Documentation of a practice incident

Once steps have been taken to prioritize the health and safety of the patient, documentation should begin as soon as possible within the pharmacy’s practice incident management platform. This information is a component of the patient record, so the pharmacy’s policies and procedures must ensure that the entire history of a practice incident can easily be located, tracked, and cross-referenced for each patient involved. This might include, for example, noting the incident number from the practice incident management platform directly in the patient record in the pharmacy’s dispensing software or in a practice incident log.

The following elements must be included in the documentation of a practice incident, at a minimum:

• the date the incident occurred,
• the type of incident,
• who the incident was discovered by,
• the medication system stages involved in this incident,
• whether the incident was medication related,
• the medication(s) involved in the incident,
• the degree of harm to the patient due to the incident,
• an incident description including how the incident was discovered,
• the contributing factors identified, and
• all actions taken at the pharmacy level.

Optional data fields include the

• time the incident occurred,
• patient’s gender,
• patient’s age,
• incident background information, and
• shared learning/comments.

While these fields are optional, it is important for pharmacy team members to document as much information as possible about the incident to support its analysis and the opportunities for learning.

Entry options for each field must conform to those accepted by the National Incident Data Repository. Platform providers must work with ISMP Canada to ensure appropriate mapping of fields in a manner that is acceptable.

The practice incident management platform should enable thorough documentation of all the above elements and support all requirements for record retention as outlined in the Health Information Act.

Documentation and anonymity

Practice incident documentation is a component of the patient record; therefore, documentation may contain patient identifying information, pharmacy team member identifying information, and identifying information of other healthcare professionals involved in the incident.

However, any practice incident or close call documentation that is submitted outside of the practice incident management platform to the NIDR must be de-identified. Pharmacy team members must pay special attention to ensure that information entered in free-form text fields that will be submitted to the NIDR does not contain any individually identifying information (e.g., patients, pharmacy team members, healthcare providers, others).