In community pharmacy, every decision and workflow step has the potential to influence patient safety. Alberta’s new CQI+ (Continuous Quality Improvement) program emphasizes the importance of recognizing, documenting, and understanding incidents so that pharmacies can prevent them from happening again.
At the centre of CQI+ is the term “practice incident.” But what exactly does this mean, and how can pharmacy teams confidently identify what must be reported and reviewed?
This article explains the ACP definition in clear terms and provides practical examples to help pharmacies meet expectations, strengthen safety culture, and comply with CQI+ requirements.
What Is a “Practice Incident”? (ACP Definition)
The Alberta College of Pharmacy defines a “practice incident” as:
An event that may lead to inappropriate drug use or patient harm that has reached a patient. Practice incidents may be related to professional practice, drugs, procedures, and systems, and include assessment, prescribing, order communication, product labelling/packaging/nomenclature, compounding, repackaging, dispensing, distribution, administration, education, monitoring, and use.
In other words, a practice incident is any event that reaches the patient and has the potential to cause harm or result in inappropriate therapy. This broad definition reflects the complexity of pharmacy practice—risks can occur at any stage of the medication-use process.
Why Understanding Practice Incidents Matters
Identifying practice incidents early helps pharmacies prevent similar events from happening again. Recognizing these incidents supports the purpose of CQI+: to strengthen systems, reduce risk, and protect patients.
A clear understanding of practice incidents also helps pharmacies prepare for ACP inspections, communicate effectively during CQI meetings, and build a positive safety culture where staff feel supported and empowered to report issues.
Examples of Practice Incidents in Everyday Pharmacy Work
Below are examples mapped to ACP’s definition to provide clarity on what counts as a practice incident.
Assessment
Errors in reviewing allergies, missing contraindications, or failing to collect a complete medication history.
Prescribing
Incorrect doses prescribed by a pharmacist, inappropriate therapeutic substitutions, or prescribing outside clinical guidelines.
Order Communication
Misinterpreting verbal orders, misreading faxes, or selecting the wrong medication due to look-alike/sound-alike names.
Product Labelling, Packaging, and Nomenclature
Incorrect labels, confusing auxiliary labels, or choosing the wrong product because of similar packaging.
Compounding and Repackaging
The wrong ingredients, incorrect concentrations, or mislabelled compounded products.
Dispensing
Dispensing the wrong medication, strength, or dosage form; incorrect quantities; or inaccurate directions on the label.
Distribution
Giving a bag to the wrong patient, delivering to the wrong address, or misplacing items in patient bins.
Administration
Errors in administering vaccines or injectables, or incorrect administration instructions provided to a patient.
Education
Incorrect counselling, missing interaction warnings, or incomplete instructions for high-risk medications.
Monitoring
Not following up on high-risk medications, missing required lab values, or failing to adjust therapy when needed.
Use
Confusing directions, unclear labels, and packaging issues that cause a patient to use a medication incorrectly.
Any event that reaches a patient and may cause harm or inappropriate drug use is considered a practice incident.
Practice Incidents vs. Close Calls
A “practice incident” is an event that reaches the patient.
A “close call” is intercepted before the patient receives the medication.
Both must be recorded under CQI+, but practice incidents require deeper review, discussion, and follow-up during CQI meetings.
How PhIX Helps Pharmacies Identify and Manage Practice Incidents
PharmaSafe’s PhIX platform is designed specifically to align with Alberta’s CQI+ expectations. It removes guesswork, simplifies reporting, and strengthens system-based improvement.
Key PhIX Services
CQI+ Compliant Incident Reporting
Fast, intuitive digital forms with role-based access and automatic classification of practice incidents and close calls.
Integrated SPPSA (Self-Assessment)
Complete the Pharmacy Safety Self-Assessment directly in PhIX and link findings to improvement initiatives.
CQI Meetings and Safety Huddles
Create agendas, attach incidents, document discussions, and assign follow-up actions.
Improvement Initiative Tracker
Assign responsibilities, set timelines, and track progress until completion.
Analytics and Dashboards
Trend analysis, system-level insights, and exportable reports for ACP inspections.
Privacy and Compliance
Full alignment with Alberta’s Health Information Act (HIA). PIA and IMA included.
How PhIX Simplifies Identifying Practice Incidents
PhIX guides pharmacy teams through structured event classification to determine whether an event is a “practice incident,” a “close call,” or a “hazardous condition.”
The platform highlights contributing factors, groups similar events, and supports pharmacy teams in analysing root causes during CQI meetings. This shifts the approach from reactive to proactive and helps prevent recurrence.
Final Thoughts
Practice incidents are not simply errors—they are opportunities to strengthen systems, improve workflows, and protect patients. By understanding what constitutes a “practice incident” and using the right tools to track, analyse, and address them, pharmacies build a safer environment for patients and a stronger team culture.
PhIX equips Alberta pharmacies with everything they need to meet CQI+ expectations confidently and efficiently.
