On March 13, 2016 Melissa Sheldrick woke up to the news that no parent ever wants to face. Her son Andrew, a fun-loving eight-year-old boy, had died overnight. It would take the family four and half months to learn that the cause of death was a medication error.
Melissa shared her and Andrew’s story on November 7 at a public lecture hosted by the Waterloo School of Pharmacy. Called Eliminating Medication Errors: There is a patient behind every prescription, the event began with Hallman Director David Edwards addressing the medication use process and discussing where and how errors can occur. Edwards was followed by Sheldrick’s presentation on how the tragedy her family endured has turned into her campaign for improved medication error reporting across Canada.
For eighteen months, Andrew’s parents were visiting their pharmacy in Mississauga, picking up refills for a medication that treated Andrew’s sleep disorder. On March 12, they gave Andrew his usual dose. The next morning, they found him dead in his bed.
“The liquid medication didn’t look different at all. Andrew didn’t say it tasted funny,” said Sheldrick. “But we learned that it contained Baclofen, a muscle relaxant, at three times the lethal dose for an adult.”
The mix up in medications had dire consequences, but when Melissa looked up what happens after an error at the pharmacy, she learned that the mistakes were not reported to anyone. From that point, she vowed to make medication error reporting mandatory in Ontario.
“This wasn’t good enough for me. It wasn’t good enough for Andrew. It wasn’t good enough for our family, our friends, or people who live in our province, our country, and our world,” said Sheldrick.
The lack of reporting makes the prevalence of medication errors hard to know. Edwards’ presentation covered some of the contributing factors: busy work environments, miscommunication between health care providers, and overworked staff all potentially can impact the quality of care a patient receives. But in identifying the cause of errors, Edwards stressed the importance of assessing the process when responding to mistakes.
“It is critical that we shift our culture away from blaming and shaming those who have made errors to one that focuses on identifying the root cause of the error.” said Edwards. “This is the only approach that will allow us to correct processes and improve training to prevent future errors.”
Since then, Melissa has been consulted by the Ontario College of Pharmacists in their initiatives to implement mandatory error reporting in all of Ontario’s 4,300+ community pharmacies. On November 1 2018, the College announced that it was doing just that: the error reporting program is called Assurance and Improvement in Medication Safety (AIMS). It makes the reporting of both errors and near misses (mistakes that are caught before they reach the patient and cause harm) mandatory. AIMS will be implemented across Ontario by spring of 2019. The A and S in the acronym AIMS are a tribute to Andrew Sheldrick.
Sheldrick has been in contact or collaborated with representatives from all provinces in her efforts to make medication error reporting mandatory nationwide. Near misses are a key part of this process:
“Collecting data on near misses is important,” she said. “They have not reached the patient, they have not caused harm, and yet this information will give us incredible insight so that we can ensure the issue does not happen again.”
The audience joined the discussion after Edwards and Sheldrick spoke, and questions centred around the implementation of AIMS: what role do robotics play in improving safety and how might financial repercussions contribute to increased safety. An audience member also asked about what patients can do to be proactive about avoid medication errors.
“Communication is key. To not be afraid to ask a pharmacist a question, to not feel like you’re interrupting their day. It’s part of their job to counsel you,” Sheldrick replied. “Having that open dialogue with that professional will help guide you in the right way. You may be apprehensive about asking questions, but you have to. We have to self-advocate.”