Quick Links

Use the quick links below to find the resources and information you need to implement and maintain Safety IQ in your pharmacy.

Share Learning and Communicate

Safety expert James Reason argued that “the most detrimental error is failing to learn from an error.” When healthcare professionals share what they learn from incidents within teams and across disciplines, safety improvements are passed along to all Canadians. Through Safety IQ, community pharmacy teams share valuable learnings to improve patient outcomes on team, provincial, and national levels.

Sharing information and talking openly about medication incidents and near-miss events in your pharmacy generates solutions and demonstrates commitment to patient safety and safety culture. Consistent reporting of medication incidents and near-miss events contributes to professional transparency and improvement in pharmacies across Canada.

At the pharmacy team level, medication incidents and near-miss events should be shared with all pharmacy staff to ensure team members have a chance to contribute to building and maintaining improvement plans.

Use the resources, information, and Manitoba-based case studies below to learn more about shared learning and communication.

Your pharmacy’s annual CQI Meeting is another excellent opportunity for shared learning and communication. Please visit the following link for more information: http://safetyiq.academy/continuous-quality-improvement-meeting/

Shared Learning from Safety IQ: Manitoba Case Studies

Continuous quality improvement (CQI) to reduce the chances of patient harm from medication incidents is an ongoing process that requires a preoccupation with safety. Your pharmacy can use the resources below to stimulate staff discussion about medication incidents and near-miss events, examine your pharmacy’s practices through an improvement lens, or strengthen your knowledge of CQI.

Shared learning is a cornerstone of Safety IQ and the resources below are a representation of community pharmacy’s commitment to CQI in Manitoba. Your reports and CQI stories are contributing to shared learning across Canada.

Share Your Improvement Stories with Manitoba Pharmacy Professionals

If your pharmacy has experienced an incident or near-miss event that would be a good learning opportunity for other pharmacies, please forward your story to the Safety IQ team at safetyiq@cphm.ca. Your story will be shared with the profession through CPhM publications and any identifying information about the pharmacy or staff will be kept anonymous.

CPHM would like to acknowledge the pharmacy professionals who shared their experience for the benefit of their colleagues. CPhM also thanks the Ontario College of Pharmacists for permission to adapt their Pharmacy Connection Spring 2019 article, AIMs Program: Exercise Professional Judgement When Deciding to Record a Near Miss.

Near-Miss Event Case Studies

A near-miss event is an discrepancy that could have resulted in inappropriate medication use or patient harm but is discovered by a pharmacy professional before the prescription reaches the patient. Pharmacy professionals excel at this type of ‘good catch.’ Near-miss event reporting and analysis is an opportunity to proactively address gaps in existing pharmacy systems or procedures to prevent a near-miss event from becoming a medication incident in the future.

Not all near-miss events are valuable from an improvement or learning perspective. Every pharmacy should have official protocol on near-miss reporting, but staff should always consider the following when deciding to report a near-miss event:

  • The potential impact on the patient: Would the patient be harmed if they used the incorrect medication?
  • The recurring nature of the near-miss event: Does the same-near miss happen repeatedly? If yes, there are potential areas of risk or weakness within the pharmacy process or system that pharmacy staff should review and change.
  • The potential shared learning for others: Could learning from a near-miss event benefit colleagues and patients in other pharmacies?

The following scenarios from Manitoba pharmacies demonstrate the benefit of near-miss reporting and provides examples of what types of near-miss events your team should be reporting. 


The pharmacy receives a faxed prescription for an antibiotic suspension for a new patient. The patient’s parents are called to collect general information (address, PHIN, etc.) and to confirm that the prescription was to be filled. The pharmacy professional did not assess the patient’s medical history or allergies during the phone conversation.


The prescription for the antibiotic suspension is prepared and during patient counselling the pharmacy professional asked the patient’s parents to confirm the patient has no allergies. At that point, it was determined that the patient is, in fact, allergic to the antibiotic prescribed. A pharmacy professional contacts the prescriber and the prescription is changed to an appropriate antibiotic.

