Sixteen

On June 19 of this year, Andrew was supposed to turn 16. He was supposed to be studying for his G1 driver’s permit. He was supposed to be gearing up for the summer soccer season before grade 11. He was supposed to be in the middle of a growth spurt and adjusting to his lowered voice, but he’s not. I had the privilege of attending the Patient Safety Movement Foundation Summit a couple of weeks ago and I heard over and over, “I am sorry on behalf of the health care system, this shouldn’t have happened, and it was totally preventable.” While I can appreciate the sentiment behind this, it’s not enough. There are resources, data, technology, and evidence about how to systemically reduce preventable harm and there are willing people, yet it’s not being done. Every day, we hear more stories about medication errors, hospital acquired infections, surgery mishaps and it goes on. What we don’t hear about often enough is what people are doing to prevent these incidents. Read: Watch out for these three common errors with diabetes medications My question is, what small thing are you doing to contribute to improving patient safety? When I speak to students, I tell them that not every step forward has to rely on funding or huge shifts, but there are “just do its” that they can implement every day if they take the time to take a step back and evaluate, analyze. We, patient safety activists (thank you Sue Sheridan for coining this term), those who have been the most deeply affected by this harm, are the ones yelling from the roof tops and there are days when it seems like the right people are not listening and days when it seems no one is listening. It sometimes seems like no matter how hard we push the envelope, it goes nowhere. Thankfully, there are dedicated supporters of the work we do – I work with them, I speak to them, I learn from and with them. You are likely one of them. I see proof of change when efforts are combined and innovation pushes tradition to the side. Read: ISMP analysis highlights errors that can happen with look-alike, high-alert medications So how do we move this forward? Together: listen, learn, act. This is doable. If you are one of those who have the power to make decisions that can improve safety – no matter what level – I would implore you to do it. Today and everyday. And we’ll help; just ask. It will save a lot of apologies and it will prevent the pain that we “activists” live every day. Happy birthday, Andrew. Melissa Sheldrick is the mother of Andrew Sheldrick, a little boy who died in 2016 after a medication error in which he was dispensed a fatal dose of compounded Baclofen instead of the Tryptophan he had been prescribed for a sleep disorder. Since Andrew’s death, Melissa has been a tireless advocate for medication error reporting and was instrumental in the creation of the Assurance and Improvement in Medication Safety Initiative launched by the Ontario College of Pharmacists. Melissa is well-known in the pharmacy community internationally.

Sixteen

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