- Owner
- Pharmacist in Charge
- Effective date
- September 15, 2026
- Review cycle
- Every 12 months
1.Purpose
To respond to dispensing errors and near misses in a way that protects the patient first, corrects the record, and uses a non-punitive review to prevent repeat errors.
2.Scope
Applies to any dispensing error or near miss discovered by staff, the patient or the prescriber, whether the medication has already been picked up or is caught before release.
Definitions
- Near miss
- An error caught and corrected before the medication reached the patient.
- Dispensing error
- A discrepancy between what was prescribed and what was actually filled, labeled or handed to the patient.
- Root cause analysis
- A structured review to identify the underlying process or system factors that allowed an error to occur.
3.Responsibilities
- Pharmacist
- Assesses patient safety risk, corrects the record and leads the root cause review.
- Pharmacy Technician
- Reports errors or near misses observed and assists with correction under pharmacist direction.
- Pharmacist in Charge
- Reviews significant errors, decides on required external reporting and tracks corrective actions.
- Patient
- Reports suspected errors and provides information needed to assess and correct the issue.
RACI matrix
| Activity | Pharmacist | Pharmacy Technician | Pharmacist in Charge | Patient |
|---|---|---|---|---|
| Assess immediate patient safety risk | R/A | I | I | C |
| Contact patient about a dispensed error | R/A | I | I | C |
| Document the error or near miss | R | R | A | - |
| Conduct root cause analysis | R | C | A | - |
| Report to prescriber or external body if required | R | I | A | I |
R = Responsible, A = Accountable, C = Consulted, I = Informed
4.Materials and PPE
Materials, tools and systems
- →Incident and near-miss report form
- →Patient contact log
- →Root cause analysis worksheet
- →Corrective action tracker
- →Pharmacy dispensing system audit trail
5.Procedure
- 5.1
Recognize and stop the process
Pharmacy TechnicianAs soon as an error or suspected error is identified, pause the related workflow so no further steps compound the issue while it is assessed.
- 5.2
Assess immediate patient safety risk
PharmacistDetermine whether the medication has been taken, and evaluate the potential clinical impact of the error before deciding next steps.
Checkpoint: Patient safety risk is assessed and documented before any other corrective step begins.
- 5.3
Notify the pharmacist in charge for significant errors
PharmacistNotify the pharmacist in charge immediately for any error with clinical significance or that has already reached the patient.
- 5.4
Contact the patient if medication was dispensed
PharmacistCall the patient promptly to explain the error, advise on any needed action, and arrange correction or medical follow-up as appropriate.
Warning: Do not delay patient contact while internal paperwork is completed; patient safety comes first.
- 5.5
Correct the prescription record
PharmacistCorrect the electronic record and any physical label or product still in the pharmacy's possession to reflect the accurate prescription.
- 5.6
Document the error or near miss
Pharmacy TechnicianComplete the incident report form describing what happened, how it was caught, and the immediate action taken, regardless of whether the patient was affected.
- 5.7
Classify the error type and severity
PharmacistCategorize the error, such as wrong drug, wrong strength, wrong patient or labeling error, and rate its severity using the pharmacy's classification scale.
- 5.8
Conduct root cause analysis
PharmacistReview the workflow steps involved to identify the underlying cause, such as a look-alike product, a workflow gap or a distraction, rather than stopping at individual blame.
- 5.9
Notify the prescriber if applicable
PharmacistContact the prescriber's office when the error could affect the patient's therapy plan or requires their awareness for follow-up care.
- 5.10
Report externally if required
Pharmacist in ChargeReport the error to the state board or another required body if it meets the threshold set by local law or pharmacy policy.
- 5.11
Review with staff in a non-punitive huddle
Pharmacist in ChargeShare the root cause and any process change with the team in a blame-free huddle so everyone understands how to help prevent a repeat.
- 5.12
Track corrective actions to closure
Pharmacist in ChargeLog any process, training or system change identified in the corrective action tracker and confirm it is implemented and effective.
6.Quality checks
- →Every error and near miss is documented, regardless of severity.
- →Patient safety risk is assessed and, where dispensed, the patient is contacted the same day.
- →Root cause analysis looks at process factors, not just individual blame.
- →Corrective actions are tracked until confirmed complete.
7.Records
- →Incident and near-miss reports
- →Patient contact log
- →Root cause analysis worksheets
- →Corrective action tracker
8.KPIs
- →Number of near misses reported per month (higher can mean better reporting culture)
- →Number of errors reaching the patient per month
- →Average time from discovery to patient contact
- →Percentage of corrective actions closed within the target timeframe
9.Common mistakes
- →Correcting the record without documenting the error at all.
- →Delaying patient contact until an internal report is finished.
- →Treating root cause analysis as a way to assign blame rather than fix the process.
- →Not tracking whether a corrective action was actually implemented.
10.Revision history
| Revision | Date | Description | Reviewed by |
|---|---|---|---|
| 1.0 | September 15, 2026 | Initial release | Ilia Pirozhenko |
This is a template. Adapt it to your organization, equipment and local regulations before use.
