MISTAKES IN PROVISION OF HEALTH CARE

As a former pharmacist, now retired, I have some in depth knowledge about the possibility of mistakes in filling prescriptions. From 1958 to 1992 I was president of a chain of prescription pharmacies, and in that period time there were errors made but, and this is important, none resulted in serious illness or death. It was not pure luck as it is nearly impossible to practice day in and day out and never go wrong. Our prescriptions were filled by registered pharmacists or pharmacy assistants but in any case they were all checked by a qualified person, the pharmacist before they were given to the patient. There are 9000 pharmacies in Canada, not counting hospital dispensaries, and to make the mathematics easy let us say each one fills 100 prescriptions each day. That figure is probably low. That makes 900,000 medicines going out on a daily basis. A lot of room for error!

I am writing this blog, at this time, as you may be aware for a reason. A young boy in Ontario, just 8 years old had a condition called parasomnia. It is a sleeping disorder. The young lad had a problem swallowing the tablets and the mother went to a compounding pharmacy to put the tablets in a liquid form. Here is where the error occurred and Baclofen, a muscle relaxant, was substituted for Tryptophan for sleeping disorders. The muscle relaxant given was three times the dosage even for an adult. The boy never woke up. It would have been nearly impossible  for the mother to detect the  error as the tablets had been incorporated into a liquid that resembled the original prescription. Just a series of coincidences that led to the death. If the tablets had been given to the mother she would have instantly recognized the mistake. The mother was informed by the police coroner why her son died, three months later. There is no question that a mistake was made by the pharmacy but because of the nature of the error, it may well be the pharmacist was not even aware of what happened. Hopefully for the pharmacy, the prescription was filled by a qualified person, even though an error occurred.

The  mother of the boy is calling for an Ontario law that every mistake must be reported, but to who?  Certainly the Ministry of Heath and officials there are not set up to handle occurrences such as this , and even the Ontario College of Pharmacists under whose jurisdiction it falls would be at a loss to handle any but serious problems, and that is exactly what happens. Each health profession in Ontario should handle their own mistakes as they occur, but it has to depend on the individual practitioner and their associates. It is nearly impossible to be on top of every situation. A death or a very serious happening brings everything to the surface. Never forget that self-interest governs all and this applies to the individuals and their licensing body.

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