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Is your pharmacy team patient safety SMART?

November 15, 2011

ACP, in collaboration with the Institute for Safe Medication Practices Canada (ISMP Canada), is pleased to introduce a new resource to help your pharmacy team reduce recurrence of drug incidents and to become competent patient safety advocates.

The Systems Approach to Quality Assurance for Community Pharmacies is a comprehensive guide that will prompt your team to:

  • clearly identify what happened to cause a particular incident,
  • determine why it happened through the use of triggering questions and visualization aids, and
  • find SMART solutions to prevent recurrence.


Learn more:

SMART action plans are more likely to be successful in preventing recurrence of incidents as they are Specific, Measurable, Attainable, Relevant, and Time-based.

The systems approach is based on the following principles:

  1. Create a patient safety culture, remembering that patients are your primary focus.
    • Ensure the environment and equipment are both designed to support patient safety.
  2. Shift the focus from the actions of individuals to the system-based causes of events.
  3. Include all members of your pharmacy team and other health care practitioners whose care of the patient may be affected by a drug incident. Systems analysis is a team approach. Team members will serve as the “change agents” who will assist you in successfully implementing strategies to reduce incident recurrence.
  4. Share information about drug incidents with ISMP Canada to facilitate learning by fellow colleagues.
  5. Document your analysis and prevention strategies in a manner that facilitates compliance with the Standards for the Operation of Licensed Pharmacies.

Figure 1: Systems Approach Process

ACP has created new and improved drug incident report forms and quarterly review reports with sample completed versions of each which incorporate principles of systems analysis. Use these reports to document a drug incident the next time one should occur in your pharmacy, and keep them handy so that your Pharmacy Practice Consultant (PPC) can discuss them with your team on their next visit. 

To get you started with the systems approach to incident analysis, please review the Incident Analysis Process Summary and Quick Reference Guide. This tool is designed to assist your pharmacy team to analyze, investigate and document incidents and find SMART solutions for everything from drug incidents to burglary prevention and work flow. Quality Assurance for Community Pharmacies – The Systems Approach: A Patient Safety Primer provides some additional detail to help your team make the most of this tool. Your PPC will be visiting your pharmacy to assist your team in implementing these quality assurance tools to enhance patient safety in your practice setting.

In addition to the aforementioned resources, those of you who are visual and auditory learners can find three narrated PowerPoint presentations on the ACP website that will provide you with a comprehensive understanding of systems analysis:

  • Quality Assurance for Community Pharmacies Part I: Leading Up to Systems Analysis of Drug Incidents: A brief presentation outlining the differences between drug incidents, adverse drug events and drug errors, and the organizational process for managing critical incidents.
  • Quality Assurance for Community Pharmacies Part II: The Systems Approach to Investigating Drug Incidents: A journey through the incident analysis process, this presentation takes you through an example of a drug incident to illustrate how to apply the principles of systems analysis.
  • Quality Assurance for Community Pharmacies Part III: Application of Systems Analysis Beyond Drug Incidents: Workflow and burglary prevention case examples will be used to demonstrate the utility of systems analysis beyond drug incidents.

Review these quality assurance resources to obtain non-accredited learning CEUs as part of your learning portfolio. Simply document what you have learned by completing a Non-accredited Learning Record. We wish you success on your path to becoming patient safety advocates!