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. 

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!

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