A just and safety culture is not consequence-free. While your pharmacy shouldn’t punish staff for errors that happen due to a systemic issue, your staff are  accountable for following protocols, procedures, and practice directions. It’s important for your pharmacy to ensure that behavioural and work expectations are clear and that staff have the resources, education, and processes and procedures to work safely and within regulatory requirements.

It is important to have an accountability framework in place that ensures that leadership responds to medication incidents in a way that is expected, practiced, and applied uniformly across the entire workforce.

A Framework for Safe, Reliable, and Effective Care combine two of the best known accountability algorithms from David Marx and James Reason and CPhM has adapted this version to pharmacy practice in Manitoba. Download the algorithm from the following link:

http://safetyiq.academy/wp-content/uploads/2022/07/Accountability-Algorithm-1.pdf

Leaders and pharmacy team members should also be familiar with their obligations under provincial and federal legislation including, but not limited to the following:

• The Pharmaceutical Act and Regulations
• Code of Ethics
• The Apology Act
• The Personal Health and Information Act
  
  

The CPhM Guide to Pharmacy Practice outlines the legislation, standards of practice, practice directions, and Code of Ethics that pharmacists must uphold.

The Pharmaceutical Act (The Act) outlines pharmacists’ responsibilities when it comes to the unsafe conduct of colleagues. Section 97(1) of The Act and Statement VIII of the Code of Ethics requires pharmacists to notify the Registrar or Deputy Registrar of CPhM if they believe another pharmacist is suffering from a physical or mental condition that presents a risk to patient safety:

“A member who believes that another member is suffering from a physical or mental condition or disorder of a nature or to an extent that the other member is unfit to continue to practise or that his or her practice or pharmacy operation should be restricted, must inform the registrar of that belief and the reasons for it.”

As per Section 97(2) of The Act, pharmacists who disclose information to the CPhM are exempt from liability, unless the disclosure was made maliciously. Every effort should be made by the employer and/or manager to support an employee to address conditions or life circumstances that impact patient care.

A professional approach in broaching the subject with a colleague can be intimidating; however, an honest and nonjudgmental expression of concern is important. Ensuring that the colleague is connected to appropriate supports such as an addiction specialist, group support meetings, an addiction sponsor, counsellor, or practitioner is key to supporting positive change.

Some key resources include:

• Addictions Foundation of Manitoba
• Klinic Community Health Crisis Support
• Canadian Mental Health Foundation
  
  

Under section 98(2) of The Act, employers must report the termination of a pharmacist employee to CPhM when their position is terminated for suspected professional misconduct, incompetence or incapacity. The employer must promptly report the termination to the Registrar in writing and give the pharmacist a copy of the report.

Data and Resource Development

Safety IQ is a non-punitive program intended to foster a culture of safety and open communication about medication incidents and near-miss events to encourage shared learning and improve the safety of pharmacy practice in Manitoba.

Individual pharmacy incident and near-miss reports submitted to the National Incident Data Repository for Community Pharmacies (NIDR) are anonymous. The College of Pharmacists of Manitoba (CPhM) will only have access to de-identified aggregate data summaries including the total number of incidents and near-miss events, type and degree of harm, medications involved, etc. CPhM will review provincial incident data summaries for trends to improve standards and guidelines and develop resources and education to help pharmacy professionals reduce risk and improve patient safety.

CPhM will continuously assess Safety IQ to ensure that pharmacy professionals have the tools and resources to foster safety culture and reduce patient risk. Together, we can make a safe system even safer.

Pharmacy Site Inspections

During CPhM pharmacy visits and inspections, field officers will provide support and education to help pharmacy staff fully implement the Safety IQ program. CPhM field operations officers will assess how pharmacy staff engage with Safety IQ:

• Are all staff trained on Safety IQ and the pharmacy’s reporting tools?
• Is the pharmacy reporting medication incidents and near-miss events?
• Does pharmacy staff openly discuss incidents to identify contributing factors and develop changes in processes to reduce recurrence? How do they have discussions – informal huddles, staff meetings?
• Are process changes documented and reviewed to determine if they are effective?

For more information on what CPhM inspectors will look for when they visit, please review the Pharmacy Quality Assurance Self-Assessment.

Complaints and Discipline

Just and safety culture is neither blame nor consequence free and professional accountability must be upheld. A patient or member of the public can submit a complaint about a medication incident to CPhM and it must be fairly investigated and resolved as appropriate. Non-compliance with the Medication Incident and Near-Miss Event Practice Direction can also be referred to the Discipline Committee if concerns of professional misconduct are identified.

Failure to report a medication incident can result in serious consequences for patients and possible discipline for pharmacists. It is imperative that the pharmacy maintain an accurate and complete record of all medication incidents (by reporting to your pharmacy’s medication incident reporting platform), the resulting improvement plans, and the actions taken to ensure the incident does not happen again. If your pharmacy’s platform does not permit records with a direct link between the patient and the medication incident, you must find a way to ensure the patient and the incident and follow-up are connected. For example, you could add the incident number to your patient’s record.

Please see the Safety IQ Quick Guide: Documentation for a brief overview of documentation requirements.