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CPSI Share                                                    
Leader; Provider; Public
3/6/2019 5:00 PM

Melissa SheldrickMy name is Melissa Sheldrick and I am a wife, mom, teacher and patient safety advocate. I came into the role of advocate when our eight-year-old son Andrew was taken from us two and a half years ago due to a substitution error made at our pharmacy.

Andrew was a healthy little boy who was diagnosed with parasomnia and was prescribed five tryptophan tablets daily before bed. Parasomnia refers to all the abnormal things that can happen to people while they sleep and in Andrew's case, he went into his REM sleep twice as quickly as he should have which disrupted his whole night's sleep cycle. The large chalky tryptophan tablets were too big for him to swallow at the tender age of six, so I asked the doctor about a different kind of ingestion method. She suggested that we find a compound pharmacy so that they could make it into a liquid for him. We did so for a year and a half, and on Friday March 11, 2016, I called the pharmacy to order a refill. We picked up the bottle Saturday afternoon, put it in our fridge and it stayed there until bedtime. When it was time for bed, I gave Andrew his dose, tucked him in and kissed him goodnight.  What unfolded the next morning, is what nightmares are made of.

For four months, we did not know why Andrew died and we then learned that the bottle of medication that the police seized from our fridge on Sunday, March 13th, contained no Tryptophan at all, but contained Baclofen, mixed to the same concentration as Andrew's prescription, three times the lethal dose for an adult. Careless errors cost the life of our little boy.

When I learned that the pharmacy was not mandated to report their error, I couldn't live with even the idea that nothing would change and another pharmacy could make a mistake that cost a life or caused harm and no one would know about it. I petitioned for change in Ontario, and the College of Pharmacists swiftly created an anonymous error reporting program that is a part of a larger continuous quality improvement program through a company called Pharmapod . Soon, every pharmacy in Ontario will be required to report all medication incidents and near misses so that data can be collected and reports can be compiled to help prevent future errors.

Medication errors are common, everyday occurrences that are harming patients of all ages. These errors are avoidable and preventable and we must work harder and have regulations and policies in place that reduce their number, frequency and severity. When examining the errors, there has to be a, "what happened and why?" system instead of a, "who did this?" stance. This system aims to build preventative measures into the pharmacy's processes so that the same errors do not recur. Communication and collaboration are key to maintaining and increasing patient safety, and the learnings must be shared. When incidents are recorded, analyzed and learnings are shared, medication delivery becomes safer. This is Andrew's legacy of care.

Melissa Sheldrick is an elementary school teacher and a member of Patients for Patient Safety Canada. She was a member of the Ontario College of Pharmacists' Medication Safety Task Force and provided an invaluable perspective as a patient advocate in the development and implementation of a continuous quality assurance program for medication safety.