Melissa Sheldrick
Medical Error
Canada

My son Andrew was taken from us because someone made a grave error one day in March 2016.  That person took the wrong bottle from the shelf of the pharmacy and mixed Andrew’s prescription.

Andrew was a typical little boy who loved trains, soccer and his Xbox. He was an avid swimmer, took karate and drum lessons. At the age of 5, Andrew was diagnosed with a sleep disorder and the doctor prescribed tryptophan every day before bed. He was given a compounded formulation as he was too small to swallow the large, chalky tablets. The treatment worked well for Andrew, and he slept better. He took the tryptophan for 2 and half years. One night, I gave him his dose, kissed him goodnight and tucked him in. He did not wake up the next morning.

For four months, we did not know why Andrew died, and then we learned that the bottle of medication that had been tested in a lab contained no tryptophan at all, but contained only baclofen, mixed in the same concentration as Andrew’s prescription, 3 times the lethal dose for an adult. The coroner suspected that an error was made at the dispensing level but could not be sure at that time. Further investigations were conducted by police and the Institute for Safe Medication Practices Canada (ISMP Canada), and it was concluded that this was, in fact, an error made at the pharmacy level.

Then, I discovered that if the pharmacist didn’t tell anyone about their mistake and what had happened to Andrew, to our family, no learning would come of it. I discovered there was no accountability on the pharmacy and pharmacist to make changes so that this could not, would not happen again.

I couldn’t live with the idea that potentially nothing would change, and another pharmacy could make a mistake that cost a life or caused harm and no one would know about it. I began to advocate for mandatory, continuous quality improvement programs in my home province of Ontario, Canada and then across the country. These programs would require community pharmacy teams to report medication errors and near misses, take time to analyze them and come up with strategies to prevent recurrence. I have worked with some of our regulatory colleges across the country to support planning and implementation of these programs, in varying degrees.

I have vowed that no other family should ever feel the pain and despair that our family has, and if I can help prevent even one error, then it is worth it. Andrew was an incredibly caring kid who was sensitive to the needs of others. It is my responsibility now to continue Andrew’s legacy of caring, to increase patient and medication safety in community pharmacies. I continue to collaborate with professionals from across Canada and the globe who share my vision.