A key element of ACP’s CQI+ program is that pharmacy teams will be required to submit anonymized reports of practice incidents and close calls to a national database for analysis. The results of these analyses are shared with pharmacy teams across Canada in an effort to prevent practice incidents from occurring in the future.
The organization that coordinates this effort is the Institute for Safe Medication Practices (ISMP) Canada, which is an independent, national, not-for-profit organization committed to the advancement of medication safety in all healthcare settings across Canada.
“Our mandate includes receiving and analyzing practice incident and close call reports, identifying contributing factors and causes, and making recommendations for the prevention of harmful medication incidents,” said Enna Aujla, ISMP Canada’s Director of Community Pharmacy Reporting and Learning.
ISMP Canada works with other organizations—such as Health Canada, the Canadian Institute for Health Information, Patients for Patient Safety Canada, and Healthcare Excellence Canada—as part of the Canadian Medication Incident Reporting and Prevention System (CMIRPS). The collective goal of CMIRPS is to reduce and prevent harmful medication incidents in Canada throughout various healthcare settings.
Pharmacy teams must begin submitting practice incident and close call information to the National Incident Data Repository for Community Pharmacies (NIDR)—a component of CMIRPS—using a practice incident management platform that meets ACP criteria by February 1, 2026. The reported practice incidents and close calls are submitted anonymously by community pharmacies to the NIDR for the purpose of improving medication safety in the community and elsewhere. Alberta has become the seventh province where community pharmacies submit anonymous reports into the NIDR.
ISMP Canada works with any community pharmacy—independent or part of a chain—to collect anonymous close call and practice incident data, which is entered into the NIDR. Once collected, ISMP Canada aggregates and analyzes the data.
“We also collect reports of incidents from other healthcare practitioners, consumers, patients, caregivers, and others so that the knowledge can be used to understand what issues and errors are occurring with medications and why,” said Enna. “With this knowledge, we develop and disseminate lessons learned with compelling, actionable, evidence-informed recommendations for reducing preventable harm related to medications.”
This knowledge is shared in multiple ways, including
- ISMP Canada’s Safety Bulletins, which are shared via email.
- Provincial Safety Briefs which share aggregate quantitative data from a province such as number of incidents by harm level and top five types of incidents. This publication shares learning which may be unique to a province, as well as national learning.
- A National Snapshot is a publication which shares NIDR quantitative, aggregate data at the national level.
- Safe Medication Use Newsletters are publications for consumers or patients which include shared learning from NIDR and other CMIRPS database analyses.
“By reading about findings from incidents reported and shared in ISMP Canada publications, pharmacists can assess whether the same risks exist in their own pharmacy and then make proactive changes to mitigate these risks,” said Enna. “A shared learning approach can help pharmacists and licensees analyze their own incidents. Reading about incidents that occurred in another pharmacy can help prevent an incident in their own pharmacy, as they may recognize a system improvement that would benefit patients.”
Regular pharmacy safety meetings, a required component of CQI+, are a good opportunity for pharmacy teams to discuss results of their local analyses and ISMP Canada analyses.
“ISMP Canada resources are designed to be shared with the whole team,” said Enna. “Safety Bulletins and Safety Briefs can be used by the team as a guide for how to make continuous quality improvements in their own pharmacy. There are also many useful resources and tools available on the ISMP Canada website to aid in incident analysis and prevention. For example, community pharmacy teams may use the Hierarchy of Effectiveness or the Canadian High-Alert list. These resources may help when developing action plans within the pharmacy. The Guide to CQI+ recommends that pharmacy teams review relevant information from external sources, so these could proactively inform safety strategies in the pharmacy.”
What does all of this look like in action? Enna shared a recent example of what ISMP Canada was able to do after receiving multiple reports describing outcomes of harm, including death, as a result of inadvertent selection errors with midodrine and Midamor®. Reports were received from both community pharmacies and hospital pharmacies.
“ISMP Canada medication safety specialists completed an analysis of the incident reports and identified factors that can potentially contribute to mix-ups between the two medications,” said Enna. “This detailed analysis yielded different recommendations for different groups in the Safety Bulletin: Prevent Harm from Midrodrine and Midamor Mix-Ups.”
There were four key groups that were identified for the recommendations: leadership in community pharmacies and healthcare organizations; prescribers who could be physicians, nurse practitioners, and other prescribers; pharmacy teams, including pharmacists, pharmacy technicians, students, and unregulated employees; and pharmaceutical manufacturers.
“It’s my pleasure to share that the manufacturer, as a result of the shared learning, will be submitting to Health Canada an improved label design. It’s hoped the improved label design will help reduce the chance of this error recurring,” said Enna. “What was interesting is that many of the incident reports were good catches or close calls. This really highlights that when general strategies to prevent lookalike and soundalike errors are implemented, and when the patient or caregiver is engaged in the treatment plan, incidents are detected before harm can occur. Learning from close calls can save more patients from experiencing harm.”
As described earlier, all data that is submitted to the NIDR is done so anonymously. Enna reassures all pharmacy team members that ISMP Canada does not collect any information that directly identifies patients, prescribers, pharmacies, or pharmacy staff.
“ISMP Canada does not need to know the names of individuals involved in practice incidents, and we are unable to identify individual pharmacies or pharmacy staff in the incident report,” she said. “We are only able to identify the province from which a report was submitted. When we share learning with various audiences, we have a triple-check process that the information cannot be used to identify a person, place, or professional. Our goal is to analyze practice incident reports and develop recommendations for enhancing patient safety in provinces and across Canada. Practice incidents submitted are used only for the purpose of analysis, shared learning, and formulation of incident prevention strategies in all healthcare settings.”
ACP recognizes that some individuals may feel hesitant to report an incident because of the stigma that may exist around making an error. This approach of anonymity serves to reassure pharmacy teams that the focus of the program is to support sharing and learning that can make pharmacies safer.
