Sarah’s Journey with Pharmapod: A Story of Enhanced Pharmacy Practice

Smiling female pharmacist looking at camera

When Sarah, a community pharmacy manager, first heard about Pharmapod, she thought it might be just another tool to learn. Another login. Another checklist. Another “solution” that added more work than it solved.

But what she got wasn’t just new software, it was a turning point.

From Reporting Burden to Built-In Workflow

Before Pharmapod, incident reporting in Sarah’s pharmacy meant paper forms, inconsistent details, and far too many follow-ups. It was something the team delayed, partly out of fear, but mostly because it was a time-consuming hassle.

Pharmapod changed that.

Incident and good catch reporting became part of the daily workflow, not a separate chore.

Customizable digital forms walked staff through the process, capturing the required information quickly, confidently, and consistently.

No more paper chasing. No more guessing what to include.

Building a Just Culture, One Report at a Time

As reporting got easier, something else shifted: the culture.

Sarah used Pharmapod to reinforce a Just Culture, where reporting wasn’t about blame, but about learning. Staff felt safe flagging issues and good catches, knowing the focus was on improving care, not pointing fingers.

And with that came trust, transparency, and a steady flow of valuable insights.

From Data to Decisions: Spotting the Patterns

The real turning point? Pharmapod’s analytics dashboard.

Within weeks, Sarah could see patterns she’d never noticed before:

  • A spike in prescribing errors on busy Monday mornings
  • Dispensing challenges tied to specific drug classes
  • Repeated near misses caused by small process gaps

Insights that were once buried were now clear, actionable, and available in real-time. She wasn’t just logging events anymore, she was preventing them.

When Compliance Feels Effortless

Regulatory audits used to send Sarah into scramble mode. Now? She’s ready with a few clicks.

Pharmapod automatically generates clean, comprehensive audit reports, complete with incident history, resolution steps, and trend data.

With Pharmapod, Sarah’s data is documented, organized, and ready to go!

Did you know: Pharmapod users have reported an 80% reduction in time spent generating reports! 

The Ripple Effect: Stronger Team. Safer Pharmacy.

With less time spent on admin, Sarah’s team had more time for patients. They saw how their reports led to real changes, and that boosted morale.

It wasn’t just about reporting anymore. It was about making care safer and working better together.

Ready to See What Pharmapod Can Do for Your Pharmacy?

If you see yourself in Sarah, it’s time to consider Pharmapod.

No matter your pharmacy’s needs, Pharmapod adapts to your workflow, simplifies compliance, and supports real improvement in patient safety. 

Getting Started

Already a Pharmapod member? Log in today and start reporting.

Not yet a member? Contact us today for a demo and discover why Pharmapod is the medication incident reporting tool of choice used in over 70% of pharmacies across Canada. 

Avoid the Blame Game: How to Effectively Handle Medication Incidents in Pharmacies

Pregnant customer at pharmacy counter with two pharmacists reviewing her medication

Medication safety is at the heart of every pharmacy’s mission, yet errors and near misses, or “good catches,” still occur. These incidents can have serious consequences—not only for patients but also for the pharmacy team. While tackling these issues is no small task, one thing is clear: playing the blame game only makes the situation worse.

Fear of repercussions is one of the main reasons pharmacy workers don’t report medication errors. This culture of fear prevents the whole pharmacy team from learning important lessons that could stop similar incidents in the future. But there’s a better way. By fostering a just culture that focuses on learning, not punishing, we can transform medication errors into opportunities for growth and safer practices. This blog explores how to build that culture and effectively handle medication incidents.

What is a “Just Culture” in the Pharmacy Setting?

A just culture is an approach to workplace accountability that balances fairness and responsibility. Instead of immediately pointing fingers when errors happen, a just culture seeks to understand why the mistake occurred. It recognizes that most errors result from system failures rather than individual negligence.

Key principles of a just culture include:

  • Learning over Blaming: Mistakes are seen as opportunities to improve processes and identify systemic issues.
  • Fair Accountability: While reckless behaviour is addressed, actions are evaluated based on intent, not just outcomes.
  • Psychological Safety: Employees feel safe to report errors and near misses without fear of punishment, fostering open communication.

Adopting a just culture can ensure that medication incidents lead to better risk management, rather than contributing to workplace stress and fear.

Why Fear Holds Pharmacies Back

Fear of repercussions is a significant barrier to progress in many pharmacies. Employees might hesitate to report errors for reasons such as:

  • Fear of Losing Their Job: Many pharmacy workers worry that even a minor mistake could result in termination.
  • Reputation Concerns: Employees fear judgment from colleagues or supervisors if they admit to mistakes.
  • Past Experiences: If a pharmacy has a history of harsh punishment for errors, this legacy can discourage honest communication.

This fear-based culture not only prevents errors from being reported but also creates an environment where similar mistakes are likely to occur, putting both patients and employees at greater risk.

Shifting the Focus to Learning

Transitioning from a blame culture to a just culture requires intentional steps. Here’s how pharmacies can approach this shift:

1. Foster Open Communication

Create an environment where employees feel comfortable discussing errors and good catches. Regularly emphasize that reporting incidents is not about punishment but about protecting patients and improving outcomes.

