Inspectors' Advice on Medication Error Management

Although pharmacists try very hard to avoid medication errors, sometimes they occur in pharmacy practice. The way a pharmacist handles a medication error often has a direct effect on the patient, and affects the likelihood of another medication error occurring at the pharmacy.

At all routine pharmacy inspections, PSI inspectors review medication error management records in place at the pharmacy. This review includes checking that the pharmacy has policies and procedures to assist all members of staff in dealing with, and learning from, medication errors, as well as that records of medication errors and near misses are maintained at the pharmacy.

To assist pharmacists and other members of the pharmacy team, our inspectors have prepared some frequently asked questions and answers on this important subject.

What is Medication Error Management?

Medication error management is a key part of the pharmacy’s quality management system. A pharmacy must have a clear, documented system for the management, continuous review and recording of medication errors and near misses. The purpose of error management is to:

  • identify mistakes,
  • make sure the appropriate action is taken to safeguard the health of the patient where a mistake has taken place,
  • ensure accurate records are maintained,
  • learn from mistakes, and
  • minimise the risk of future mistakes.

The maintenance and review of an error and near miss logs as part of an error management system will facilitate the identification of any patterns or repeated errors, help identify learning needs and the consequent re-training of staff, and contribute to the continuous review of the policies and procedures of the pharmacy.

Template documents that can be used for the recording of medication errors and near-miss incidents are provided below.

Information and Resources

Expand all

  • Who is responsible for medication error management?

  • What is a Corrective Action?

  • What is a Preventative Action?

  • What Records do I need to keep?

  • Why do I need to keep a record of Near Misses?

  • Where can I find templates of an error log and a near miss log?