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Yasmin Mohamed Essa became the licensee of her pharmacy in Okotoks in February 2024. The first thing she realized she needed to do was change the culture of her team—from a culture of blaming and shaming individuals for practice incidents to a healthy just culture where team members feel safe to discuss practice incidents. A just culture is an atmosphere of trust in which healthcare workers are supported and treated fairly when something goes wrong with patient care.
“It was my biggest challenge when I started here,” said Yasmin. “Changing the culture is not easy, so I had to have a plan. We started with a discussion about my approach. My mentality is that practice incidents are not something to be blamed on a person. We don’t call names. We take it as a learning experience. We talked about the importance of documenting practice incidents and close calls in our online practice incident management platform and how it has to be done in a timely manner. Another thing that I focused on is that our first goal is to take care of the patient involved. That will switch the mindset from ‘I’m caring about what I did’ to ‘I’m caring about what happened to the patient.’”
As the licensee of the pharmacy, Yasmin wanted to ensure that continuous improvement systems were developed to support her team in managing incidents. To make sure patients are the focus, Yasmin created a step-by-step plan for team members when practice incidents take place. The first step is to check on the patient and their safety. Second is to investigate and discuss what happened to figure out why it happened. Then, the team documents and reports the incident.
“I made it very, very important that they have to include me as a licensee for every step,” said Yasmin. “First, I need to know what happened so I can help analyze the practice incident. Maybe it was because of staffing. Maybe there was a distraction. There could be many reasons. That’s why our reporting platform is very inclusive. Every time a team member enters a practice incident report, I get a copy. I will review it in detail and then we can discuss it as a team. We disregard who made the error because it’s all about how we are going to solve the cause of the error to prevent it from happening again.”
As part of the CQI+ requirements, Yasmin holds quarterly continuous quality improvement (CQI) meetings with the team. At the meetings, she shares a quarterly report of all the practice incidents and close calls, and they discuss the findings together.
“We look at what is the most frequent practice incident and the most frequent reason for the incident,” said Yasmin. “I ask the team what they think, how we can avoid this type of incident in the future, and they provide suggestions. We also have weekly team huddles. This is where the licensee will introduce new regulations or changes to the workflow to make our practices safer.”
One example of a common practice incident that was occurring in Yasmin’s pharmacy was that instant-release (IR) medications were being mixed up with extended-release (XR) medications of the same name.
“A pharmacy intern discovered a patient was taking the wrong formulation of a medication,” said Yasmin. “Mainly, it’s an entry problem. So, we started using tall man lettering (mixing upper-case and lower-case letters within the name of the drug) to avoid confusion. When you use this strategy of tone and letters, it makes it very clear for verification of strengths or formulations like IR or XR.”
For these and other solutions, Yasmin involves her entire team in the process, from analyzing what went wrong to brainstorming solutions to prevent recurrence, focusing on the cause and the solution rather than who was involved. A just culture supports open reporting and recognizes that incidents often involve multiple contributing factors, while maintaining appropriate professional accountability.
“This is actually the most important part,” said Yasmin. “Our team is engaged. It doesn’t have to be official meetings. Ongoing casual conversations are important, too. Sometimes I’ll just call whoever is on shift for a quick chat in one of the clinic rooms about something that has happened and how we can avoid it from happening again. I will write notes from their suggestions. Having the pharmacy team engaged in the conversation and sharing their ideas is the best thing for the whole team.”
Yasmin says the improvement with the culture of her team has been noticeable since she first arrived as licensee almost three years ago.
“I’m really proud of the team with how we handle things now,” said Yasmin. “Because now we have a very successful work culture where everyone understands that they practise in a safe place and that they can do whatever is best for the patient.”
