Bad medicine: No system in place to track pharmacist errors in Ontario

“I could’ve died.”

Doreen Summers has had several near misses with death and severe illness, and it’s usually the result of errors at the pharmacy.

“I started to swell and itch until it got to my face and it was completely distorted,” she says. “I looked like a caricature. I had to go to the hospital and they knew right away (and asked) ‘What did you take?’ And I had my pills with me and they said “Oh, you’re allergic to penicillin, you shouldn’t be taking Suprax.”

But Summers had been taking the medication for about a week, even though her medical file at her local pharmacy said she was allergic to penicillin. Nobody warned her that this drug could have the same effect. When Summers confronted the pharmacy, the pharmacist admitted he made an error.

“They said red flags came up on their computer but they decided I could take it anyways,” Summers says.

This wasn’t the first time Summers had a dose of bad medicine – she’s picked up prescriptions that were meant for somebody else, she’s been given bottles with crushed pills, and given another with double her blood pressure dosage.

“If I took those pills that were double dosage, would they know? They would say ‘She took many blood pressure pills, that’s why she’s dead.’ It’s too late then – (I’d be dead) because it was the wrong dosage.”

She reported the double dose to the pharmacist. “It didn’t do me a lot of good,” she explains. “They said ‘Oh, that was a mistake.’” Summers didn’t go back to that pharmacy, and has switched pharmacists several times over the past few decades because of errors – errors that are never tracked.

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There are just over 15,000 practicing pharmacists in Ontario, but there isn’t a mandatory reporting or tracking system for pharmacists that make mistakes. The Ministry of Health and Long-Term Care doesn’t have “any role” in tracking pharmaceutical errors, according to spokesperson David Jensen. And the Ontario College of Pharmacists, the industry’s regulating body, doesn’t require pharmacists to report errors either.

“While we do not require pharmacy professionals to report errors, we do require them to demonstrate that they have a system in place to identify and act on them,” explains College spokesperson Jasmine Graham.

Graham says practice advisors look for these systems when they conduct routine assessments. “The focus is on continuous quality improvement and strengthening the system.”

Nova Scotia is the only province where pharmacists must report errors, as well as near misses. SafetyNetRX, the province’s mandatory – but anonymous – reporting system was first launched in 2008. It’s been credited with helping pharmacists reduce errors like incorrect dosages, length of treatment and unsafe drug combinations.

In its initial pilot project, involving only 13 pharmacies, 813 potential errors were reported in just eight months. Once the program became mandatory for all pharmacies, 75,000 errors were reported over a three-year span. This includes “near misses,” where a mistake was caught before the prescription made its way to a patient, but were still captured in order to help prevent future mishaps.

Saskatchewan recently launched its version of SafetyNet-RX, called COMPASS (Community Pharmacists Advancing Safety in Saskatchewan). In Phase I of its pilot project, 575 incidents were reported from 10 participating pharmacies. Only five of those incidents resulted in any level of harm to patients, and most (84 per cent) were near-misses. In February, Phase III was launched with 120 participating pharmacies, and to date 5,719 incidents have been reported, most of which were “near misses” (4,342), with 50 resulting in actual harm to the patient.

The Saskatchewan College of Pharmacy Professionals is expanding the program, and hopes to eventually include all pharmacies in a mandatory reporting system.

There are no such plans for Ontario.

“We support the work of the Institute for Safe Medication Practices (ISMP) Canada,” Graham says. “Their practice is to collect and analyze national data about medication incidents and use it to create learnings for pharmacy professionals.”

The ISMP is a non-profit organization that works closely with Health Canada and regulatory colleges across Canada. It runs the Community Pharmacy Incident Reporting Program, which is intended to help reduce errors – reporting errors is not only voluntary, but requires pharmacies to have a paid subscription to the service.

Summers is convinced there are thousands of people who fall victim to medical errors every year, and without mandatory tracking and reporting, she doesn’t think there will be any meaningful improvement.

“People can die from – I call it ‘neglect’ – the pharmacist signs off on the medication and that’s who I hold responsible.”

She’s lost faith in drug stores and pharmacies and researches every new drug she’s prescribed before she takes it. She says she’s lucky she didn’t overdose on medications given to her in error, but believes others have.

“I don’t know how many people have died. I don’t know if anybody does.”