Strategies for Enhancing Medication Safety Culture Through Incident Reporting

Two pharmacists engaged in a discussion while standing in a pharmacy, with one pharmacist holding a tablet and both individuals focused on the screen. The pharmacy environment includes shelves of medication in the background, conveying a scene of professional collaboration and communication.


Safety IQ aims to support community pharmacy in creating a safety culture where pharmacy staff feel comfortable discussing medication errors and as a team focus on system errors rather than human to generate solutions to prevent future errors. 

In 2023, ISMP Canada conducted an analysis of medication incidents associated with harm in Manitoba using the Medication Safety Culture Indicator Matrix (MedSCIM) tool. MedSCIM is a novel tool to assess the quality of medication incident reports for a more robust evaluation of the overall medication safety culture in various healthcare settings. ISMP Canada safety analysts reviewed medication incident reports for level of completeness (can the reader understand what happened and why) and maturity of culture to medication safety (does the reporter view the incident from a system-based perspective rather than focusing on individual fault).  

Overall, Manitoba pharmacies excelled in many areas of patient safety culture, with most reports classified as positive medication safety culture. However, the MedSCIM report encourages Manitoba pharmacies to continue providing detailed descriptions of medication incidents and including contributing factors to help understand how an incident occurred, as well as system-based solutions to prevent recurrence. 

Ask yourself the following questions as you record and review your incident description to ensure your report has its greatest impact:

  • Does your description include the “What? When? Where? Why? and How?” of the incident? 
  • Is the incident description clear and concise? Is sufficient detail included to easily understand what happened? 
  • Have contributing factors been identified and included in the incident description or using the contributing factor checklist in your pharmacy reporting program (if available). 
  • Is the action to be taken to prevent recurrence included in the incident description or in relevant optional fields?  
  • Does the report focus on system-based factors (i.e. environmental) rather than human factors? 
  • Is your description free from patient, provider, or staff identifiers?  

Complete and quality medication incident reports, and pharmacy team discussions can generate effective changes in pharmacy workflow, processes, or systems to prevent future harm. The continuous efforts of Manitoba community pharmacies to report medication incidents to the National Incident Data Repository for Community Pharmacies also contributes to national multiple incident analysis by ISMP Canada. 

The CPhM ‘Quick Start to Reporting’ resource can be posted at workstations to support pharmacy staff. 

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