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In 2016, Melissa Sheldrick, mother to eight-year-old Andrew lost her son tragically due to a medication error.

A report by Ontario's Office of the Chief Coroner concluded that an independent compounding pharmacy which prepares personalized medications for patients had made a mistake and substituted one drug for the other. 

Shortly following this incident, the Institute for Safe Medication Practices (ISMP) published a number of recommendations to prevent this from happening again, namely that each ingredient in compounding formulas should have a unique identification number.

To ensure that the right medications are ordered, HealthPRO, Canada’s group contracting provider for healthcare, has added the Chemical Abstracts Service (CAS) number to its online contracting portal accessed by over 1,300 hospitals across the country.

“The CAS registry number provides a unique, unmistakable identifier for chemical substances,” says Christine Donaldson, Vice President, Pharmacy at HealthPRO. “By ensuring that this number is visible in our contracting system, we are doing our part to prevent such tragic incidents from happening in the future.”

The presence of the CAS registry number on a product’s label is also an important evaluation criterion when a product is submitted to HealthPRO for a contract opportunity. As further risk mitigation, ISMP recommends that hospital staff consider including the CAS registry number on their formulation sheets as a double check that the correct product is selected for compounding.

Melissa Sheldrick who continues to advocate for changes that protect patients was pleased to learn of this change.

“I am so touched and proud that Andrew's legacy is driving systemic change. It's such a step forward in safety,” she said.