CPhM and ISMP Canada Publish Manitoba Community Pharmacy Medication Incident Data Analysis and Improvement Recommendations
The College of Pharmacists of Manitoba (CPhM) is pleased to present ISMP Canada’s Multi-Incident Analysis (MIA) of Incidents Associated with Harm Reported by Community Pharmacies in Manitoba. A summary of the MIA report is available here. This report commissioned by CPhM represents the shared effort of community pharmacy professionals to report medication incidents to the National Incident Data Repository (NIDR) for Community Pharmacies which is a component of the Canadian Medication Incident Reporting and Prevention System.
Medication safety specialists at ISMP Canada analyse your aggregate reports and share them to promote provincial, national, and international learning about medication incidents and near-miss events in community pharmacy. This MIA report and summaries are one way your data is translated into actionable recommendations to improve pharmacy practice.
The MIA report looked at 3898 submissions to the NIDR from April 1, 2017 – March 31, 2022. A total of 137 incidents (3.5 per cent) were associated with harm and 90 per cent of errors were reported to have caused mild harm. Most incidents occurred in the order entry and dispensing stages of prescription processes. These findings are similar to other MIA of harm events in Canada including a CMAJ study (2018) and ISMP Canada Safety Brief (2020).
How can we use this information to improve processes in our pharmacy?
- Read the full report and summary. CPhM strongly encourages pharmacy managers and CQI coordinators to read the full report to implement the report’s recommendation into their pharmacy’s practice. The report features a handy chart in the appendix that provides guidance to pharmacy managers on which recommendations pharmacy managers should implement as leaders and policy makers.
- Use the summary report as a topic for conversation during staff safety huddles. Some guiding questions for your safety huddle could include: How do the recommendations in the report compare with your pharmacy’s current practices? Has your pharmacy experienced a similar incident or near-miss, and can the recommendations be part of a broader improvement plan?
- Post the summary throughout the pharmacy to prompt discussion among all staff about the MIA findings and recommendations.
CPhM and the Safety IQ team commend your contributions to the NIDR and your efforts to reduce the chances of patient harm in your pharmacies.
If you have any questions or concerns about the MIA report, please contact us at safetyiq@cphm.ca.
CLOZARIL (clozapine) – COVID-19 Health Canada Guidance Update
In March 2020, Health Canada issued interim recommendations to be implemented by health care providers on the monitoring of clozapine bloodwork during the pandemic.
While the situation has improved, Health Canada recognizes that under extenuating circumstances related to the COVID-19 pandemic, challenges may still exist that hinder access to testing for some patients. Consequently, the current flexibility around hematological testing has been extended by an additional 12 months (until September 30, 2023).
Please review the following letter for further details:
- English Copy – CLOZARIL® (clozapine) – COVID-19, update Health Canada Guidance
- French Copy – PrCLOZARILMD (clozapine) – COVID-19, mise à jour des lignes directrices de Santé Canada
Infusion Errors Leading to Fatal Overdoses of N-Acetylcysteine
The College of Pharmacists of Manitoba wants pharmacy professionals to be aware of reports of fatal overdoses of intravenous N-acetylcysteine resulting from errors in pump programming. Several protocols for the dosing, preparation and administration of IV N-acetylcysteine are in use across Canada and have been identified as contributing factors.
The College is sharing the ISMP Canada Safety Bulletin on the issue to help prevent adverse events and deaths associated with N-acetylcysteine treatment errors.
ISMP is asking practitioners to report their experiences related to N-acetylcysteine protocols through the individual practitioner reporting portal, at https://www.ismp-canada.org/err_ipr.htm, or by email to info@ismpcanada.ca.
CPhM 2023 Renewal Reminder
All current licences issued by the College of Pharmacists of Manitoba expire on December 31, 2022.
Pharmacists and Pharmacy Managers are reminded to renew their corresponding practice licence using the online renewal process.
This year, the deadline to complete the renewal process is Tuesday, November 15, 2022. Late fees are automatically assessed after the deadline. Failure to renew a licence on or before the November 15 deadline will result in a late fee, equal to 50% of the original licence fee, being added.