  • Use anonymous reporting tools that allow workers to report errors without fear of identification.
  • Hold regular staff meetings to review medication incidents in a way that focuses on solutions rather than fault.
  • Provide feedback on what was learned from the trends, how reports led to improvements, and reward those who are reporting events into the Pharmapod platform

2. Analyze the System, Not Just the Incident

Most mistakes stem from systemic problems, not individual failures. When an error occurs, take a step back and ask:

  • Were there unclear or outdated procedures? (e.g., storage of cold chain products)
  • Was the workload too high or unmanageable? (e.g., duplicating work unnecessarily)
  • Were employees adequately trained on relevant processes? (e.g., new medications  or new technologies) 

Using root cause analysis (RCA) can help identify underlying issues that contribute to errors, like a flaw in automation systems or storage mismanagement.

3. Reward Good Catches

Celebrate moments when team members proactively identify potential issues before they escalate. Positive reinforcement demonstrates that vigilance and problem-solving are valued.

For example:

  • During team meetings, recognize employees who spot and stop potential errors. (e.g., Good catches of duplicate drugs or missing drugs  while checking compliance packages)
  • Implement an incentive program where reporting good catches earns points or rewards. (e.g., free coffee for the most good catch events per week)

4. Establish Clear Accountability

A just culture doesn’t eliminate accountability; instead, it ensures fairness by distinguishing between human error, at-risk behaviour, and reckless behaviour. Address each scenario with appropriate responses:

  • Human error (e.g., an honest mistake): Use coaching and system improvements.
  • At-risk behaviour (e.g., cutting corners): Provide training to reinforce best practices.
  • Reckless behaviour (e.g., a willful disregard for safety): Address this firmly with formal actions.

Consistency in how incidents are handled reinforces trust in the system.

5. Promote Collaboration

Encourage teamwork to solve problems together as a pharmacy unit. When the focus shifts away from blame, employees are empowered to collaborate on identifying patterns and creating preventative solutions.

Building a Safer, More Supportive Pharmacy Environment

Handling medication incidents effectively requires a cultural shift. By creating a just culture rooted in fairness, learning, and collaboration, pharmacies can address errors in a way that prioritizes safety, fosters trust, and prevents future mistakes.

Remember, mistakes don’t define employees, but how your pharmacy responds to mistakes will define the kind of culture you build.

Take the First Step

Is your pharmacy ready to move past the blame game? Start by holding a team meeting to discuss the importance of open communication and include everyone in the process of creating a safer, just culture. The improvements you make today could transform your pharmacy for years to come.

Ready to take the next step in improving pharmacy safety? Discover how Pharmapod makes it easy for your team to report medication errors and good catches, learn from mistakes, and implement process improvements. Contact us today for a demo. 

Medication Error Myths vs. Facts: Breaking Down Common Misconceptions

Pharmacist looking at iPad while colleague examines medication shelf in the backgroud.

Medication errors present a significant challenge in the world of pharmacy, with serious implications for patient safety. However, these issues are sometimes left unaddressed due to widespread myths and misunderstandings about error reporting. 

Understanding these myths can change how you perceive error reporting and its importance in patient care. Below, we break down six common misconceptions and reveal the facts behind them. 

Myth 1: Reporting a Medication Error Means Someone Will Be Punished 

Fact: The primary purpose of reporting medication errors is improving patient safety, not assigning blame. 

Reporting into Pharmapod enables pharmacy teams to focus on learning from mistakes to prevent future incidents. These systems are designed to foster growth and create better workflows within the pharmacy, ensuring that errors don’t happen again. 

Myth 2: Only Errors That Harm Patients Need to Be Reported 

Fact: Reporting near misses or “good catches” is just as critical as reporting errors that cause harm. 

Good Catches reveal vulnerabilities in the system, some that the pharmacies can address and some that they cannot, but adding the information into the system enables system-level change. By understanding trends and frequent duplications of good catch events, pharmacies can address and prevent similar errors before they impact patients. 

Myth 3: Reporting an Error Will Damage My Professional Reputation 

Fact: Transparency in error reporting highlights a commitment to patient safety and ongoing improvement. 

Most organizations value employees who actively prioritize safety and take the initiative to improve processes. Humans make mistakes, and what you do with the mistake that matters more than the mistake itself. Regular reporting will strengthen processes and help everyone work more safely.  

Myth 4: Reporting Is Too Time-Consuming 

Fact: Pharmapod is designed for quick and easy standardized event submissions and the insights pro data is available in real time. Like anything, the more you use it the faster you are.

Pharmacists can often complete a report in just a few minutes, and the long-term benefits of avoiding repeated errors far outweigh this small investment of time. 

Myth 5: Someone Else Will Report the Error 

Fact: Every pharmacy team member shares an equal responsibility to report incidents. 

Assuming someone else will report errors or good catches puts critical insights at risk of being overlooked. Effective systems rely on collective accountability from every member of the team. 

Myth 6: Reporting Won’t Make a Difference 

Fact: Every report provides valuable data for bettering systems and enhancing safety. A great is how drug shortages, which are beyond individual pharmacy control, can be addressed as a systemic issue when pharmacies collectively report events. This pooled data builds a strong case for driving meaningful system-wide change.

Over time, consistent reporting helps identify trends, adjust workflows, and improve patient outcomes. This not only strengthens pharmacy operations but demonstrates a clear focus on patient welfare. 

