Guest Author:
Ely Yatsun, PharmD
Ely is a graduate of the College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba. He recently completed a fourth year elective rotation with the College of Pharmacists of Manitoba, where he contributed to this work. Through his training in both hospital and community pharmacy settings, he has developed a strong understanding of pharmacy practice and the systems that support safe and effective patient care
Continuous Quality Improvement (CQI) meetings are a key component of the Safety IQ program and play an essential role in identifying risks, analyzing medication incidents and near misses, as well as implementing system-level changes to improve patient safety. When used effectively, these meetings support proactive learning and help prevent harm. The following sample case highlights how ineffective use of a CQI meeting can result in missed opportunities to address known risks and ultimately lead to a preventable medication incident.
Importance of CQI
Background
A community pharmacy holds their required annual CQI meeting, but the meeting is rushed and treated as a formality rather than a meaningful safety discussion. Only a few staff members attend, and the team does not review recent medication incidents or near-miss events in detail. Incident data from the reporting platform is not analyzed, and no discussion occurs about previous improvement plans or trends in dispensing errors.
Situation
Over the past several months, the pharmacy has experienced multiple near-miss events involving similar patient names, where prescriptions were nearly dispensed to the wrong patient. These events were reported individually in the reporting system but were never discussed collectively during the CQI meeting. Since the team did not review incident trends or develop an action plan, the underlying system issue, (patients with similar names in the software system) was never addressed.
Several weeks later, a prescription is dispensed to the wrong patient with the same name, and the error is not caught during counselling. The patient takes the medication before the mistake is discovered, resulting in a medication incident that required follow-up with the prescriber and monitoring for adverse effects.
Consequences
- A preventable medication incident reached the patient.
- The pharmacy team must perform additional follow-up and documentation due to this error.
- Trust between the patient and pharmacy may be affected.
- The pharmacy identifies that similar near-miss events had already occurred but were not acted upon during the CQI process.
Analysis
The incident could have potentially been prevented if the pharmacy had used the CQI meeting effectively to:
- Review medication incident and near-miss trends from the reporting platform.
- Discuss recurring risks and contributing factors.
- Develop and document an improvement plan to address the issue.
CQI meetings are intended to review incident data, assess improvement plans, and create new action plans based on safety trends. When these meetings are not used effectively, opportunities to identify system weaknesses and prevent harm may be missed.
Potential Corrective Actions
Following the incident, the pharmacy team:
- Conducts a comprehensive CQI meeting with full staff participation.
- Reviews the incident data summary and previous near-miss reports to identify patterns.
- Implements system changes such as bolding similar patient names in the software and confirming date of birth at prescription drop-off and counselling.
- Documents the discussion and action plan from the CQI meeting and assigns staff responsible for monitoring progress.
- Schedules regular quarterly reviews of incident and near-miss data to ensure issues are identified earlier.
The case above highlights the importance of CQI meetings in identifying contributing factors to near misses and medication incidents and developing strategies to prevent recurrence. Through structured analysis and discussions, CQI meetings support a culture of learning and patient safety. The findings of this case align with existing CQI data, reinforcing the value of system-based improvements, effective communication, and ongoing quality improvement efforts in pharmacy practice. For more information and data on Continuous Quality Improvement, visit https://safetyiq.academy/continuous-quality-improvement-meeting/ .
