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Establishing a ‘Just Culture’ in Your Pharmacy

Medication incidents and near-miss events occur in pharmacies every day – and though they may never be completely avoidable, there are steps pharmacies can take to limit risk.

For most pharmacies, this starts with consistent reporting of incidents and near-miss events. Without reporting, it’s impossible to identify the process gaps that are contributing to errors and is therefore impossible to fix.

However, in many pharmacies and healthcare settings, errors and near-miss events are under-reported or worse – not reported at all – due to fears of disciplinary or legal action. When this occurs, system fixes are not made, meaning the error is likely to occur again in the future.

To help combat this, many provinces and states have introduced ‘Just Culture’ principles that encourage pharmacies to establish blame-free, transparent work environments where pharmacy staff feel safe reporting and discussing incidents.

Getting Started: The Benefits of a Just Culture

In a just culture, patient safety is always top of mind. Staff prioritize safety and continually look for risks that could pose a threat. When honest mistakes are made, they are treated as learning opportunities, with a focus on identifying and fixing what went wrong, rather than assigning blame or reprimanding specific individuals.

Communication is open and transparent, with an emphasis on sharing learnings and ideas to prevent one person’s mistake from becoming another’s in the future. Involving all staff members in honest discussions following an incident is also critical to help ensure everyone feels engaged, accountable, and inspired to be more careful in the future.

When staff feel safe reporting mistakes and near-misses, incidents are more consistently reported, more data is gathered around how the error happened, and subsequently, more process gaps are identified and corrected. As more issues are remedied over time, it becomes harder for staff to commit unintentional errors.

Simplify Reporting with Pharmapod  

Establishing a just culture in your pharmacy relies on consistent reporting. To encourage reporting, you must make it easy for pharmacy staff to do so – Pharmapod’s medication incident reporting platform makes it simple.

When reporting, Pharmapod walks pharmacy staff through a series of predefined questions to ensure all relevant information surrounding the incident or near-miss is captured. Staff have their own logins so multiple members can contribute to a report simultaneously. They can also be given different degrees of access, so they will not see information that is not relevant to them.

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Support your pharmacy’s just culture journey – contact Pharmapod today to learn more about the Medication Incident Management Platform and how it can help your pharmacy improve patient safety.


Pharmapod and MDBriefCase are members of the Think Research family of companies.

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