Pharmacists are at the forefront of patient care, ensuring the safe and effective use of medications. Despite pharmacists best efforts, incidents can result in complaints, even if there is minimal impact on the patient and immediate resolution has occurred. This Practice Alert explores the importance of incident reporting, and how pharmacists can use their reflections and learnings to guide continuous quality improvement (CQI) and their professional development.
When should you report an incident?
- Each and every time regardless of the severity as reporting an incident is a requirement of the PDL Master Policy.
- Any time an actual or perceived error, or near miss has occurred. PDL defines a near miss as an error that’s been corrected BEFORE the medication is handed to the patient. Any time a patient is aware an error has occurred, PDL considers this an incident which may give rise to a complaint.
- If a patient interaction could lead to a complaint, even if it appears trivial at the time. Patients may discuss errors or unpleasant interactions with friends, family, colleagues or other health practitioners who may encourage them to complain or report.
- If you have received a complaint from a patient or regulator.
What are elements of a well-written incident report and why?
- Be objective and factual, describing contributing factors, incident resolution and follow up actions.
- Avoid admissions of liability.
- A copy of the internal incident report may be requested by a complainant or regulator so it is important the report is of a professional standard.
What are the benefits of incident reporting?
- The PDL Professional Officers review every incident report and will follow up with pharmacists if they have concerns or if further advice is beneficial.
- Reports made at the time of an incident can assist in preparing a response to a regulatory complaint.
- Both the incident report form and the Professional Officers can help with reflection on the incident leading to practice change.
- The Professional Officers analyse the report data allowing for the tracking of trends within the profession and communicate these trends to members.
- Reporting of near misses can identify potential risks to patients and pharmacists.
- It demonstrates proactive commitment to patient safety which is an expectation of the profession.
What can you do post-incident?
- Contact PDL to speak to a Professional Officer for non-judgemental support and advice.
- Complete an internal incident report to notify the owner of the pharmacy.
- Embrace the mindset of CQI by engaging in self-reflection to identify contributing factors, areas of improvement and gaps in knowledge.
- Tailor CPD activities to address those gaps and document it in your CPD log.
- Develop and implement necessary steps/risk mitigation strategies to prevent it in the future.
- Drive proactive efforts to enhance patient care.
- Apply the principles of open disclosure and a non-punitive approach as set out in Principle 4 of the Ahpra Shared Code of conduct.
How to lodge an incident report with PDL
Utilise the online incident reporting form available in the PDL member portal. Click on ‘Notify PDL of an incident’ to initiate the reporting process.
By mastering incident reporting, pharmacists can contribute to a safer healthcare environment and continuously improve their professional practice. Every incident is an opportunity for growth and enhanced patient care.
For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7.