Incident Management & Reporting
Policies and Procedures
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Date last revised:
PODSA Bylaws part II Section 10 (c) states that “A community pharmacy manager must develop,
document and implement an ongoing quality management program that … includes a process
for reporting, documenting, and following up on known, alleged and suspected errors, incidents
and discrepancies”.
Introduction
According to the Framework of Professional Practice Role 3 all pharmacists, regardless of their
responsibility, contribute directly or indirectly to the effective operation of a pharmacy. This
includes minimizing, managing, reporting and prevention of practice errors and omissions,
unsafe practices and professional misconduct.
This Policy and Procedure Manual has been developed to support pharmacies in documenting
policy and procedures that support ongoing quality management within a pharmacy. However,
be aware that your pharmacy may require additional policy and procedures based on your
specific practices.
Each section includes open field description boxes to be completed with your practice’s
policies/procedures or checkboxes meant to act as an acknowledgement that the statement
that follows applies to your practice.
Description fields and check boxes are marked in grey so that they are easily identified.
Description fields are simple to use, just click and type into the space. Checkboxes require a
double-click followed by selecting “Checked”.
You may choose to print this booklet out upon completion to have a copy available for your
staff that need to refer to this guide while keeping the electronic copy saved when updates
need to be applied.
BCPhA has no objection if you add your organization’s logo or otherwise customize the
template. If you do so, please retain the footer crediting BCPhA.
BCPhA has made its best effort to develop this template to assist members.
The user is solely responsible for its obligations.
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Contents
Quality Assurance ..................................................... Error! Bookmark not defined.
Policies and Procedures ......................................................................................... 1
Introduction ........................................................................................................... 2
Pharmacy Staff Meetings ....................................................................................... 4
Medication Incident Response ............................................................................... 5
Protocol for Handling Medication Incidents .............. Error! Bookmark not defined.
Pharmacy Complaint Response ................................. Error! Bookmark not defined.
Pharmacy Complaint Form........................................ Error! Bookmark not defined.
Breach of Confidentiality .......................................... Error! Bookmark not defined.
Adverse Drug Reaction Reporting ............................. Error! Bookmark not defined.
Managing / Triaging Poisoning .................................. Error! Bookmark not defined.
Oral Cytotoxic Drug Exposure Plan............................ Error! Bookmark not defined.
Robbery Guidelines ................................................... Error! Bookmark not defined.
Duty to Report .......................................................... Error! Bookmark not defined.
Emergency Preparedness.......................................... Error! Bookmark not defined.
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Pharmacy Staff Meetings
Policy
Staff meetings will take place on a regular basis and are mandatory for all pharmacy staff.
Purpose
To ensure pharmacy staff are up to date on current issues, policies and practices that will
impact the operation of the pharmacy.
Implementation Procedures
The pharmacy manager is responsible for organizing staff meetings.
Staff meetings will be held on a monthly basis.
Staff meetings will be minuted.
Staff that are unable to attend the staff meeting must read the minutes & review any
materials discussed at the meeting.
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Medication Incident Response
Policy
Registrants respond to, take corrective action when applicable, document and report as
necessary on medication incidents.
Purpose
To ensure that incidents are recorded, reported to the appropriate individuals and corrective
action is taken to prevent similar incidents in the future.
References
NAPRA - Minimizing Medication Errors
Handling Dispensing Errors, Pritchard (1995)
Institute of Safe Medication Practices Canada
College of Pharmacists of Manitoba – Medication Incident and Discrepancy Report Form
College of Pharmacists of Manitoba – Medication Incident and Discrepancy Log Form
Implementation Procedures:
All medication related incidents will be handled seriously and professionally.
All medication incidents will be assessed according to the “Protocol for Handling
Medication Incidents” (see proceeding page).
All medication incidents will be documented using a standard template (College of
Pharmacists of Manitoba – Medication Incident and Discrepancy Report Form).
All medication incidents will be tracked using a standard template (College of Pharmacists
of Manitoba – Medication Incident and Discrepancy Log Form).
All medication incidents are reported the pharmacy manager. The manager and owner
discuss how to resolve the incident.
All medication incidents are reported to the pharmacy’s insurance company.
Medication incidents will be discussed during staff meetings.
The pharmacy manager is responsible for taking corrective actions to prevent similar
incidents from occurring in the future.
Documented incidents will be maintained in a binder named “Medication Incidents”.
Incidents will be reported to those whom it affects, which may include the patient`s
prescriber.
The pharmacy manager will determine if a medication incident will be reported to the
ISMP. https://www.ismp-canada.org/err_ipr.htm
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