Feedback for Implementation of Continuous Quality Assurance for Medication Safety

Pharmacist  ·  May 1, 2017

1) Do you see the CQA Program benefiting the practice in your own pharmacy? --> Yes. I believe reflection and analysis of incidents, both near misses and actual ones, is useful, and an important part of continuous quality improvement within a pharmacy. Oftentimes, when an error or near miss occurs, we do not take the time to reflect on how and why it occurred, as well as what we could do on a local/staff level to prevent it from happening again. I think we owe it to our patients to ensure that whenever incidents or near misses are made, that we take thoughtful action and considerations as to how we can ensure that we do our due diligence to improve on and learn from these occurrences. Just as with any intervention in patient care, if it wasn't documented, it did not happen. Likewise, if we do not document our CQA discussions and activities in a consistent or standardized manner, there is no evidence that these endeavours even occurred.

  1. What would support a successful implementation? --> Clear guidelines and details regarding the implementation of such a CQA program, with respect to, but not limited to: what constitutes a medication error and a near miss, what types of errors are to reported on, who should do the reporting/whose responsibility it is to implement the CQA process within the pharmacy, how and when training will be provided, etc. --> Also, a CQA program would not be as effective if there is a negative or blaming culture exists within the workplace. A culture of openness that does not allow for reprisal or blaming must be in place as the foundation for the CQA process to be established, and in order for the staff to fully engage in reporting.

  2. How could the College help with the implementation? --> Set clear, detailed guidelines on what should be reported, who is responsible, how and when the training will be provided to each pharmacy, helpful resources and tools, and encourage a culture of openness within pharmacies. Emphasize that this initiative is for patient care and patient safety, not as a punitive or burdensome activity. --> Set clear and detailed expectations on what the CQA program will entail, what it encompasses, and what each pharmacy should strive to

4) What are you already doing in your pharmacy around CQI and CQA? --> Informal and open staff meetings, alerts and reminders where previous near misses and errors have occurred, encouraging increased documentation to avoid communication gaps that can lead to potential errors, open verbal communication amongst staff regarding ambiguous or problematic situations

5) Is it reasonable to implement the CQA program in two phases? --> Yes. The transition should be gradual, as a CQA program is new and the lessons learned (of what went well and what didn't) can be gleaned and modifications made to improve upon the second phase

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