 My name is Melissa Sheldrick, and I'm a wife and a mom to two beautiful kids and I spent most of my career as a teacher and taught public school young kids and then I moved into the patient safety landscape about seven years ago in 2016. In 2016, we lost our eight-year-old son Andrew to a medication error. Andrew was on a daily prescription for tryptophan. And it was compounded into a liquid because he was too small to swallow the pill's whole. And so we would refill his prescription every two weeks and it would stay in the fridge and he would get his dose at night and it was such a change for him in his sleep patterns. He didn't wake with night terrors anymore. He wasn't afraid to go to sleep. He had better days and better evenings. And then one Saturday in March we picked up the refill and took it home and I gave him his dose before bed and kissed him goodnight and tucked him in and then he didn't wake in the morning. But for four and a half months, we didn't know why he had died so suddenly. And then we were contacted by the police department and the coroner's department and they suspected that this was a medication error made during the dispensing process of his compounded medication. And sure enough, after investigations by the coroner's office and the Institute for Safe Medication Practices Canada, it was confirmed that Andrew's prescription had been substituted with baclofen. There was no tryptophan in his bottle at all when the police took it from our fridge that Sunday morning. He contained only baclofen mixed in the same concentration as his tryptophan, three times the lethal dose for an adult. We were shocked and we were angered and we had even no idea that medication errors happened. We had full trust in this system of receiving medications that heal us and not harm us. And so I began to wonder what might come of this. How are we going to move forward to make sure this doesn't happen to anybody else and anybody else's family? At that time, I learned that there was no accountability on the community pharmacist to report this mistake to the regulator. And that was not okay with me because it meant that there was no information being gathered. And there was no way to look at why this substitution error happened and how to prevent it from happening again. So I set out to make that change in my home province of Ontario, Canada. With the Ontario College of Pharmacists, we formed a task force to develop and implement a continuous quality improvement program. It included the reporting of errors and near misses. Now in Ontario, we have the Assurance and Improvement in Medication Safety, the AIMS program. And this program is fully implemented for community pharmacies across the province, over 4,500. In 2016, when I started this work, there was only one province in Canada who had this kind of a program. It was a small province in Atlantic Canada, Nova Scotia. And so I had to begin to make these changes across the country. And so I went province by province. And now in 2023, it gives me great pleasure to say that there are six provinces in this country who have this kind of a CQI program in play. And so I continue to advocate for these programs here in Canada, across the world in Australia, with the WHO and now here in the United States. And it is my goal and my work to come alongside clinicians, health care providers, pharmacists, students, whoever I can to get my story across, to get my message across, that we have to come together and we have to know what's going wrong with medications so that we can analyze them and share the learnings and prevent these things from happening again.