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The following definitions are taken directly from CPBC’s bylaws and provide important context for understanding CIRCL program requirements:
Contributing factor: A circumstance, action or influence that is thought to have played a part in the origin or development of a medication incident or near miss, or to increase the risk of a medication incident or near miss.
Culture of patient safety: The component of organizational culture involving the shared beliefs, attitudes, values, norms and behavioural characteristics of employees, and that influences staff member attitudes and behaviours in relation to their organization's ongoing patient safety performance, resulting in an enabling patient safety culture characterized by leadership that leads by example, transparent communication, psychological safety facilitating reporting of errors, patient and family engagement, and a commitment to ongoing improvement.
De-identify/De-identified: In relation to data and reports, means the data or report does not contain any information about an identifiable individual, including the individual who completed or submitted the report, any pharmacy staff involved in the medication incident or near miss, any patient or patient's representative, or any other individual.
Just culture: The environment of a workplace in which consideration is given to wider systemic issues when things go wrong, enabling professionals and those operating the system to learn without fear of retribution, and where, to encourage reporting of safety issues, inadvertent human error, freely admitted, is generally not subject to sanction, but people are held to account where there is evidence of unprofessional conduct or deliberate acts.
Medication incident: Any preventable event that may cause or lead to inappropriate medication use or patient harm that has reached the patient and that may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labelling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
National database: A data repository that (a) contains de-identified medication incident and near miss reporting data submitted from across Canada, (b) is appropriate for the pharmacy's licence type, and (c) is an established component of the collaborative pan-Canadian program for reducing and preventing harmful medication incidents known as the Canadian Medication Incident Reporting and Prevention System (CMIRPS).
Near miss: An event that could have resulted in unwanted consequences but did not because, either by chance or through timely intervention, the event did not reach the patient.
Peer support: Emotional and practical support between two people who share a common experience, such as a mental health challenge or illness.
Reporting platform: The computer software used by pharmacy staff for recording medication incidents and near misses at the pharmacy level and reporting them to a national database.
Root cause: The most fundamental reason, or one of several fundamental reasons, a suspected failure, a medication incident, a near miss, or a situation in which performance does not meet expectations has occurred.
Root cause analysis: An objective analytical process that can be used to perform a comprehensive, system-based review of critical incidents including without limitation the identification of the root and contributory factors, the determination of risk reduction strategies, and the development of action plans along with measurement strategies to evaluate the effectiveness of the plans.
Safety self-assessment: A process used regularly by pharmacy staff to proactively identify potential safety concerns, which may help decrease the number of medication incidents and near misses and identify opportunities for improvement at a pharmacy in order to mitigate risks to patients.
Team meeting: A regular meeting of pharmacy staff to proactively review and assess summary reports and analyses of pharmacy-specific data and available summary reports and analyses of available regional-, provincial-, and national-level data and determine how to address them.