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Kansas News: Changes in Incident Reporting
Published in the December 2008 Kansas State Board of Pharmacy Newsletter
On September 24, 2008, a public hearing was held on proposed changes to the Incident Report Regulation. These changes were necessary to ensure continuity between this regulation and the continuous quality improvement (CQI) statute passed by the legislature this year. A CQI law was enacted in 2008 requiring each pharmacy in Kansas to establish a CQI program no later than July 1, 2009. The purpose of the program is to assess errors in dispensing or furnishing prescription medications so that the pharmacy may take appropriate action to prevent a recurrence of any errors.
The new provisions in the Incident Report Regulation related to incident reports will delineate what constitutes a “reportable incident for purposes of preparing the incident report.” A pharmacy must report preventable medication errors involving a prescription drug and resulting in the following:
1. the patient receiving the wrong drug;
2. the patient receiving an incorrect drug strength;
3. the patient receiving an incorrect dosage form;
4. the drug being received by the wrong patient;
5. inadequate or incorrect packaging, labeling, or directions; or
6. the dispensing of a drug to a patient in a situation that results in or has the potential to result in serious harm to the patient.
The pharmacist-in-charge (PIC) shall ensure that procedures exist requiring pharmacists who become aware of a reportable incident as defined above to alert the PIC of the incident as soon as practical so that a report can be prepared. The responsibility of preparing an incident report falls on each pharmacist involved in the incident and the PIC. Any employee involved in the incident must sign the incident report. Incident reports must be maintained for a minimum of five years. The incident reports should be reviewed at least once per quarter of each calendar year and a CQI report should be generated. The CQI report takes the place of the Plan of Action Requirements. The CQI report should list those persons in attendance at the quarterly meeting, the list of incident reports reviewed, and a description of the steps taken or to be taken to prevent a recurrence of each incident that was reviewed. All reports generated by the CQI program are available for inspection by the Board of Pharmacy.
