Every pharmacy manager is responsible for creating and maintaining written policies and procedures for conducting continuous quality improvement and reporting activities for their pharmacy. These policies and procedures must ensure that staff, equipment, and facilities meet all legislative, bylaw, and policy requirements that apply to their specific pharmacy setting.
These requirements are outlined in:
These policies and procedures must:
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Include a continuous quality improvement program
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Describe how the pharmacy monitors its own compliance with these policies
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Set out clear steps for reporting, documenting, analyzing, following up on, and learning from medication incidents and near misses
More, specifically, the policies and procedures must include adequate and appropriate processes for:
- Reporting Incidents
- Analysis and Review of Medication Incident and Near Misses
Reference: PODSA Bylaws s. 24(2),
PODSA Bylaws s. 29(1), (1.1)
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Identifying root causes, contributing factors for medication incidents and near misses, and performing incident analyses as appropriate.
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Reviewing and assessing pharmacy-specific, regional, provincial, and national data and analyses.
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Reviewing and updating policies and procedures based on assessments of pharmacy’s incident analyses, safety self-assessments, and objective analyses from pharmacy-specific data, and regional - provincial-, and national-level data.
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Implementing a continuous quality improvement plan and monitoring the effectiveness of improvements that have been made.
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Implementing further updates to the pharmacy’s procedures if previous improvements are not effective.
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Following up with staff involved in medication incidents and encouraging them to seek peer support when appropriate
- Mandatory Team Meetings
- Mandatory Team Meetings
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