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. 

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.

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Pharmapod software meets all the reporting platform requirements for mandatory CQI programs in Nova Scotia, Saskatchewan (COMPASS), New Brunswick, Manitoba (Safety IQ), 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. 

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.

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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! 

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.

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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! 

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.

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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.

Pharmapod helps you report, analyze and document medication incidents to ensure MedSTEP compliance

In an effort to improve medication and patient safety, the Newfoundland & Labrador Pharmacy Board (NLPB) is implementing Medication Safety through Error Prevention, or MedSTEP NL. Key components of MedSTEP include medication error reporting, root cause analysis, implementation of corrective actions, and ongoing quality improvement initiatives.

With the deadline for compliance quickly approaching – pharmacies must comply by March 2024 – your pharmacy will require a solution that makes it easy to report, analyze, and document both medication errors and near-miss events and learn from data to prevent future incidents.  Pharmapod is the solution. 

How Pharmapod Can Help Ensure MedSTEP Compliance

Pharmapod is a comprehensive digital pharmacy platform designed to streamline medication safety processes, facilitate compliance with regulatory requirements, and 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 board requirements, and have tailored our solution to ensure all needs are met. 

Here’s how Pharmapod can assist pharmacies in Newfoundland & Labrador with MedSTEP compliance:

Simplified Medication Error Reporting

Pharmapod simplifies and standardizes medication error and good catch reporting, allowing pharmacies to quickly and accurately document incidents per MedSTEP requirements. A comprehensive dashboard provides a detailed view of your data, enabling you to easily drill down into the root cause of errors, near misses, and adverse events, so you can make process improvements and prevent future incidents. 

Built-In Continuous Quality Improvement (CQI) Tools

Powerful CQI tools built into the platform 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.

Reporting and Analytics

Reduce administrative burden and make preparing for quality meetings and staff meetings a breeze! Pharmapod provides an instant Safety Report summary for your meeting agenda, and can also generate a range of comprehensive reports in just one click, including event trend analysis, and root cause analysis. 

Data is automatically populated into charts and graphs with customizable filters to enable comparisons by region/facility/time frame, so you can monitor trends, and measure and track key performance indicators. 

Implementation of Corrective Actions 

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 also be completed directly within the platform.  Pharmapod streamlines communication between pharmacy staff, facilitates task assignment, and monitors progress towards resolution, ensuring timely implementation of improvement measures.

Training and Education

Pharmapod offers live support, a robust resources library, and monthly training to 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 MedSTEP compliance to meet regulations and enhance patient safety.

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Simplify MedSTEP compliance in your pharmacy. By standardizing incident reporting, facilitating root cause analysis, and supporting ongoing quality improvement initiatives, Pharmapod empowers your pharmacy to enhance medication safety practices and improve patient care. 

Contact us for a demo to get started. 

Is improving medication and patient safety a priority for your healthcare organization in 2024? Then you need a medication incident reporting tool that makes it easy to report and track good catches and errors and learn from the data to prevent future incidents. If you haven’t already implemented Pharmapod in your pharmacy or healthcare setting, here are 10 reasons why you should consider it in 2024.

1. Comprehensive Medication Incident Management

Pharmapod empowers healthcare professionals with a comprehensive incident management system. Our platform’s robust features facilitate the seamless recording, tracking, and analysis of medication incidents, enabling you to swiftly implement resolutions and preventive measures.

2. Enhanced Patient Safety Protocols

By leveraging Pharmapod, your pharmacy or healthcare team can easily bolster patient safety protocols. Pharmapod’s functionalities facilitate real-time reporting, fostering a proactive approach to identifying potential risks and mitigating them promptly.

3. Streamlined Reporting and Analysis

Pharmapod simplifies the often-complicated task of reporting and analysis. Its user-friendly interface and analytics tools enable in-depth insights into medication incidents, allowing for data-driven decisions and continuous improvement initiatives.

