When ACP began developing CQI+, the college’s due diligence included a review of similar programs already underway in Canada, a literature review, and an external consultation. This provided the background ACP needed from a pharmacy perspective, but patients’ perspectives were also needed to develop a program that would achieve ACP’s goals of preventing practice incidents in pharmacy and making pharmacy practice safer.
“Person-centred care is at the core of ACP’s standards and everything that pharmacists and pharmacy technicians do,” said Brett Baumback, ACP’s Quality Improvement Project Lead. “So, early in the process of conceptualizing CQI+, we wanted to thoughtfully reflect on how we could ensure our program would be person centred. We were curious about the public’s perceptions of what safety in pharmacy really means, and how to bring patients along on this journey with us.”
Most importantly, ACP wanted meaningful collaboration with patients that would make a tangible difference.
“We didn’t want to create the program just for patients; we needed to create it with patients,” said Brett. “To take that one step further, we thought it would be really valuable to create it with individuals who had personal experience with a practice incident, and a desire to share that experience in hopes of helping others.”
ACP worked with an external consultant to identify individuals who had experienced a practice incident and would be willing to share their perspectives, and help ACP engage with them in a person-centred way to ensure that they felt their voices would be heard and included. From there, the CQI+ Patient Working Group was formed. The group includes three patients—Melissa Sheldrick from Toronto, Roxie Malone-Richards, and Kathy Kovacs Burns (both from Edmonton)—Brett, and ACP deputy registrar Jeff Whissell.
Melissa serves as co-chair of the group. In 2016, Melissa and her family’s world was turned upside down when their eight-year-old son, Andrew, passed away due to a medication error. The family’s community pharmacy in Ontario had dispensed the wrong medication, leading to the worst outcome imaginable.
Since then, Melissa has dedicated her life to making changes in pharmacy systems to help ensure that practice incidents like the one her family experienced never happen again. Melissa is a patient and family advisor at the Institute for Safe Medication Practices (ISMP) Canada and a member of Patients for Patient Safety Canada. She has worked with pharmacy regulators across Canada—including ACP—and internationally to support the implementation of continuous quality improvement programs in community pharmacies.
“The main purpose of our group is to ensure that the program is person centred and helps maintain public safety,” said Melissa. “The core of the CQI+ program is to establish and maintain a safety culture that includes learning from errors and then finding ways to prevent them from recurring and prevent them from causing harm to people. We have been consulted throughout the development of the program on the goals, the structure, what it looks like, and how it’s going to roll out to pharmacies. We’ve been consulted on the website development, some of the communications, and I suspect that moving forward, our voice will continue to be important to maintain that person-centred focus for pharmacy teams as they come on board.”
Other members of the working group bring their own real-world lived experience. Shortly after Roxie’s daughter was born and in the neonatal intensive care unit, she was given 10 times the amount of Lasix she was supposed to get. The incident was dealt with seriously by the hospital.
“It was handled with complete honesty and transparency, with the accountability and urgency required, and very respectfully,” said Roxie. “The nurse who administered it wrote me a letter, a very heartfelt, sincere letter of apology. Ultimately, the reason I didn’t freak out is because I felt the experience would make them better at what they do.”
Kathy’s lived experience was with her father, when he was prescribed a new medication that negatively interacted with a medication he had already been taking. As a result, he suffered a stroke and a heart attack and was hospitalized. Kathy discussed the incident with the doctors and community pharmacy involved.
“The pharmacy team thought that they had checked everything quite thoroughly and had missed this because it was a new prescription,” said Kathy. “They had missed some of the side effects. Fortunately, my dad survived, but I think we learned that there had to be a double check somewhere. We followed up with the pharmacy to see what the learning opportunity was for them and for us. We went back to the family doctor as well, because that medication should never have been prescribed in the first place.”
By bringing this group together, ACP was able to learn from their collective experiences to not only shape CQI+, but how it is presented to regulated members and communicated to the public to ensure everyone understands not only the “what” and the “how” of the program, but, most importantly, the “why.”
“I think what’s unique is the group can help us understand not just what matters, but what matters most, because they’ve lived through it,” said Brett. “They bring their storytelling. They bring the heart. They can really help us understand that patient journey.”
The patient working group’s feedback was considered and applied throughout the program, which has been appreciated by the group’s members.
“ACP values not only our lived experience but also our safety,” said Melissa. “There’s been authentic engagement to put people at the centre of their care. It’s really shown an innovative spin and has been centred around a willingness and openness to learn from people. That two-way communication is super important when it comes to putting a program like this together.”
The patient working group is first to acknowledge that pharmacy team members are human and mistakes—though often preventable—will inevitably happen. How pharmacy professionals respond to practice incidents is incredibly important to those affected.
“Our expectation is that errors are acknowledged, and that we would be engaged in an open discussion about them with the healthcare team,” said Kathy. “I think an apology is an expectation. We did get that, but I think just the acceptance that there was an error made and then talking us through that to help us understand what happened and what the follow-up steps were was important. My dad still went back to the same pharmacy and asked for the same pharmacist. The trust was still there.”
