The Alberta College of Pharmacy’s (ACP) continuous quality improvement program—CQI+—was launched to help pharmacy teams prevent practice incidents and close calls before they happen. In fact, “prevent” is the first of five key activities of CQI+, which was featured in the April 29, 2025, edition of The Link. In this edition, we’ll focus on the second key activity: Respond.
Part of safety culture is acknowledging that, despite our best efforts, mistakes can happen. When they do, it’s important for pharmacy team members to understand how best to respond to each individual situation. These unfortunate events are upsetting to patients, their caregivers, and pharmacy team members alike, particularly when patients experience harm, and our subsequent actions can play an important role in minimizing both physical and psychological harm to all individuals involved.
Responding to practice incidents and close calls is something pharmacy teams already do, but
CQI+ can help prepare team members to be able to provide the most appropriate response to any given incident. The Respond webpage in the CQI+ section of the ACP website provides a list of the elements that should be included in a comprehensive response to a practice incident.
When it comes to responding to a practice incident, ACP has heard from patients how important disclosure and apologies are. At the same time, knowing what to say, or how to say it, has been identified as a challenge for regulated members. With the introduction of CQI+, we’ve included enhanced guidance on disclosure and apologies. This guidance includes
- the elements of disclosure,
- what an apology means for the health professional (as per the Alberta Evidence Act),
- information gathering, and
- notification of other health professionals involved in the affected patient’s care.
You can also learn more from the Health Quality Council of Alberta’s Guide to Disclosure of Harm, which outlines the foundations for disclosure, understanding disclosure, and what the disclosure process should look like.
But what about incidents that are discovered before they reach the patient? Even when an incident doesn’t reach a patient, close calls must be documented, analyzed, and reported. Close calls are not a new concept in Alberta—we previously referred to errors that never reached a patient as near misses—but the terminology has been updated to minimize confusion and align with the Health Quality Council of Alberta’s glossary of recommended terms. Although they haven’t reached a patient, close calls must be documented, analyzed, and actioned in the same manner as practice incidents. This is because they represent an important opportunity for learning and preventative action.
Regulated members can use the following criteria to determine if a close call has occurred:
- Were it to reach the patient, the close call may have caused harm.
- The close call has been a recurrent issue in the pharmacy.
- The close call provides a learning opportunity for the pharmacy or for pharmacy practice in general.
Licensees and proprietors play a critical role in supporting the pharmacy team when a practice incident occurs. They need to be mindful of the wellbeing of pharmacy team members who were involved or have been impacted by a practice incident recognizing and mitigating potential psychological harm by offering support. Visit the Disclosure and patient care webpage for a list of some potential measures of support you can offer your colleagues.
Remember that your practice incident management platform is intended to support you in documenting your response and your analysis of the incident or close call. Don’t forget to check out our practice incident management platform article and stay tuned for our upcoming article on the next key activity: Analyze.