Related: See what one customer said about how Pharmapod helped her long-term care home enhance efficiencies, reduce workloads, and positively impact medication and resident safety. Watch the testimonial here.

4. Collaboration and Communication

Pharmapod acts as a centralized hub for all staff members to report medication errors, ensuring seamless sharing of vital information.

When safety issues are identified, staff work together to problem-solve and make improvements. This sense of collaboration positively impacts morale and inspires staff to look for additional areas where improvements can be made.

5. Regulatory Compliance and Standards

Medication incident reporting is a regulatory requirement in many jurisdictions. Reporting into Pharmapod makes the process easy for staff and ensures all relevant information is captured. Comprehensive data and reports can be generated in a few clicks to provide to regulatory authorities when needed, ensuring your pharmacy is in full compliance.  

6. Foster a ‘Just Culture’

Medication incidents and near-miss events are often under-reported – or not reported – due to fears of disciplinary action. And while mistakes might never be fully avoidable, the only way to learn and prevent them from reoccurring is through consistent reporting.

Pharmapod makes it easy for staff to report all medication issues. When honest mistakes happen, they can be treated as learning opportunities with a focus on identifying what went wrong in the process, rather than shaming or blaming the individual who made the error. When staff feel safe reporting errors knowing they will be treated as opportunities to improve, they are more likely to report regularly. As more incidents are reported, and more processes are improved, it becomes harder for staff to commit avoidable errors.

7. Data-Driven Decision-Making

To improve processes and enhance medication safety, you need to identify gaps or areas of risk that are causing issues. Harnessing Pharmapod’s analytics capabilities provides access to a wealth of data that facilitates evidence-based decision-making, empowering teams to enact targeted interventions for improved patient outcomes.

8. Efficient Incident Resolution

Pharmapod expedites incident resolution through its systematic approach. The platform’s functionalities enable efficient investigation, root cause analysis, and the implementation of corrective actions, minimizing the impact of medication incidents.

9. Enhance Staff Engagement and Retention

Providing staff with tools and technology that enable them to work more efficiently can help reduce burnout and enhance job satisfaction. When staff can easily report and discuss errors and see a clear line of sight from reporting to actions necessary for improvements, they know their efforts directly impact patient safety, which provides a sense of purpose and keeps them engaged.

10. Patient-Centric Care Enhancement

Above all, Pharmapod champions patient-centric care. By proactively managing medication incidents and prioritizing patient safety, healthcare professionals using Pharmapod elevate the standard of care, fostering a culture centred on patient well-being.

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Ready to improve medication safety in your pharmacy or healthcare setting? Book a demo today and learn how Pharmapod supports a culture of continuous improvement and unwavering dedication to patient well-being. BOOK YOUR CUSTOM DEMO TODAY.

The human element of healthcare means that mistakes can and will happen, no matter how careful we are. In pharmacies, this often results in accidental (or sometimes intentional) medication errors. Every pharmacy has medication errors, but not all are recording them. This needs to change. Consistently recording all mistakes and near-misses (aka good catches) is the most effective way to learn from errors to prevent them from happening again. 

It’s also important to remember that more recordings does not mean the pharmacy is unsafe; rather, it means the pharmacy is aware and documenting as many events as possible to identify the trends.

Regular reporting gives us the data we need to determine contributing factors, so we can make proactive improvements that will limit the risk of it reoccurring. Here are five ways that medication incident reporting can help improve pharmacy safety.

1. Identify problems earlier

When reporting medication errors/incidents and near-miss events, pharmacists and healthcare workers can easily review the data collected to identify patterns and trends in the errors. For example, are there repeated problems with specific medications or errors happening at a similar time of day? Analyzing the data helps pinpoint issues and enables us to take proactive action to prevent an incident before it happens again. By identifying problems earlier, pharmacists can develop an evidence-based approach to pharmacy safety.

