Pharmacy CQI: What to bear in mind when you fill out that incident report

Key Points

Every pharmacist knows that a key element of continuous quality improvement is learning what caused the last error and using this information to avoid the next error. This is part of the element of monitoring built into every CQI program. Only a handful of pharmacies in the United States use monitoring to its full potential. This piece of error reduction will be discussed in a later article. We focus here on a danger inherent in the way many pharmacies collect and use incident reports.

Incident reports

The pharmacy manager must be informed of incidents occurring at the pharmacy level in order to evaluate operations and to analyze the proper workings of the department. The manager will need to make a decision as to whether a "customer relations" call to the patient or anyone else is necessary and, if so, who should make the call.

The home office must be informed of all negative, potentially serious ramifications that may come from any error, even if the patient did not take the medication in question.

The pharmacy's insurance company or risk management department must analyze each error in order to determine which may result in a claim, so that reserves can be set against future losses. Failure to file a timely report with an insurance company can result in denial of coverage if a lawsuit is filed.

Managers, home offices, and insurance companies do not want to be surprised by negative news that the pharmacy could have reported and did not. In many pharmacies, failure to report an error may be a cause for firing the individual who failed to report.