Medication Incident Reporting in Community Pharmacy: Determinants of Reporting and Regulatory Effectiveness

As many as 7 million medication errors (e.g., wrong drug, dose, person) and near misses (e.g., caught before the error reaches the patient), collectively known as medication incidents (MI), could occur in Canadian community pharmacies this year alone. Yet, despite their frequency of occurrence and potential implications to both the pharmacy and public, the under-reporting of MIs in the community pharmacy setting is high. This underreporting represents a lost opportunity for key pharmacy stakeholders to improve the safety of the Canadian health care system by learning from MIs, taking steps to reduce the likelihood of similar ones recurring both within the pharmacy and throughout the province, and disseminating key lessons learned throughout the country. The objectives of this research are to (1) Identify the key in-pharmacy and regulatory authority success and risk factors influencing MI reporting and learning among Canadian community pharmacies; (2) Assess the extent that the existing policies, standards of practice, and acts of Canadian pharmacy regulatory authorities promote the success factors and address the key risk factors of MI reporting and learning; (3) Assess how well each provincial regulatory authority performs relative to others in Canada in enabling MI reporting and learning to occur. In the absence of information related to various risk and success factors underlying MI reporting, provincial regulators are less able to prioritize their inspection and monitoring activities and standards of practice to develop. In addition, developing effective policies to improve MI reporting is especially challenging when the factors impacting MI reporting in Canadian community pharmacies are currently unknown. Once such factors have been identified, however, it will be possible for regulators to better focus their efforts on high-risk sectors, undertake targeted preventative and educational interventions, and develop more effective policies for MI reporting.