Andrew Sheldrick was just eight years old when he took his nightly medication, hopped in bed, and never woke up.
It was more than four months until his mum Melissa found out why.
“Andrew had a sleep disorder and so he was on a daily medication,” she said.
“It wasn’t actually a medication, it was an amino acid which was made into a liquid for him because he was so young he couldn’t take tablets.
“We picked up his refill one day and I gave him his dose and he went to sleep and then he didn’t wake up the next morning.
“After an investigation they discovered that there was a substitution error made [at the pharmacy] and the wrong medication was put in his liquid.”
That wrong medication was actually a muscle relaxant and Andrew was given three times the prescribed dose.
This was in Canada only three years ago, and Ms Sheldrick is now pushing for law reform across the world to stop the sort of mistake that led to her son’s death.
Her campaign has brought her to Australia this week, where health experts are warning our system could lead to similar tragic cases.
The Pharmaceutical Society of Australia (PSA) has backed Ms Sheldrick’s cause, and has released research showing an “alarming” number of medication-related errors.
- 250,000 hospital admissions annually are a result of medication-related problems
- This has an annual cost of $1.4 billion
- 400,000 additional presentations to emergency departments are likely to be due to medication-related problems
- 50 per cent of this harm is preventable
“We think that’s just an alarming number of preventable incidents,” PSA deputy CEO Belinda Wood said.
Call for mandatory reporting of errors
The PSA and patient safety advocates like Melissa are pushing for a change in Australian laws that would require pharmacists to report mistakes they’ve made when dispensing medicine.
In Ms Sheldrick’s home province of Ontario, Canada her advocacy has led to these laws being introduced and she said it was some comfort knowing that will be Andrew’s legacy.
She will speak at the PSA’s national conference in Sydney this weekend and said mandatory reporting wasn’t about blaming pharmacists.
“It is absolutely about learning. We don’t know what we don’t know,” she said.
“We need to collect the data to be able to see where the mistakes are happening, how they’re happening.
“It’s not about who did it. It’s about how it has happened and what can we do to prevent it from happening again.”
Ms Wood echoed the sentiment, saying she accepted humans made mistakes but it was a system-wide issue that needed to be fixed.
“Medication errors can happen at the point of prescribing, at the point of dispensing, and even at the point of administration,” she said.
“What we really want to see happen here is continuous quality improvement and learning from the mistakes and the near misses that are happening so that we can reduce the number of medication errors.
“What our pharmacists are telling us is they really do want to be able to enact the changes required, but that’s going to require some workforce change and that requires resourcing.”
PSA’s research also found 98 per cent of aged care residents have at least one medication-related problem, and more than half are exposed to at least one potentially inappropriate medicine.
They are calling for pharmacists to be integrated into aged-care facilities, and greater input from the federal government.
“We’ve called for medicine safety to be declared a national health priority area,” Ms Wood said.
Federal Health Minister Greg Hunt will address PSA’s conference on Friday and is expected to outline the Government’s plans to improve medication management.
“Medication management is of fundamental importance, and the government is committed to working with doctors, pharmacists and other healthcare professionals to improve medication management, medicine adherence and addressing avoidable hospital admissions related to medication misadventure,” a spokesperson for Mr Hunt said.