+ + +

By actively reporting errors and near misses, pharmacy professionals build a culture of trust, transparency, and continuous learning. These efforts result in safer systems and better patient care, ultimately transforming the standard of practice across the industry. 

Let’s improve patient safety together. Contact us today to get started with Pharmapod. 

Report That Good Catch! Why Every Near-Miss Matters in Pharmacy Practice

Male pharmacist discussing medication with elderly patient.

Pharmacists and pharmacy workers play a crucial role in safeguarding patient health, ensuring medications are dispensed accurately, and preventing errors. Among these efforts, one action often doesn’t get the recognition it deserves — reporting good catches.

Good catch reporting is just as vital as reporting medication errors themselves. It provides an invaluable opportunity to improve medication safety, identify patterns, and prevent issues before they happen. But far too many good catches go unnoticed, unacknowledged, and unreported.

What Is a “Good Catch”?

A good catch (also called a close call) is a situation where a potential medication error is noticed and stopped before it reaches the patient. Essentially, it’s a near-miss prevented through vigilance. Think of it as a heroic save, where a small action protects against what could have been a significant threat to patient safety.

However, despite their importance, good catches are often underreported. Many pharmacies experience at least one reportable good catch every week, but without proper documentation, these near-misses don’t translate to meaningful changes.

Why Reporting Good Catches Is Critical

You might wonder—if the error didn’t reach the patient, is it really worth reporting? The answer is a resounding yes, and here’s why:

  • Preventing Future Errors: A good catch caught today could be a fully developed error tomorrow. Without a report, there’s no data to analyze and act on to prevent similar mistakes from recurring.
  • Spotting Patterns: Systemic issues often manifest as repeated good catches. Documenting these events can spotlight flaws in workflows or technology that need addressing.
  • Enhancing Patient Safety: Reporting good catches is a proactive way to protect patients in the long run. It’s not just fixing mistakes; it’s improving the system.

Without records, the next occurrence may not be caught in time. Reporting your good catches ensures that every opportunity to strengthen the safety net isn’t missed.

Examples of Good Catches Worth Reporting

Here are just a few examples of good catches that can have a significant impact. Each of these scenarios illustrates a moment where your alertness can prevent harm — and reporting these incidents ensures that your vigilance benefits the entire pharmacy system.

Wrong Medication Detected: Spotting a prescription mistakenly filled with the wrong drug due to a selection error.

Incorrect Dosage Identified: Catching a dosage that’s too high or too low based on the patient’s medical history or age.

Allergy Alert: Identifying a prescribed medication that a patient is allergic to before it’s dispensed.

Drug Interaction Flagged: Preventing a dangerous interaction between a new prescription and the patient’s current medications.

Pediatric or Geriatric Dosing Error Prevented: Correcting a pediatric dose that would have been too strong or adjusting a geriatric dose to avoid adverse side effects.

Duplicate Therapy Caught: Stopping a prescription that would have introduced duplicate treatment, potentially leading to overmedication.

Look-Alike/Sound-Alike Medication Error Avoided: Preventing a mix-up between two medications with similar names or packaging.

Overcoming the Barriers to Reporting

We understand reporting good catches can feel tedious or unnecessary, especially when strapped for time. But this small step can make a monumental difference in the long run. When good catches go unreported, pharmacies lose opportunities to strengthen safety measures.

Here are some tips to streamline the process:

  1. Use Pharmapod – Reporting in Pharmapod ensures all necessary information is captured, making reporting and root cause analysis quick and easy. 
  2. Foster a Team Culture – Encourage open communication and emphasize the importance of patient safety, so reporting good catches becomes second nature. 
  3. Acknowledge Reports – Celebrate your team’s good catches to reinforce the value of diligence.

Learn more about how Pharmapod can simplify good catch and medication incident reporting. Contact us today for a demo!

Already a Pharmapod user? Log in today and report your good catches.

CQI+ Practice Incident Management Compliance for Alberta Pharmacies: What You Need to Know and How We Can Help

Two pharmacists looking at a computer

The Alberta College of Pharmacy has announced the plan to implement CQI+, an initiative to empower the safety culture in Alberta community pharmacies through continuous quality improvement processes and the sharing of information about practice incidents. CQI+ is represented in Domain 6 of the new Standards. The deadline for compliance with CQI+ is February 1, 2026. 

It’s essential for pharmacies to align their practices with these new standards sooner rather than later. This is more than a deadline—it’s an opportunity to elevate pharmacy operations to exceptional levels of safety and efficiency. Pharmapod can help – we are the leading global cloud-based software system for incident management and quality improvement work.

What You Need to Do

Domain 6 of the Standards for the Operations of Licensed Pharmacies (SOLP) is effective as of February 1st, 2025, and it requires pharmacies to foster a culture where all team members are dedicated to continuous quality improvement by supporting the following six standards:

  1. Safety culture and just culture
  2. Prevention of practice incidents 
  3. Managing practice incidents 
  4. Analysis of practice incidents and close calls
  5. Follow-up process
  6. Collecting patient feedback and managing patient concerns

The standards emphasize continuous learning and improvement over a punitive approach. Instead of attributing blame, pharmacies are encouraged to examine systemic factors that might contribute to practice incidents. 

