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Related Concept Videos

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Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
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Medication errors in community pharmacies: Evaluation of a standardized safety program.

Shaleesa Ledlie1,2,3, Tara Gomes1,2,3,4,5, Lisa Dolovich3

  • 1Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada.

Exploratory Research in Clinical and Social Pharmacy
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Summary

Community pharmacies in Ontario reported over 31,000 medication errors and near misses to the Assurance and Improvement in Medication Safety (AIMS) Program. Analysis reveals common errors and contributing factors, aiding future prevention strategies.

Keywords:
AIMS, Assurance and Improvement in Medication SafetyCommunity pharmacyMedication errorsOCP, Ontario College of PharmacistsPharmacistsPharmacy staff

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Area of Science:

  • Pharmacy Practice
  • Patient Safety
  • Medication Error Analysis

Background:

  • Mandated reporting of medication errors in community pharmacies serves as a crucial learning opportunity.
  • Incidents include inappropriate medication use and near misses intercepted before patient administration.

Purpose of the Study:

  • To examine reporting uptake, trends, and initial learnings from medication errors reported by community pharmacists.
  • Focus on the Assurance and Improvement in Medication Safety (AIMS) Program in Ontario, Canada (April 2018–June 2021).

Main Methods:

  • Descriptive analysis of all events reported to the AIMS Program during the study period.
  • Utilized a web-based reporting form with mandatory and optional fields.
  • Medications were grouped into broader classes for analysis.

Main Results:

  • Over 31,768 event reports from 2856 community pharmacies (19,639 incidents, 12,129 near misses).
  • Reporting increased rapidly after program expansion in 2018; ~60% of pharmacies reported at least one event.
  • Most frequent errors involved incorrect drug (19.5%), concentration (17.2%), or quantity (14.5%); 90.5% reported no patient harm.
  • Antihypertensives, opioids, and antidepressants were common in events.
  • Staffing issues and interruptions were frequent contributory factors.

Conclusions:

  • The study offers insights into community pharmacy engagement with the AIMS Program.
  • Identified circumstances and medications involved in incidents and near misses.
  • Aids in developing strategies to prevent future medication-related events.