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Learning from practice incidents

March 19, 2024
Portrait of Melissa Sheldrick, patient safety advocate.
Patient safety advocate, Melissa Sheldrick, will share her story at ACP Connect events in Edmonton and Calgary.

In 2016, Melissa Sheldrick and her family’s world was turned upside down when their eight-year-old son, Andrew, passed away due to a medication error. The Sheldrick’s community pharmacy in Ontario 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 and internationally to support the implementation of continuous quality improvement (CQI) programs in community pharmacies, including anonymous error reporting. ACP is currently developing a CQI program for Alberta.

ACP is honoured to have Melissa as the guest speaker at our next ACP Connect events, where she will share her personal story, the work she’s done to advocate for patient safety, and the change she has helped inspire and implement across Canada.

“There has been learning on my part, on pharmacy professionals’ part, on regulators’ part, on everybody’s part, on how we can come together and make improvements in the systems so we can prevent these kinds of errors from happening again,” said Melissa. “I’m hoping we can learn together at this event so we can figure out what this might look like in Alberta.”

A key element of CQI programs is mandatory, anonymous practice incident reporting, which is done from a systems—not personal—point of view.

“Reporting incidents is not about the ‘who’—it’s about the ‘what happened,’” Melissa said. “I think learning about these programs can be a bit daunting for people at first, but error reporting is anonymous. No one can trace it to anybody, and it isn’t about that person. It’s about the failures in the systems that allow the errors to get through.”

As part of her work, Melissa travels across Canada to speak to pharmacy professionals and other healthcare providers to share her story and inspire change. She hopes to make the value of practice incident reporting real.

“When I speak, it brings the human element,” she said. “People are so intimately connected to and impacted by their medications. There’s an openness to hearing my perspective because of my background and my willingness to support and collaborate with healthcare providers. Also, I worked in a drug store for 10 years. I have seen first-hand what goes on and I understand the pressures pharmacy teams face. I think that lends credibility to what I do, as well. I speak to a lot of pharmacy students. Often, after I speak, someone will come up to me and say that I have changed the way they look at the profession and they’ll never forget my story, and they’ll never forget my son. That’s the reason I do this—to bring hearts and minds together.”

In addition to her presentation, Melissa will take part in an interactive panel discussion which will invite questions, comments, and sharing from pharmacy professionals in attendance, either in person or online. Melissa hopes the pharmacists and pharmacy technicians who attend will see how they can be part of change, part of improvement.

“I come with a collaborative spirit,” said Melissa. “Everybody is part of this process of improvement. It’s bigger than one person. It’s bigger than one pharmacy. I hope what they hear and what they learn will help them as they reflect on their own practices and apply what they’ve learned.”

Melissa will be joining us in person at two ACP Connect events as follows:

  • Edmonton (with virtual option) – Monday, April 15, 2024, from 7:00-8:30 p.m. MT; and
  • Calgary – Tuesday, April 16, 2024, from 7:00-8:30 p.m. MT

An email with links to register to attend in Edmonton, in Calgary, or virtually was sent to registrants on Tuesday, February 20, 2024. If you have questions or did not receive the email, please contact

We hope to see you there!