Sask. pharmacists adopt program to report drug dispensing errors

Saskatchewan is introducing a mandatory system for reporting drug dispensing errors by pharmacists, a move that's being applauded by a grieving Ontario mom.

Mother of Ontario boy who died from drug error applauds move

Changes made today in Saskatchewan are designed to provide greater medication safety practices for pharmacy teams. (CBC)

Saskatchewan is introducing a mandatory system to try and prevent potentially dangerous drug errors by pharmacists, a move that's being applauded by a grieving Ontario mom. 

I won't stop until each province has this in place.- Melissa Sheldrick 

Melissa Sheldrick's son Andrew took tryptophan, an amino acid that is sometimes used to treat people suffering from sleep disorders.

Sheldrick told CBC Radio's Saskatoon Morning, that after Andrew took his medicine one night last March, he did not wake up the next morning.

"We didn't know for four-and-half months why Andrew died," she said. "We worried; we suspected."

In the end, the family learned that the pharmacist had dispensed a muscle relaxant, instead of liquid tryptophan.

"That one dose was lethal, it was fatal," said Sheldrick.

Eight-year-old Andrew Sheldrick died after the pharmacy that dispensed his sleeping medication accidentally switched it for something else. He was found dead the morning after taking the wrong medication. (submitted by Melissa Sheldrick)

Grief fuels push for change

The news that Andrew had died because of human error at the pharmacy was devastating. Sheldrick said the family was forced to re-live the boy's death and grieve his loss all over again. 

"It added to my anger, and it added to my frustration, so I started campaigning for change," she said.

As Sheldrick dug deeper, she learned there was no requirement for pharmacists to report drug mix-ups. 

"What's causing these mistakes? Why are there errors? Who are they happening to? When are they happening?"

Greater medication safety

On Thursday, Saskatchewan became the second province to implement a mandatory program to provide greater medication safety practices in community pharmacies.

The Community Pharmacy Professionals Advancing Safety in Saskatchewan (COMPASS) program, among other things, includes tools needed to anonymously report drug errors. 

"We know that pharmacy care in Saskatchewan is already safe," said Justin Kosar with the Saskatchewan College of Pharmacy Professionals.  

"During our pilot program, data revealed that over 99 per cent of medication incidents were caught before reaching the patient and the small percentage that did, resulted in little to no harm being done. So this program is not being implemented to react to a problem."

The program also encourages patients to ask their doctor, nurse, and pharmacist a series of key questions about the drugs they have been prescribed.  

Melissa Sheldrick wants legislation that would force pharmacies to make prescription errors public. (CBC)

A mom's desire

Sheldick applauds the move made by the Saskatchewan College of Pharmacy Professionals and said that she hopes it is adopted favourably by front line workers in the province.  

"I would love for the pharmacists to really embrace this program and champion it," she said. 

But what the announcement will not do is lessen Sheldick's desire to force change nationwide. 

"I won't stop until each province has this in place." 

About the Author

Danny Kerslake is an award-winning journalist who has worked in radio stations across Western Canada. In his career with CBC Saskatchewan, Danny has reported from every corner of the province and has lived and worked in Saskatoon, Regina and Prince Albert. Danny is a newsreader and digital AP for CBC Saskatoon.

with files from CBC Radio's Saskatoon Morning