2. Improve communication

Medication incident reporting helps improve communication amongst pharmacy staff, which is essential in preventing errors. When incidents are documented, it presents an opportunity for staff to discuss areas where improvements can be made. Open, transparent communication helps build a just culture, where mistakes are treated as learning opportunities, not opportunities to assign blame. Employees feel safe discussing incidents and good catches, knowing the ultimate goal is improving the overall safety of the pharmacy.

3. Enhance processes and training

Regularly reporting medication incidents and near-misses gathers the data needed to help pinpoint process errors or gaps in training programs where improvements can be made to enhance safety. For example, are errors frequently occurring after employees get distracted answering phone calls? Could processes be improved by assigning one employee to handle all incoming calls so that others can remain focused on their work? This approach to education and training can be more effective, as it targets specific areas of need rather than a generalized approach.

4. Create a culture of safety

When reporting medication errors and near-miss events into Pharmapod, employees gain a clear line of sight from reporting to actions necessary for improvements. Knowing their efforts are directly impacting processes and patient safety provides a strong sense of purpose and motivates employees to look for additional areas where safety improvements can be made.

5. Meeting regulatory requirements

Medication incident reporting is a regulatory requirement in many areas. Reporting into a platform like Pharmapod makes the process easy for staff and ensures all relevant information is captured. Comprehensive data and reports can be generated in a few clicks to provide to regulatory authorities when needed, ensuring your pharmacy is in full compliance.  

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Ready to improve safety in your pharmacy, long-term care home, or healthcare setting? Request a demo today to discover how Pharmapod simplifies medication incident reporting, reduces risk, and enhances pharmacy efficiency.

Pharmacists everywhere understand the importance of reporting medication incidents – especially when patient harm occurs – but many remain less convinced about the importance of reporting near-miss events, or ‘good catches.’

Good catches occur regularly in pharmacies when medication errors or potential safety issues are caught before they reach the patient. Most believe that because no harm actually occurred, reporting the issue might not be worth their time.

However, reporting good catches in addition to medication incidents is critical.

In many pharmacies, good catches occur more frequently than medication incidents. If they’re not reported, we’re missing a huge opportunity to learn from trends in the data that identify similar problems within the system that can be improved to eliminate the risk of future harm. Taking a few minutes to report your good catches is truly one of the most effective ways to support system changes that will improve patient safety everywhere — and help save you time and money in the long run.

For example, consider this scenario:

Drug shortages are a common problem impacting pharmacies. A shortage of the drug Altace HCT 10mg Ramipril/12.5mg Hydrochlorothiazide meant pharmacists need to change the drug to perhaps two separate drugs e.g., Ramipril 10 mg and 12.5mg Hydrochlorothiazide.

In one pharmacy, the change was mistakenly prepared as two tablets of AltaceHCT 5mg Ramipril/12.5mg Hydrochlorothiazide, but the pharmacist caught the error before it was dispensed to the patient. The pharmacist who caught the error assumed it was an isolated incident not worthy of reporting, however, because the drug shortages were occurring on a national level, similar scenarios were playing out in pharmacies across the country.

By reporting the factors that contributed to the good catch – in this case drug shortages – we’re able to collect and analyze data on both a provincial and national scale and share the findings with stakeholders and regulatory authorities who have the power to implement change.

One pharmacy reporting a good catch appears as one tree. Many pharmacies reporting the same issue makes a forest. The bigger the forest, the easier it is to see the scale of the problem and how it impacts the trees.

Reporting good catches can also make big impacts on a smaller scale and help you identify areas within your specific pharmacy that can be improved. For example, if medications are frequently confused because they look alike, could it be resolved by stocking different brands for look-alike, sound-alike drugs so they look different. Would marking them help better differentiate them?  By making small changes in your unique location, operational efficiencies are gained and reduction of duplication of work is quickly realized.

When Should Good Catches be Reported?

Remember, the goal of reporting good catches is not to add more administrative burden to your day. The goal is to help identify the root cause of problems so solutions can be proactively implemented. The more data we have, the better we can understand when and where things are going wrong.

To encourage employees to report good catches (and medication incidents), common barriers to reporting must be removed. These typically include: lack of reporting culture, absence of a reporting system, management behaviour, and fear of consequences.

