pharmacy, University of Waterloo BACKGROUND Although pharmacy professionals and pharmacy organizations aim to provide error-free patient care, medication incidents are inevitable. Medication incidents are defined as any preventable events that may cause inappropriate medication…
Pharmacists, pharmacy technicians and pharmacy managers (i.e., Designated Managers and those who are in charge of a hospital pharmacy) have certain responsibilities to ensure that all controlled substances are securely stored and maintained and that all appropriate measures are taken to reduce the opportunities for diversion and manage any losses that are identified. In this article, the College has outlined some of the key expectations that pharmacy professionals andpharmacy managers must meet to prevent diversion,…
In the Spring 2017 edition of Pharmacy Connection, the College published A Framework for Ethical Decision Making. The framework provided a process to guide decision making in practice that supports the commitment to serve and protect patients’ best interests. As part of a new feature in Pharmacy Connection, the College is launching “What Would You Do?” a new column that will explore issues in practice that present an ethical issue or dilemma for the pharmacy…
Compounding IV medications is an important core competency of pharmacy practice both in hospital and community settings. In September 2016 the Ontario College of Pharmacists adopted the NAPRA Model Standards for Pharmacy Compounding for both Non-hazardous and Hazardous Sterile Preparations. These documents have provided the standards and framework that pharmacies must follow in order to ensure the quality of products dispensed. The standards are broken into three main areas: training, product preparation and quality assurance.…
“Close-Up on Complaints” explores incidents reported to the College that have occurred in the provision of patient care and which present learning opportunities. Ideally, pharmacists and pharmacy technicians will be able to identify areas of potential concern within their own practice, and plan and implement measures to help avoid similar incidents from occurring in the future. Summary This incident occurred when a patient visited the pharmacy with a prescription, containing only a stamped signature, for…
By Ian Stewart R.Ph, B.Sc.Phm. I have received numerous reports of medication errors resulting from a failure to correctly identify the patient. The potential for patient harm is an obvious concern. In addition, patients receiving medications meant for another patient may also receive confidential personal health information belonging to that patient including medication history and name of their physician, along with identifying information like their name or address. Pharmacists must be reminded that as health…
CASE SUMMARY A 77 year old woman died six weeks after admission to a Long Term Care Home (LTCH). The reported cause of death was bilateral subdural hematomas as a consequence of anticoagulation therapy with a contributing factor of pneumonia. Concerns over the monitoring of anticoagulation therapy led the coroner’s jury to refer the case to the Geriatric and Long Term Care Review Committee to assist the Office of the Chief Coroner in the investigation.…
