When a pharmacist at your institution is involved in a medication error, what methods do you use in order to discuss the incident and close the communication loop on changes that were made? Are there any other actions taken?

For example, we send out a template letter to the pharmacist. The letter briefly describes the incident as we know it, then asks several questions regarding details recalled from the event, contributing factors leading to the event, and any suggestions for improvement (performance, system, or otherwise). Supervisors may also follow up with the employee.

Thank you,
Meghan Frear, PharmD
UC Davis Medical Center