(As told by Andrew’s mother Melissa)
In 2016, we lost our eight-year-old son Andrew to a medication error. He was on a daily prescription for tryptophan, which is often prescribed to improve sleep quality. It was compounded into a liquid because he was too small to swallow the pills whole.
We would refill his prescription every two weeks, and he would get his dose each night. It made such a difference to his sleep patterns. He no longer suffered from night terrors anymore and was not afraid to go to sleep. Then one Saturday in March 2016, we picked up the refill as usual. I gave him his dose before bed, kissed him good night, tucked him in, and he never woke up.
For four and a half months, we had no idea why he had died so suddenly, until we were contacted by the police department and the coroner’s department who said they suspected that a medication error had been made during the dispensing process. Sure enough, investigations confirmed that Andrew’s prescription had been mistakenly substituted with another drug called Baclofen.
Mixed in the same concentration as his tryptophan, Andrew received three times the lethal dose for an adult. We were shocked and angered. We had full trust in the system, we had no idea that medication errors even happened. So, I began to wonder, what might come of this? How would we move forward and make sure the same did not happen to anybody else?
So, I moved into the patient safety landscape. I learnt that there was no accountability on the part of the community pharmacist to report the substitution mistake which killed Andrew to the regulator. That was not ok with me, so in partnership with the Ontario College of Pharmacists, we formed a task force to develop and implement a continuous quality improvement programme that would include the reporting of errors and near misses.
Now we have the Assurance and Improvement in Medication Safety (AIMS) program which is fully implemented for community pharmacies across the province. I continue to advocate for these programs here in Canada, in the United States, and with the World Health Organization across the globe.
It is my goal to come alongside the nation’s healthcare providers, pharmacists and whoever I can, to get my message across that we must come together and understand what is going wrong with medications, so we can analyse these incidents, share the learnings, and prevent these things from happening again.