ICHP Position Statement - Medication Error Reporting and Support for a Just Culture

The Illinois Council of Health-System (ICHP) supports the role of the pharmacist as a key participant in the identification, prevention, and management of medication errors. Pharmacists, in conjunction with other health care professionals, must continually collect data on and evaluate the medication use process as part of an ongoing quality improvement program in order to minimize the risk of medication errors.

Medication error is defined as: An episode in drug misadventuring that should be preventable through effective system controls involving pharmacists, physicians and other prescribers, nurses, risk management personnel, legal counsel, administrators, patients, and others in the organizational setting, as well a regulatory agencies and the pharmaceutical industry1.  Such events may be related to professional practice, health care product, procedures and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

ICHP is committed to improving the quality of patient care and recognizes the identification of medication errors and near misses as an opportunity for improvement.  ICHP supports the concept that errors occur due to a breakdown in systems and processes.  ICHP encourages pharmacists to exert leadership in establishing a non-threatening reporting environment to encourage pharmacy staff and others to report actual and potential medication errors in a timely manner.  In addition, ICHP encourages pharmacists to exert leadership in establishing a just culture in their workplace that supports staff involved with an adverse outcome by recognizing that:

  • Human error is not 100% avoidable
  • Open transparent culture is essential for improvement
  • An emphasis on system opportunities rather than individual fault fosters voluntary reporting
A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control, and that many of these represent predictable interactions between human operators and the systems in which they work.  However, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct.2 

The evaluation of medication use systems must employ continuous quality improvement techniques in conjunction with a fully utilized, non-threatening reporting mechanism and concurrent pharmacist intervention in the prescribing, dispensing, administering and monitoring of medications. At a minimum, this includes appropriate review of medication orders by a pharmacist, ensuring that pharmacists are fully involved in drug treatment plans and pharmacist participation in nationally established medication error reporting programs. Further, ICHP encourages the use of automation such as robotics, other automated dispensing technology, bar coding and computer technology for the purpose of alerting the pharmacist and other health care practitioners to prevent and/or minimize patient harm.

1Billstein-Leber M, Carrillo JD, Cassano AT, Moline K, Robertson JJ.  ASHP Guidelines on Preventing Medication Errors in Hospitals.  Am J Health-Syst Pharm 2018;75(19):149301517.

2American Society of Health-System Pharmacists.  ASHP Policy Positions 2009-2018 (with rationales):  Medication Misadventures.  Number 1115 Just Culture.  https://www.ashp.org/-/media/assets/policy-guidelines/docs/browse-by-document-type-policy-positions-1982-2017-with-rationales-pdf.ashx (last accessed 3/26/2019)

3American Society of Health-System Pharmacists.  ASHP Statement on Reporting Medical Errors. 2000.  https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/reporting-medical-errors.ashx (last accessed 3/26/2019)

Revised 6/2019