It’s important to establish a just culture in your pharmacy, where reporting is encouraged. Incident and near-miss reports should always be viewed as learning opportunities, not an opportunity to shame or blame individuals. 

While it might not be feasible to report every good catch that occurs in your pharmacy, there are certain scenarios that should always be reported. These include:

1. The good catch would have caused harm had it reached the patient.
e.g., 5 units of insulin vs 50 units.

2. The problem is a recurring issue in the pharmacy.
e.g., lookalike/soundalike drugs are dispensed in error. 

3. It provides a learning opportunity for the pharmacy practice.
e.g., the incident leading to the good catch was a result of skipped steps in pharmacy processes. 

4. Reporting the issue aligns with guidance set by your provincial regulator.
e.g., near-miss event reporting is expected in Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia

Tips for Getting Started

Start small – commit to reporting one or two good catches per week to get in the habit. 

Set aside 10 to 15 minutes per day – dedicate a small amount of time each day to complete reports. 

Share the responsibility – reporting doesn’t need to fall solely on the shoulders of one individual. The Pharmapod reporting platform allows for roles-based access, so certain employees can access and input information as required.

Increase communication – ask employees if they have any good catches they’d like to share. Take the time to discuss what happened, and share how future incidents can be prevented.  

Get more advice on simplifying medication incident and near-miss reporting here. 

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Simplify Reporting in Your Pharmacy

Interested in learning how Pharmapod’s industry-leading medication Incident reporting platform can simplify medication incident and near miss reporting in your pharmacy or healthcare setting? Contact us today to book your custom Pharmapod demo. 

By Carla Beaton, Pharmacist and VP of Quality Improvements and Innovations

Pharmacists across Canada fill more than 600 million prescriptions every year, and though somewhat rare, medication incidents do occur. When COVID-19 hit, it put unprecedented pressure on the industry. Virtually overnight, pharmacists were thrust to the frontlines of healthcare and overwhelmed with an influx of phone calls and visits from patients seeking reassurance, advice, and appointments for COVID-19 vaccinations and other health issues. Not surprisingly, as pressure mounted and labour shortages intensified, mistakes increased in certain areas.

A study by Safe Assured on behalf of Pharmapod analyzed data representing more than 60,000 entries of medication errors and near-miss events from 65 percent of Canadian pharmacies pre- and post-COVID-19. They found that some areas of risk remained consistent with pre-COVID reporting, but as stress and workloads intensified in pharmacies throughout the pandemic, five areas of risk significantly increased and tended to be involved when harm occurred.

Here are the five categories of contributing risk factors that occurred in Canadian pharmacies throughout the pandemic – plus actionable items for limiting risk moving forward.

1. Environmental Distractions – OVER TENFOLD INCREASE

Environmental distractions were most often caused by:

• Numerous phone calls and inquiries about COVID, vaccinations, testing, etc.
• Influx of walk-in traffic , workload higher than normal
• Interruptions
• Multitasking beyond the usual process

Actionable Item: Online booking systems and standardized website information updates can help limit or divert phone calls to the pharmacy. Assign one employee to handle phone calls each day or to screen calls which can be delegated to the appropriate person. Manage customer/patient expectations – something the restaurant industry has mastered – by displaying wait times, busier than usual times of the day, dedicated immunization or clinical service times, and by implementing call or text when ready functions, and the ability to have the prescriptions delivered at a later time.

2. Operational Processes – TENFOLD INCREASE

Operational process errors were commonly caused by:

• Communication failures
• Missing or incorrect data entry
• Lack of clarity in policies and/or policies not followed
• System failures
• Timing disconnect or failure
• Inefficient or ineffective workflows

Actionable Item : As each pharmacy operates to accommodate their clientele, it is not a one-size-fits-all answer here. Control what you can. Complete a PSSA (Pharmacy Safety Self Assessment) to identify areas of risk and set goals to improve any gaps in your pharmacy.