If you’re concerned about complying with CQI+, Pharmapod can help you manage your practice incidents. Our cloud-based platform offers the tools you need to comply with CQI+, including:

  • Mandatory and optional data fields
  • Privacy and Security: SOC2 accredited, all data is stored in Canada
  • Training and Support: live and online 
  • Anonymous data integration with the National Incident Data Repository (NIDR)
  • Patient-centred forms for both incident and close-call reports. 
  • Continuous Quality Improvement (CQI) tools, built-in root cause analysis, learning points, action plans, follow-ups, notifications 
  • Safety Reports: consolidated data into one report for staff meetings
  • Analytics: built-in dashboards and charts

READY TO GET STARTED? Email carla.beaton@thinkresearch.com or chris.crocco@thinkresearch.com.

How Pharmapod Can Help Ensure CQI+ Compliance

Pharmapod is a comprehensive digital pharmacy platform designed to:

  • streamline medication safety processes
  • facilitate compliance with regulatory requirements
  • enhance patient care outcomes

As the CQI tool of choice in over 70% of pharmacies across Canada, we understand the complexities of complying with various pharmacy regulatory requirements and have tailored our solution to ensure all needs are met. Our platform helps you establish a structured continuous quality improvement (CQI) program to identify and address risks by reporting incidents and close calls, analyzing root causes, and implementing action plans to prevent future incidents. 

1. Safety and Just Culture

The new standards provide a roadmap for implementing effective change through what is known as a “just culture.” This framework promotes accountability and is built on the belief that all incidents and close calls offer valuable learning opportunities.

Implementing a safety culture is reliant on regular reporting of errors and good catches/close calls – these provide opportunities to learn and improve processes. However, fostering this type of workplace culture requires tools that make reporting and communication seamless—and that’s where Pharmapod excels.  

Anonymous Reporting: Pharmapod’s user-friendly platform enables pharmacists and staff to quickly and easily report incidents or risks. Only data fields from the ISMP data sharing agreement (flagged in the reports) are automatically shared anonymously with the NIDR, ensuring transparency and compliance. 

Clear Procedures: The system provides step-by-step guidance for reporting incidents, ensuring that no detail is overlooked and everyone on your team feels empowered to contribute.  

Built-In Training: Pharmapod also offers training tools that reinforce the principles of a safety culture and a just culture, ensuring staff are consistently aligned with safety expectations.  

By embedding safety and just culture practices in its platform, Pharmapod enables you to establish a foundation of trust and accountability within your pharmacy teams. This open and honest environment fosters teamwork and collective responsibility for patient safety, and, over time, makes it more difficult for pharmacy staff to commit avoidable errors and supports a more reliable and efficient pharmacy operation. 

LEARN MORE about establishing a Just and Safety Culture in our on-demand webinar. WATCH NOW

2. Prevention of Practice Incidents

Preventing practice incidents starts with identifying risks before they escalate. The ACP underscores the need for CQI systems, procedures, and strategies designed to anticipate potential issues. By tailoring CQI plans to your pharmacy’s unique needs, you can effectively mitigate risks and improve patient outcomes.

Pharmapod’s powerful CQI tools ensure all relevant information is captured, stored, and easily accessible in one location. All recorded medication incident data is automatically populated into the platform’s CQI tools, preventing duplication of work while providing actionable insights to optimize patient care. 

In just a few clicks, pharmacies can identify systemic issues and implement targeted corrective actions to prevent the recurrence of errors. CQI reports for staff meetings can also be generated instantly within the platform. 

The result? Pharmacies that leverage Pharmapod see fewer incidents because they can act preventively—not reactively.

3. Managing Practice Incidents Effectively

When incidents do occur, an organized response is crucial. The ACP standards require the patient to be promptly informed and provided with the appropriate care. Pharmacies are also required to discuss details of the incident with applicable team members and take action to prevent a possible recurrence. 

The first step in incident management is precise documentation, which is easily done in Pharmapod. Once the documentation is in place, pharmacy teams should adopt a collaborative approach to identify solutions. By involving all relevant team members in the problem-solving process, pharmacies can develop more effective action plans, helping prevent similar incidents from occurring in the future.

Pharmapod provides an instant report summary and can generate a range of comprehensive reports, including event trend analysis and contributing factors. 

4. Analyzing Trends in Incidents and Close Calls  

CQI+ isn’t just about fixing problems—it’s about leveraging data to make smarter decisions. Pharmapod’s advanced analytics tools allow you to extract valuable insights from practice incidents and close-call events, helping refine your processes over time.  

Detailed Metrics and Reports: Pharmapod breaks down incidents by type, root cause, frequency, and more—saving you time and giving you the full picture of what’s occurring within your operations.  Data is automatically populated into charts and graphs with customizable filters to enable comparisons by region/facility/timeframe, so you can monitor trends and measure and track key performance indicators.

Trend Analysis: Use Pharmapod’s visual dashboards to uncover patterns that can inform better prevention strategies. Reporting all close calls quickly provides the data required to see the trends in your organization.

Data Sharing Across Teams: Share insights with your team using Pharmapod’s collaborative tools, ensuring all stakeholders stay informed about the latest trends and action points.

With Pharmapod providing meaningful insights at your fingertips, analyzing incidents turns from a chore into a strategic advantage.

5. Follow-Up Process

What you do with an error or good catch matters more than the mistake itself. Pharmapod helps pharmacies track and manage corrective and/ or preventative actions with Action Plan templates and reminders. Proactive Self Assessments and Quality Improvement Plans can be completed directly within the platform. Everything you need is conveniently in one place. Pharmapod streamlines communication between pharmacy staff, facilitates task assignments, and monitors progress towards resolution, ensuring timely implementation of improvement measures. 