Decision to Report

The near-miss event in this case could have harmed the patient. A standard process for gathering patient information is in place when the pharmacy receives a prescription in-person, but in the case of prescriptions delivered to the pharmacy by phone or fax, the process is not consistent.


The pharmacy team determined that all patient information including medication history, allergies, etc. must be obtained before filling all new prescriptions whether received in-person, by fax or phone. If information is missing, then the prescription must be highlighted to alert pharmacy staff to verify the missing information before they release the prescription to the patient


Pharmacy receives a prescription for a steroid cream for a patient who has the same first and last name as another family member who lives at the same address.


A relief pharmacy staff member was unaware that there were two patients with the same name. During patient counselling, the pharmacist confirmed the patient’s birthdate and discovered the prescription was mistakenly filled for the son instead of the father. The parent advised the pharmacist this has happened before and was only discovered after they left the pharmacy.

Decision to Report

Due to the similarity of names, this error has happened repeatedly and obtaining a second patient identifier such as an address is not helpful in this situation.


The pharmacy team reviewed the near-miss event and determined that for each new prescription, the date of birth of the patient should be confirmed when the prescription is dropped off. The pharmacy software can bold patient names, so the pharmacy bolds any patients with similar names to highlight the potential error for staff.


Pharmacy staff prepared a compliance package for a new patient who was starting on methotrexate 5mg weekly on Wednesdays.


When the pharmacist reviewed the medications with the patient, they noted that methotrexate was entered into the computer as weekly, but the compliance packaging contained daily doses.

Decision to Report

Methotrexate taken daily can lead to serious and life-threatening consequences. Sharing of this near-miss event is beneficial for all staff to consider changes to prevent a similar occurrence.


Pharmacy staff reviewed the near-miss event and identified some process changes including:

  • Count out medications before filling compliance packaging to try to eliminate the addition of extra doses.
  • For all methotrexate prescriptions, limit dispensed quantities of oral methotrexate to a one-month supply whenever possible.
  • Include explicit dosing instructions for methotrexate, such as day of the week, on the prescription label and medication administration record.
  • Before sealing a compliance package that includes methotrexate, perform an independent double-check to confirm only a weekly dose is included.
  • During patient counselling, double-check methotrexate discharge prescriptions for accurate dose and directions.

Medication Incident Case Studies

A medication incident is a preventable occurrence or circumstance that may cause or lead to inappropriate medication use or patient harm. Medication incidents may be caused by several simultaneous contributing issues including human factors, environmental factors, procedures, and systems. Medication incidents can happen at any stage in the prescription process including prescribing, order communication, product labelling/packaging/ nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. Medication incidents are complex events that can involve any member of a healthcare team regardless of experience or diligence.

Medication incident reporting in community pharmacies is mandatory in Manitoba.

The following scenarios from Manitoba pharmacies demonstrate the benefits of medication incident reporting and some suggestions on analysis and system improvement measures.

The College would like to acknowledge the pharmacy professionals who shared their experience for the benefit of their colleagues.


Compliance pack preparation can be a high-risk process especially when compared with traditional prescription preparation. The high number of prescriptions being dispensed in the same packaging introduces additional steps and increases the mental work that pharmacy professionals need to do[1]. This can lead to an increased risk of a medication incident like the Manitoba-based case study below.


The pharmacy prepares a monthly compliance package for a patient who is on multiple prescriptions. The patient advised the pharmacy that they were leaving on holiday the next day and needed their medications as soon as possible.

That evening the only pharmacist on duty prepared and checked the patient’s compliance packages. After picking up the compliance package, the patient informed the pharmacy that a metformin dose was missing from the morning slot in one set of blisters.

The pharmacy picked up and re-packaged the card with the missing metformin and confirmed the remaining cards were all correct.

