Learning from tragedy

March 9, 2022

A recent fatality inquiry serves as an important reminder for pharmacy teams.

On November 20, 2015, a two-year-old child died of unintentional oxycodone poisoning while in the care of his grandmother. Although some details surrounding the child’s death are unknown, including how the child accessed the pills or how many he ingested, the facts, as outlined in the 2021 Fatality Inquiry Report, are clear: this tragedy was preventable.

The child, identified only as “R,” lived with his grandmother, who was his interim guardian. R’s grandmother struggled with substance use and there were concerns about her use of prescription medication. During the night of November 19, 2015, or the morning of November 20, 2015, it is believed that R ingested one or more 5 mg tablets of oxycodone, leading to his death within a matter of hours.

Tragic and preventable deaths like R’s continue to impact communities across the province each year. According to data collected by the Government of Alberta, 95 children and young people died from opioid poisoning in 2020 alone. From 2016 to 2020, the number of deaths from opioid poisoning across all age groups more than doubled, increasing from 553 in 2016 to 1,144 in 2020.[1]

R’s story, along with the hundreds of deaths that occur each year, highlight the importance of adhering to ACP’s Standards of Practice for Pharmacists and Pharmacy Technicians when dispensing any medication to help prevent such situations from occurring. There are a number of effective measures pharmacy teams are expected to implement to support patient safety; these measures impact every step of the process, from packaging to patient counselling.

Professional relationships and patient assessment

Treating patients that use prescription opioids can be challenging for pharmacists due to the complex nature of the underlying conditions and the risks of addiction and dependence. As a result, it is vital to the success of patient assessment to establish and maintain a professional relationship with these patients.

Standards 3, 4, 5, and 6 provide pharmacists with the expectations of assessment processes for all prescriptions, and the ACP opioid guidelines provide additional context to support an effective assessment process for opioid medications. As a part of a comprehensive opioid assessment, pharmacists should discuss the patient’s environment and support systems, and advise them on the proper handling, storage, and disposal of these potentially dangerous medications

Packaging

As outlined in standards 7.3 and 7.4, pharmacy teams have responsibilities regarding child safety packaging. In most cases, prescriptions should be dispensed in child-resistant packaging, especially when children reside in the home. Otherwise, the pharmacy team must be satisfied that the patient has been warned of the risks of not using a child-resistant package or is aware of the associated risk.

Labelling

Ensure storage instructions and all potential risks are clearly indicated on the prescription container.

Naloxone

As part of the assessment process, it is important to determine if the patient would benefit from naloxone. Pharmacy teams play a key role in harm reduction through the distribution of naloxone kits. Refer to ACP’s naloxone guidelines for more information.

Destruction of drugs

Pharmacy teams also have responsibilities surrounding the collection and disposal of unused drugs, including opioids and other controlled drugs, as outlined in principle 6.3 of ACP’s Code of Ethics.

Pharmacy teams across Alberta continue to demonstrate a high level of engagement in initiatives to support the safe, responsible, and appropriate use of opioids and prescription medications. That said, opioid poisoning related to prescription opioids continues to contribute significantly to the opioid crisis. It is essential that pharmacy teams adhere to standards of practice and fulfill ethical responsibilities; these essential measures serve to protect vulnerable individuals like R.

By equipping patients with the right information, support, and resources, pharmacy teams can save lives.


[1] Government of Alberta. (2021). Minister of Justice and Solicitor General: public inquiry into the death of R.L. Retrieved from https://open.alberta.ca/publications/fatality-inquiry-2021-10-01


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