An integrated resources library, in addition to monthly training sessions, ensure pharmacy staff understand and are able to utilize the platform effectively. From onboarding sessions to ongoing support, we work with you to ensure your pharmacy achieves and maintains CQI+ compliance. 

6. Collecting Patient Feedback and Managing Patient Concerns

Patients are an invaluable source of information when it comes to continuous quality improvement. By actively seeking feedback and managing patient concerns, pharmacies can enhance their service delivery and ensure that their practices align with patient expectations.

Feedback can be added to the incident details within the platform for review and analysis to identify areas for improvement in care delivery. This functionality ensures that feedback doesn’t go unaddressed and that it contributes to continuous improvement in care quality.

Simplify CQI+ Compliance Today 

Pharmapod is purpose-built to support pharmacies in Alberta as they adapt to the CQI+ mandate. By standardizing incident reporting, enabling root cause analysis, and fostering a culture of meaningful quality improvement, Pharmapod empowers pharmacy teams to meet regulatory requirements and elevate patient safety. Choose Pharmapod as the online practice incident management platform to meet CQI+ requirements.

Get started with CQI+ compliance today and be ready for the February 1st, 2026 deadline—contact carla.beaton@thinkresearch.com or chris.crocco@thinkresearch.com.

+ + +

Pharmapod software meets all the reporting platform requirements for mandatory CQI programs in Nova Scotia, Saskatchewan (COMPASS), New Brunswick, Manitoba (Safety IQ), Alberta (CQI+), Prince Edward Island, and Newfoundland and Labrador (MedSTEP NL).
Pharmapod contributes anonymous data to the National Incident Data Repository for Community Pharmacies (NIDR) of the Canadian Medication Incident Reporting and Prevention System (CMIRPS). Incident data from NIDR is used by ISMP Canada strictly for the purposes of analysis, shared learning, and incident prevention strategy formulation. 

Enhancing Patient Safety: 4 Essential Insights Gained From Regular Reporting

Mid adult woman using cell phone while consulting with her pharmacist in choosing medicine in a pharmacy.

Being on the front lines of healthcare, pharmacists, regulated technicians and pharmacy workers play a critical role in ensuring patient safety. One of the key practices that can significantly enhance safety is the regular reporting of both medication incidents and good catches. This practice helps you gather the data needed to understand what’s contributing to errors so you can implement changes and prevent the issue from recurring. 

But the impact of regular reporting goes well beyond your pharmacy walls. When we all make regular reports, it allows us to gather the insight needed to identify how trends and systemic challenges are impacting patient safety on a broader scale. This helps support system changes that will improve patient safety everywhere. 

Here are four powerful insights gained from regular incident reporting.

1. Linking Errors to Workforce Challenges

A well-documented incident reporting system can highlight the link between medication errors and workforce issues, such as insufficient qualified staffing or insufficient training. By identifying these connections with data, pharmacies can advocate for better-qualified resources, training programs, and staffing levels to ensure that their team is well-equipped to handle the demands of patient care.

2. Monitoring Adverse Reactions with New Treatments

In the rapidly evolving world of pharmaceuticals, new treatments are introduced frequently. Regular incident reporting allows pharmacies to monitor any adverse reactions or unexpected outcomes associated with these new medications. This data is invaluable for adjusting protocols, informing healthcare providers, and ultimately safeguarding patients.

3. Addressing Supply Chain Shortages

Pharmacies are often at the mercy of supply chain fluctuations, which can lead to medication shortages. Regular reporting of pharmacy good catch events can highlight patterns where shortages are contributing to harm or potential harm, providing the necessary data to drive system change at government or system levels. 

4. Understanding the Impact of Regulation Changes

The healthcare industry is subject to frequent regulatory updates. This was evident during the constant messaging during the pandemic.  By consistently reporting incidents, pharmacies can assess how regulation changes impact their operations and patient outcomes. This awareness supports compliance efforts and ensures that pharmacies can adapt quickly to new guidelines without compromising safety.

+  +  +

The practice of regular good catch and medication incident reporting is a powerful tool for pharmacies. Not only does it help in identifying the root causes of errors to improve safety in the pharmacy, it also supports a proactive approach to patient safety and quality care. By committing to a culture of transparency and continuous improvement, pharmacists and their teams can significantly enhance their role as vital members of the healthcare industry.

Learn more about how you can foster an environment where staff feel safe reporting all medication errors and good catches.  Catch up on episode 3 of our Safety Series webinars today! 

Could Documentation Prevent the Next Medication Error?

Female pharmacist at counter talking to elderly male patient

Pharmacies today are busier than ever, and with time at a premium, it’s easy to overlook or downplay the importance of thorough medication error and good catch reporting. In fact, a recent report estimated that only 14% of medication errors and good catches are reported. This underreporting means we’re missing out on valuable data that is crucial to improving patient safety. It also leaves room for recurring errors that could result in possible patient harm.

If your pharmacy isn’t reporting at least five good catches or incidents every month, chances are, you’re underreporting. Learn more about the risks of underreporting, and common scenarios where reporting can make a big difference. 