Possible Contributing Factors

  • The patient was on multiple prescriptions making the compliance package more complex and difficult to package and check than usual
  • No independent double-check was performed by another pharmacy staff person
  • Pharmacy staff may have been stressed due to the urgency of the request and minimal staff present
  • The pharmacist was likely distracted by other duties during filling and checking steps


  • Develop a system for checking compliance packages such as
    • using a current and accurate blister card;
    • counting out medications before preparing the compliance package to ensure the correct quantity; and
    • physically counting the number of pills in each slot.
  • Minimize distractions for the staff person preparing compliance packaging to reduce chance of omission or duplication of medications.
  • Perform an independent double-check whenever possible. Have one staff member prepare and another check compliance packaging to mitigate confirmation bias.
  • If an independent check is not possible, then separate the preparation process from the checking of the packaging to a later time or the next day to reduce confirmation bias.

[1] https://www.ismp-canada.org/download/PharmacyConnection/PC2014Winter_PackPreparation.pdf


Hospital discharge prescriptions can be complex because they often include information related to discontinued or changed medications as well new prescriptions. This type of prescription can be especially risky for pediatric patients who need a compounded product that could lead to a dosing error causing significant or fatal harm. This could have been the outcome in the following real-life Manitoba case study.


A pharmacy receives a hospital discharge prescription for a pediatric patient who has had prescriptions from the pharmacy in the past. The hospital discharge includes several pages and pharmacy staff generally leave these types of prescription orders for the pharmacist to review and enter since they are often complicated and confusing.

The discharge includes a prescription for a compounded predniSONE 5mg/ml suspension and the pharmacist misreads the prescription and enters and fills the commercial predniSOLONE 1mg/ml product instead. When reviewing the medication with the pharmacist, the patient’s parent notes that the dose amount is different from what they discussed with the hospital pharmacist before the patient was discharged. The pharmacist did not follow-up on the information provided by the patient’s parent at this time.

When they arrived home, the patient’s parent compares the prescription label with the hospital discharge summary and discovers that predniSOLONE is on the label rather than predniSONE and contacts the pharmacy. Fortunately, the patient does not consume a dose of the prednisolone.

The pharmacy picked up the prednisolone medication and ordered the compounded prednisone from a compounding pharmacy.

Contributing Factors

  • The hospital discharge summary is complex increasing the mental workload of the pharmacist which increases the risk of a medication incident.
  • Look-alike/sound-alike medications are involved.
  • Staffing deficiency or lack of training as staff are uncomfortable entering hospital discharge prescriptions.
  • Lack of independent double-check with the pharmacist completing both order entry and prescription check leading to confirmation bias.
  • Lack of follow-up when the caregiver notes the difference in doses.


  • Train a variety of pharmacy staff to enter and fill hospital discharge prescriptions. This will support independent double-checks to overcome confirmation bias.
  • Raise awareness among the pharmacy team about the hazards of look-alike/sound-alike drug names and put an action plan in place that targets this hazard. For instance, discuss and/or implement ISMP Canada’s recommendations in Preventable Medication Errors: Look-alike/Sound-alike Drug Names and post ISMP’s (US) look-alike/sound alike drug list.
  • Pharmacist reviews discharge prescriptions and highlights the medications that need to be filled.
  • Use open-ended questions when counselling about the health condition, medication, and dosing information to confirm patient’s understanding and act as a double-check. Any discrepancies or conflicting information obtained during patient counselling should be immediately investigated.
  • Recognize that patients and caregivers have the privileged perspective of experiencing the entire continuum of the care they receive. They are vital members of a care team, and their concerns should be taken seriously and followed-up on.
  • Conduct patient counselling when medications are dispensed even when patients or care givers may have received pharmacist counselling at discharge from hospital.
  • Review the medication profile for a full picture of patient history to determine appropriateness of therapy and dosing.