Medication incidents and near-miss events occur in pharmacies across the US every day – and though they may never be completely avoidable, there are steps pharmacies can take to limit risk.
For most pharmacies, this starts with consistent reporting of incidents and near-miss events. Without reporting, it’s impossible to identify the process gaps that are contributing to errors and is therefore impossible to fix.
Unfortunately, in many pharmacies and healthcare settings, errors and near-miss events are under-reported or worse – not reported at all – due to fears of disciplinary or legal action. When this occurs, system fixes are not made, meaning the error is likely to occur again in the future.
To help combat this, many states are introducing ‘Just Culture’ principles that encourage pharmacies to establish blame-free, transparent work environments where pharmacy staff feel safe reporting and discussing incidents.
The American Pharmacists Association (APhA) House of Delegates is also supporting the adoption of just culture principles and have recently approved six policies aimed at helping US pharmacies establish a just culture approach to patient safety.
In their recommendations, the APhA:
- Calls for employers to adopt and implement just culture principles to improve patient safety and support pharmacy personnel.
- Encourages transparency between employers and employees by sharing de-identified medication error and near-miss data and trends as well as actions taken to promote continuous quality improvement.
- Urges the adoption of non-disciplinary and non-punitive mechanisms for use by Boards of Pharmacy to promote just culture when addressing people, systems, and processes involved in medication errors.
- Encourages national and state associations to advocate for legislation to provide protections to individuals utilizing error reporting systems to promote just culture.
- Encourages the creation of a mechanism for an industry wide effort to engage in confidential and transparent sharing of learnings and root cause findings helpful in reducing the risk of medication errors.
- Supports the development of just culture education and training in the curriculum of all schools and colleges of pharmacy, postgraduate training, and continuing professional development programs.
Getting Started: The Benefits of a Just Culture
In a just culture, patient safety is always top of mind. Staff prioritize safety and continually look for risks that could pose a threat. When honest mistakes are made, they are treated as learning opportunities, with a focus on identifying and fixing what went wrong, rather than assigning blame or reprimanding specific individuals.
Communication is open and transparent, with an emphasis on sharing learnings and ideas to prevent one person’s mistake from becoming another’s in the future. Involving all staff members in honest discussions following an incident is also critical to help ensure everyone feels engaged, accountable, and inspired to be more careful in the future.
When staff feel safe reporting mistakes and near-misses, incidents are more consistently reported, more data is gathered, and subsequently, more process gaps are identified and corrected. As more issues are remedied over time, it becomes harder for staff to commit unintentional errors.
Simplify Reporting with Pharmapod
Establishing your just culture relies on consistent reporting. To encourage reporting, you must make it easy for pharmacy staff to do so – Pharmapod’s medication incident reporting platform makes it simple.
When reporting, Pharmapod walks pharmacy staff through a series of predefined questions to ensure all relevant information surrounding the incident or near-miss is captured. Staff have their own logins so multiple members can contribute to a report simultaneously. They can also be given different degrees of access, so they will not see information that is not relevant to them.
But wait – there’s more…
The Pharmapod medication incident reporting platform also includes a Patient Safety Organization (PSO) that offers additional benefits for US pharmacies as they work on fostering their just culture.
The PSO provides legal protections designed specifically for pharmacies – when certain information is reported into the medication incident platform, it is protected from legal discovery (with a few exceptions for malicious intent or criminal behaviours).
Privileges and confidentiality of any patient safety improvement work can never be waived, meaning pharmacy staff have a safe space to report medication incidents, discuss process gaps, and evaluate quality improvement initiatives to further enhance patient safety.
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Support your pharmacy’s just culture journey – contact us today to learn more about our Medication Management Platform + PSO solution and how it can help your pharmacy improve patient safety.
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