The Risks of Underreporting

Each unreported incident is a missed opportunity to identify patterns that could lead to errors. Understanding the root causes of these incidents is necessary to implement processes that can prevent them in the future.

Consistently documenting errors and good catches helps create a comprehensive record of potential issues within your pharmacy operations. By analyzing this data, you can pinpoint what led to an error and take proactive steps to prevent similar situations from occurring again. Sharing what you have learned helps others working in your location. The aggregated de-identified can be shared with others across the country as well.

Examples of Missed Reporting Opportunities

If you’re not sure where to start, here are four examples of missed opportunities to report. 

1. A common example of a good catch is spotting and correcting a prescriber’s dosing error, for example, an incorrect antibiotic dose for an infant. It might feel like it’s not worth reporting since you caught it in time, or it’s simply part of your job. But without documentation, there’s no record to prevent the next occurrence⸺what if that one isn’t caught in time?

2. You discover an elderly patient is not taking blood pressure medication correctly and is at risk of either a stroke or falling due to hypotension. Do you simply correct them or document HOW this misunderstanding occurred? Was this due to something during the patient education process when the prescription was new or renewed that could be improved?

3. You speak with a patient who stopped taking her prednisone abruptly without tapering the dose. You discover that she picked up a new prednisone prescription for a cough, and despite the flag on the bag to ensure the pharmacist spoke to her, she was given the medication without a consultation about the proper way to take it or the potential side effects.  She was unnecessarily put at risk of adrenal crisis, a life-threatening state.  How can this be prevented in the future?

4. A patient picks up their prescription for Lamisil (a medication for toe fungus). However, due to similar-sounding names, they’re mistakenly given Lamictal (a medication to treat epilepsy or bipolar disorder). The prescriber chose the wrong one in the system drop-down. Unaware of the difference, the patient takes the medication and experiences blurred and double vision along with unsteadiness, a side effect of Lamictal. How can look-alike, sound-alike errors be prevented in the future?

How to Get Started with Reporting

If this all seems overwhelming, start small. Encourage your staff to take a few minutes to report in Pharmapod, even if it feels like a routine part of the job. Regularly review the collected data and discuss findings in team meetings to foster a culture of transparency and continuous improvement.

Effective reporting is not meant to add burden to an already busy workload; it’s about enhancing patient safety. By taking a few moments to document errors and good catches, you can safeguard your patients and strengthen your pharmacy’s operations. Start today and make a meaningful impact on patient safety.

Learn more about how you can foster an environment where staff feel safe reporting all medication errors and good catches.  Catch up on episode 3 of our Safety Series webinars today! 

7 Guiding Principles to Cultivate a Just Culture in Your Pharmacy

Two concerned looking pharmacists looking closely at computer

Pharmacies, like all healthcare settings, have a responsibility to ensure patient safety. However, achieving a culture where safety is embedded in every action and decision requires more than just policy changes—it requires a fundamental shift in the organizational mindset towards what is known as a “Just Culture.” 

In a pharmacy, a just culture is an approach that promotes accountability, learning, and safety by balancing a no-blame philosophy with responsibility for actions. It recognizes that errors can and do happen, and fosters an environment where pharmacy staff feel comfortable reporting mistakes or near misses without fear of punishment for unintentional errors.

In a just culture, there is a focus on understanding the causes of errors—whether they stem from human error, system design, or a combination of factors. This allows pharmacies to make meaningful improvements, enhancing safety and reducing the likelihood of future mistakes. However, it also distinguishes between honest mistakes and reckless behaviour. While unintentional errors are addressed through support and training, any willful disregard for patient safety or negligent behaviour is still held accountable.

By implementing a just culture, pharmacies can improve communication, encourage transparency, and build a stronger culture of safety, ultimately leading to better patient outcomes and a more supportive work environment.

If you’re ready to build a just culture in your pharmacy or healthcare setting, here are seven guiding principles to shape the foundation and guide you on your journey:

1. Engage Patients and Families as Partners in Safe Care

The first step in establishing a just culture is to involve patients and their families in the safety process. By explaining the steps taken to ensure that prescriptions are appropriate and safe, you create a partnership built on trust. Always inquire about any new drug allergies or health changes your patients might have experienced. This proactive communication not only enhances safety but also empowers patients to be active participants in their healthcare.

2. Achieve Results Through Collaborative Working

Your pharmacy staff is your greatest asset in fostering a just culture. Encourage open dialogue and invite their input on processes, staffing, and workflow. A collaborative environment is one where staff feel valued and responsible for the safety and efficiency of operations. Regular team huddles can be an effective way to gather insights and foster a sense of collective ownership over patient safety.

Related: Download our template for a 10-minute safety huddle for topics to cover in your team huddles. 

3. Analyze and Share Data to Generate Learning

Transparency is key in a just culture. Use data from error reports to educate and inform your team. By sharing this information, you encourage a collective brainstorming process to identify solutions that will help prevent future harm. This shared learning experience helps build an environment where staff members are not afraid to report errors, knowing their input will lead to positive changes.

4. Translate Evidence into Actionable and Measurable Improvement

In a just culture, small changes can lead to big improvements. Show your team that reports and suggestions lead to action, no matter how minor they may seem. Implementing small, measurable changes demonstrates that all feedback is valued and contributes to a safer environment, preventing reports from disappearing into a “black hole.”

