An Ontario mother whose eight-year-old son died in his sleep after a pharmacist gave them the wrong drug is on a mission to convince all provincial regulators to make reporting of medication errors mandatory. So far, she’s convinced four of them to act.
Melissa Sheldrick’s son Andrew had a sleep disorder called parasomnia, which caused him to wake up screaming and crying at night. He had been on a drug called Tryptophan for more than a year when a pharmacist refilled his prescription.
Sheldrick gave her son the medication on March 12, 2016 and tucked him into bed. Months after his death, tests came back showing that he had actually consumed three times the normal adult dose of a muscle-relaxant called Baclofen that night.
“It killed him fairly instantly overnight,” Sheldrick told CTV News Channel’s Angie Seth.
Sheldrick says she was shocked to learn that unless she went to the media and publicized the error, no one would even know it had happened.
“The idea that nobody would know about it because the pharmacies were not responsible or obligated to report their error ... that really upset me,” she said.
Sheldrick set out on a mission to convince all provincial pharmacist regulators to require that pharmacists report such mistakes.
At the time, Nova Scotia was the only province where reporting errors was mandatory. Now, it’s required in Manitoba, Saskatchewan and New Brunswick. As of mid-2019, it will be mandatory at all 4,300 pharmacies in Ontario.
“They designed a program that not only collects incident reports but then shares back the learnings to the pharmacies so that they can then collaborate and make changes to their pharmacies to keep their patients safer,” Sheldrick said of the Ontario College of Pharmacists.
The new program is called AIMS, short for Assurance and Improvement in Medication Safety.
“The A and the S are Andrew’s initials,” she explained. “It’s a tribute to him and to his legacy and the little boy that he is in our hearts and minds.”
