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When a medication incident occurs, pharmacy professionals must handle it openly and transparently according to the established policies and procedures of the pharmacy. This includes:
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Documentation and reporting: The incident must be documented and a report submitted to a national database using the pharmacy's reporting platform. Thorough documentation supports learning and ensures that all relevant information is captured.
At minimum, the following information must be documented for each medication incident:
- Date the incident occurred
- Type of medication incident
- Who discovered the incident (position/job title only)
- Medication system stages involved
- Medication(s) involved
- Degree of harm to the patient
- Incident description/how it was discovered
- Contributing factors
- Disclosure to the patient: The incident must be disclosed to the patient or patient's agent in accordance with a patient-centred approach appropriate to the patient's needs.
- Follow-up monitoring: Pharmacy professionals must follow up with the patient or patient's agent to monitor for effects of the incident as appropriate.
- Information sharing: Details about the incident and follow-up plan should be shared with other health professionals involved in the patient's circle of care as appropriate.
- Improvement implementation: Based on the analysis, pharmacies must develop specific action plans to address identified risks, implement improvements to pharmacy procedures, monitor the effectiveness of these changes, and make further adjustments if the initial improvements are not effective. All improvement plans and their outcomes must be documented.
- Transparency about improvements: When appropriate, information should be shared with the patient or patient's agent about how the pharmacy will improve and share learnings to prevent recurrence.