5. Base Policies and Action on the Nature of the Care Setting

Every healthcare setting is unique. What works in one pharmacy might not be feasible in another. Tailor your policies and actions to fit the specific needs and realities of your environment. This adaptability helps ensure that the changes you implement are not only practical but also effective in enhancing safety.

For example, let’s consider two different pharmacy settings: a community pharmacy focused mainly on dispensing, and a pharmacy that combines immunizations, common ailment assessments, and point-of-care testing.  

In a dispensing community pharmacy, a just culture policy could focus on error reporting and rapid response to the high volume of patient interactions and fast-paced dispensing environment.

For instance, policies might emphasize addressing issues like distractions,  look-alike/sound-alike medications and creating checklists or double-check processes for high-risk drugs. Training could be delivered in short, easily digestible sessions that fit into busy workdays, focusing on recognizing and reducing risks in a fast-paced environment.

Example Policy Adaptation: To minimize interruptions, staff may establish dedicated time blocks when the dispensing area is “distraction-free,” allowing pharmacy staff to focus solely on verification without interruption.  

In a pharmacy offering both clinical services and dispensing, a just culture policy could focus on communication techniques, feasible scheduling of appointments and safe injection procedures that are separated from the dispensing area.

For instance, policies might emphasize efficient workflows, proper privacy and follow-up procedures when required. 

Example Policy Adaptation: To minimize distracting interruptions, staff may establish how appointments are best scheduled and set expectations for patients, along with collecting required information, like the number and type of vaccines prior to the appointment, allowing the pharmacy team members to focus solely on the clinical service.  

6. Use Both Scientific Expertise and Patient Experience to Improve Safety

To make impactful changes, leverage insights from both scientific data and patient experiences. Combine the technical knowledge of your staff with the firsthand experiences of your patients to develop a comprehensive approach to safety improvements. This dual perspective enriches your understanding of safety challenges and enhances the effectiveness of your interventions.

7. Instill a Safety Culture in the Design and Delivery of Healthcare

Ultimately, the goal is to embed a culture of safety in every facet of your pharmacy’s operations. Leadership should visibly prioritize patient safety by setting clear expectations and modelling safe practices. Encourage open communication among team members to discuss safety concerns and improvements, fostering an environment where everyone feels responsible for maintaining high safety standards.

+ + +

Establishing a just culture takes time, dedication, and continuous learning. By following these seven guiding principles, you can create a culture where patient safety is at the forefront of every decision and action. Learn more about the importance of fostering a just culture and the positive impact it can have on patient safety. Catch up on episode 3 of our Safety Series webinars today! 

Why More Medication Incident Reports Indicates a Safer Pharmacy Environment

Two pharmacists looking at a computer

It’s a common misconception in pharmacies that having many medication incident reports indicates the pharmacy environment is unsafe. Actually, the opposite is true. The more events you report – whether it’s a medication error or a good catch – the safer your pharmacy. Why? Because you’re consistently gathering the information needed to pinpoint what went wrong to contribute to the incident and proactively improving to prevent the issue from recurring. Not convinced? Let’s look at why logging medication incidents and good catches is essential and how it contributes to a safer pharmacy.

The Importance of Logging Medication Incidents

Discovering the Root Cause

Medication incidents can happen for various reasons, from human error and environmental distractions to system failures. By logging these incidents in Pharmapod, you can identify patterns and root causes behind errors. This process allows for a deeper understanding of what went wrong and how similar issues can be prevented in the future. For instance, recurring errors at a certain time of day might point to a need for a change in workflow or extra support. 

Continuous Improvement

When incident reports are regularly submitted, it signals a culture of continuous improvement within the pharmacy. Each report is an opportunity to refine processes and implement safer practices. Over time, this makes it more difficult for pharmacy staff to commit avoidable errors and supports a more reliable and efficient pharmacy operation. For example, if you identify a recurring error with a specific process with compliance packaging, your pharmacy might introduce a new or streamlined procedure, thereby reducing future mistakes. It is also important to recognize what is working well and learn how to replicate that process.

Building a ‘Just Culture’

Encouraging the regular reporting of medication incidents promotes a ‘just culture’ where safety is prioritized over blame. Pharmacists and staff feel more comfortable acknowledging mistakes and focusing on solutions rather than fearing repercussions. This open and honest environment fosters teamwork and collective responsibility for patient safety.

Why More Incident Reports Indicate a Safer Pharmacy

It’s important to remember that a higher number of incident reports does not necessarily mean that more errors are occurring. Instead, it shows that your pharmacy has robust mechanisms in place to detect and report issues. This visibility ensures that potential problems are promptly addressed, reducing the risk of harm to patients. 

Failure to report good catches often means the root cause of the issue was not identified, and it will likely occur again. 

Proactive Problem Solving

With more reported events, your pharmacy can take proactive measures to address issues before they escalate. This proactive approach helps create a safer environment by preventing serious incidents. If reports indicate that a specific workflow is prone to errors, your pharmacy can redesign that process to minimize risks, e.g., errors made during drug substitutions as a result of drug shortage situations.

The Benefits of Regular Incident Reporting

Enhanced Patient Safety

Regular incident reporting directly contributes to increased patient safety by continuously identifying and addressing potential hazards. This ongoing vigilance ensures that patients receive the highest quality of care. Regularly reporting near-misses is also essential to implementing changes before any harm occurs, further safeguarding patient well-being.

