Program requirements

Each pharmacy must procure access to an online practice incident management platform that meets the requirements.
The practice incident management platform must be used to document practice incidents and close calls that occur in the pharmacy, including their associated analysis and action plans.
Details of all practice incidents and close calls meeting ACP criteria must be documented.
Anonymous detail of practice incidents and close calls must be submitted to the National Incident Data Repository for Community Pharmacies, and this must be facilitated by the practice incident management platform.

Each pharmacy must procure access to an online safety self-assessment tool.
Each pharmacy must complete and document a safety self-assessment at least every two years, or within six months of a licensee change, whichever is sooner.
The results of the safety self-assessment must be used to inform continuous quality improvement activities in the pharmacy that proactively address risks identified.

Each pharmacy must have site-specific policies and procedures in place to guide their pharmacy’s continuous quality improvement program. They must be reviewed by the licensee at least annually and updated as required.
All pharmacy team members must be trained on the pharmacy’s specific policies and procedures for continuous quality improvement in the pharmacy.
Practice incidents and close calls must be analyzed to identify and document contributing factors and root causes.
Based on the analysis of a practice incident or close call, an action plan must be documented and implemented to prevent it from occurring again.
Action plans must be routinely evaluated to assess their effectiveness and make changes, if required.
Pharmacy teams must convene at least every three months for a continuous quality improvement meeting, the results of which must be documented.