Good morning,

We are exploring creating a peer review model (for pharmacists and technicians) to review medication errors that occur in the pharmacy. The intent is to ensure that we maintain a just culture approach and avoid the perception of punitive response to slips/lapses and identify system-based issues that may lead to error. While maintaining accountability for unsafe workarounds, breaches of policy/safeguards, etc.

Is anyone using or had experience with a pharmacy peer review process?

If so, what decision making process was in place to guide review of errors to stratify slips/lapses from those requiring further review for coaching or disciplinary review?

Were managers included on the peer review team or only staff members?

Thanks for any input you can provide!

Don McKaig
Pharmacist Specialist, Medication Safety/Quality
Lifespan, Rhode Island Hosptial
dmckaig@lifespan.org