Improved Operational Efficiency

Regular incident reporting helps streamline pharmacy operations by identifying and rectifying inefficiencies. This improvement leads to better resource utilization and a more productive work environment. For instance, resolving a recurring issue with effective communication can save time and reduce confusion for both staff and patients.

Staff Development and Process Refinement

Incident reports highlight areas where additional training or action may be needed. By addressing these gaps, pharmacies can enhance their staff’s skills and knowledge, leading to better overall performance. If reports indicate frequent errors with a particular type of medication, targeted training can help staff handle it more accurately.

Overcoming Barriers to Reporting

Now that we’ve established the importance of regular reporting, how can we ensure staff feel comfortable doing so? Here are two tips to get you started:

Eliminate the Fear of Blame

One of the main barriers to reporting is the fear of blame or punishment. Staff are often too afraid to speak up over fears of losing their job or experiencing similar consequences. By fostering a no-blame culture, pharmacies can encourage more open and honest reporting. This shift is crucial for creating an environment where learning and improvement are prioritized over assigning fault. When honest mistakes are made, treat them as learning opportunities, with a focus on identifying and fixing what went wrong, rather than assigning blame or reprimanding specific individuals.

Providing Feedback and Recognition

Recognizing and providing feedback on submitted reports can motivate staff to continue reporting. This recognition reinforces the importance of their contributions to improving patient safety and operational efficiency. For example, highlighting how a reported issue led to a positive change can encourage others to report their observations.

The Role of Pharmapod in Incident Reporting

Pharmapod’s intuitive platform makes it easy for pharmacists to report medication incidents and good catches efficiently. The user-friendly interface walks pharmacy staff through the reporting process, gathering essential information so you can ensure you get to the root of the issue. This ease of use is vital for maintaining a high reporting rate and ensuring that no event goes undocumented.

Comprehensive Data Analysis

Pharmapod’s advanced analytics tools allow pharmacies to analyze reported data effectively. By pinpointing trends and identifying common issues, you can make informed decisions about where to focus your improvement efforts. This data-driven approach is essential for targeted and effective interventions.

Collaborative Learning

Through Pharmapod, pharmacies can share insights with other locations and learn from each other’s experiences. This collaborative learning environment helps spread best practices and innovative solutions across pharmacies, benefiting all participants. For example, a pharmacy location that successfully reduces a specific type of error can share its strategies with others, contributing to overall industry improvement.

+  +  +

Getting into the habit of logging medication incidents and good catches is integral to creating a safer pharmacy environment. Contrary to popular belief, a higher number of event reports often signifies a proactive approach to identifying and resolving issues. Utilizing the Pharmapod platform streamlines the reporting process, makes data analysis easy, and fosters a culture of continuous improvement.

Ready to improve medication safety in your pharmacy? Request a custom demo of the Pharmapod platform today.

Think Research’s Pharmapod Adopted in University and Colleges Across Canada to Teach Foundations of Medication Safety

TORONTO, ON – February 27, 2024 – Think Research Corporation (TSXV: THNK) (“TRC” or the “Company“), a company focused on transforming healthcare through digital health software solutions, is pleased to announce that Pharmapod, Think’s medication incident management solution is increasingly becoming an integral part of academic sites across Canada, including in both University and Community College programs. As the go-to end-to-end digital tool, Pharmapod equips students with hands-on experience in recording essential data fields around medication incidents, conducting thorough post-event analyses, and generating instant presentations and summary reports. This immersive learning experience ensures that future healthcare professionals are equipped with the necessary skills and expertise to drive medication safety and quality care.

Jamie Kellar, Associate Dean Academic, University of Toronto said, “Medication safety is paramount in healthcare. Teaching students the foundations of recording medication incidents and good catches will ensure they’re well-equipped to uphold safety in their future employment opportunities.”

Pharmapod is a cloud-based medication incident reporting platform that allows pharmacists and healthcare providers to record, track, and analyze medication incidents in real-time to quickly identify the root cause of safety events. The solution also enables users to identify ‘good catches’ and make proactive improvements to prevent medication errors from reaching patients and potentially causing harm.

The platform is currently used in 70 percent of Canadian pharmacies and more than 500 care homes across Canada to drive patient safety.

Sachin Aggarwal, CEO of Think Research said, “The widespread adoption of Pharmapod within pharmacies and care homes underscores the industry’s commitment to patient safety. This recent integration into academic programs further amplifies the dedication to safety by providing the next generation of healthcare professionals with a robust foundation in medication safety and quality care.”

Learn more at www.pharmapodhq.com 

About Think Research

Think Research Corporation is an industry leader in delivering knowledge-based digital health software solutions. The Company’s focused mission is to organize the world’s health knowledge so everyone gets the best care. Its evidence-based healthcare technology solutions support the clinical decision-making process and standardization of care to facilitate better healthcare outcomes. The Company gathers, develops, and delivers knowledge-based solutions globally to customers including enterprise clients, hospitals, health regions, healthcare professionals, and/or governments. The Company has gathered a significant amount of data by building its repository of knowledge through its network and group of companies.

Think licenses its solutions to over 14,200 facilities for over 320,000 primary care, acute care, and long-term care doctors, nurses and pharmacists who rely on the content and data provided by Think to support their practices.  Millions of patients and residents annually receive better care due to the essential data that Think produces, manages and delivers. Visit www.thinkresearch.com.