Pharmacists are reminded that they must complete their professional development (PD) activities by October 31 and enter them into their online PD Log prior to November 30, 2022. To be eligible for licence renewal, pharmacists must participate in a minimum of 25 hours of PD learning activities annually between November 1 and October 31. A minimum of 15 of the 25 hours must be from accredited learning activities.
Thank you for your prompt attention and cooperation in the renewal process. Avoid unnecessary late penalties. Renew your licence promptly.
Reminder to Complete the Mandatory Health Equity and Cultural Humility Module
The mandatory professional development (PD) module, Health Equity and Cultural Humility: An Introduction for Health Professionals in Manitoba, is now available on the Portal. Pharmacists and pharmacy technicians have until Dec. 31, 2022, and May 31, 2023, respectively, to complete the module. This module was created in collaboration with other health regulatory colleges to support awareness and knowledge of health inequity.
Please use the Registrant Login on cphm.ca to access your Portal and scroll down to “My Professional Development.” Once you view the module, you must complete the learning activity evaluation to receive your statement of participation. This proof of completion must be maintained for a minimum of three years and may be requested by the College at a later date.
You can claim the Health Equity and Cultural Humility module for up to 1.5 accredited continuing education units (CEU) in your online PD Log (no accreditation number is required) and you must claim the CEU in the PD year you completed the module.
If you have any questions, please contact profdevelopment@cphm.ca.
In Case You Missed It: 2022 Medical Examiner Webinar Recording Now Available
On October 4, 2022, CPhM hosted its fourth annual Medical Examiner Professional Development (PD) event, entitled Understanding the CPSM Standards of Practice to Provide Safer Care, and OAT Provision in the Context of Other Psychoactive Drugs, with guest speakers Talia Carter and Mike Sloan.
If you were unable to attend the live PD event, the recording is now available on the CPhM website under the Recorded PD Programs section. Answers to questions that were not answered during the live session due to time constraints will be posted in the coming weeks. To receive your statement of participation for 1.5 CEUs, please fill out the following accredited learning activity evaluation form here.
The College would like to extend its sincere gratitude and thanks to the presenters, as well as those who participated in the program.
Consultation on Proposed Amendments to the Patient Profile Practice Direction
In 2014, the College of Pharmacists of Manitoba Council implemented a policy surrounding Practice Directions, which includes the requirement for assessment and regular review at a minimum of every 5 years.
In accordance with the Practice Direction Policy, the Patient Profiles Practice Direction is currently under review by the Standards of Practice Division of the Quality Assurance Committee. Practice Directions carry similar legal significance to regulations, and it is therefore important that the formation of a Practice Direction is made with due diligence, subject to analysis, review, and response.
The Amendments
The proposed amendments to the Patient Profiles Practice Direction are outlined here.
The two proposed amendments will:
- Change the documentation requirements of sex/gender in a patient profile from mandatory to optional, based upon pharmacist professional judgement and patient preference.
- Clarify the expectation regarding the documentation of relevant medical history.
The Consultation
Council has approved a consultation on the draft Practice Direction amendments. The consultation will be open for 30 days.
The CPhM is committed to an open and transparent consultation process. All comments received will be considered by Council.
Please review the draft Practice Direction here and provide feedback by email to feedback@cphm.ca by October 29, 2022.
The College of Pharmacists of Manitoba wants pharmacy professionals to be aware of reports of fatal overdoses of intravenous N-acetylcysteine resulting from errors in pump programming. Several protocols for the dosing, preparation and administration of IV N-acetylcysteine are in use across Canada and have been identified as contributing factors.
The College is sharing the ISMP Canada Safety Bulletin on the issue to help prevent adverse events and deaths associated with N-acetylcysteine treatment errors.
ISMP is asking practitioners to report their experiences related to N-acetylcysteine protocols through the individual practitioner reporting portal, at , or by email to info@ismpcanada.ca.
Upcoming Events & Professional Development Opportunities
Opioid Agonist Therapy 101 Introduction to Clinical Practice
December 15 & 16, 2022 8:00 a.m. – 4:30 p.m.
Click here for more information and to register.
ISMP Canada Medication Safety Workshops:
MedRec and BPMH Training for Health Care Professionals Workshop
September 24, & November 18, 2022
Register here.