Identify what needs to be escalated as systemic improvements requiring more stakeholders, including government, policy makers, professional associations,  or management.

There are error prevention action plans that on the surface seem to provide the easiest and fastest solutions, however people cannot be expected to compensate for weak systems. Select high-leverage error prevention activities that are designed to fix the system, not just people, whenever possible.

Activities from highest leverage to lowest leverage include:

• Forcing functions and constraints
• Automation and computerization
• Drug protocols and standard order forms
• Independent double checks and other redundancies
• Rules and policies
• Education and information

3. Drug Related Issues – DOUBLED

Examples of Drug related errors include:

• drug shortage, back order situation, drug recalled by manufacturer, lack of inventory
• multiple concentrations of the same drug, strength not commercially available
• unclear / absent labelling
• critical drug information missing (e.g. strength, duration, area )
• dangerous/ inappropriate  abbreviations used

Actionable Item: Many of these elements are systemic and often beyond the pharmacy’s control (i.e., drug shortage / backorder / recall / strength not available / labelling ). Systemic fixes typically require outside stakeholders working toward a common goal to mitigate the risk. Pharmacies have workaround plans and procedures for people to handle this risk, however people will not eliminate the risk, only system changes can.

Concentrate on improving efficiencies you can control with workflows to avoid drug related issues. Start with measuring workflow and inventory flow to get a baseline you can work with. Implement a proper pharmacy layout so drug-related tools are at your fingertips or close to your workstation to make accessing/ordering inventory easier, addressing multiple concentrations safer, clarifying/obtaining missing information faster, and prevent unnecessary wasting of time. Automating inventory in your dispensing software provides staff time to complete other tasks and minimizes shortages you can control.

Electronic ordering of prescriptions can be programmed to avoid dangerous abbreviations and/or missing critical drug information. Work with prescribers to move to electronic ordering and have a verification check of each original, new and refill prescription.

4. Critical Patient Information Missing or Incorrect – DOUBLED

Examples of critical pieces of patient information missing include:

• medication history
• allergy information
• address
• lab values
• pregnancy status
• history of medical conditions
• information on renal or liver function

Actionable Item: It sounds simple, but when you’re feeling rushed, it’s critical to take a moment and ensure you inquire at each patient interaction about all necessary and relevant patient information. Create a checklist of essential questions to ask all patients – new and repeat – when filling prescriptions to ensure you are current with changes in their health status or location. Having an efficient workflow will reduce frustrations for both pharmacy staff and customers. Inefficient workflows result in increased wait times and can result in patients leaving the pharmacy without medication, or leaving the pharmacy without proper counselling.

5. Patient / Caregiver Education Issues – DOUBLED

Patient or caregiver education issues were most often caused by:

• Appropriate information not provided to patients or caregivers
• Lack of clarity when providing information
• Lack of understanding by patient or caregiver

Actionable Item: An estimated 60 percent of Canadian adults lack the health literacy skills needed to adequately manage their health, which can lead to difficulties comprehending medication information, misinterpretation of instructions, and/or poor adherence. Take the appropriate time to communicate effectively to ensure patients and/or their caregivers fully understand how to safely take their prescription. Work with your team to source written materials in the language your patients best understand (this could be a systems change). Study your workflow process to avoid multitasking as much as possible – this might mean delegating tasks to maximize on the scope of practice for registered pharmacy technicians and dedicating the necessary time for the pharmacist to deliver the appropriate patient and caregiver education.

Discuss the importance of improving pharmacy workflow efficiency in order to maximize pharmacist-patient interactions. As mentioned, patients who are frustrated with wait times or who do not understand what is being done for their safety behind the counter may end up leaving the pharmacy without their medication or without  counselling on how to properly take the medication, which can have dangerous consequences to their health or result in unnecessary drug waste. Waste disrupts the inventory systems and leads to further workflow issues.

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This article originally appeared on Canadian Healthcare Network. Pharmapod is a member of the Think Research family of companies.