In community pharmacy, close calls often appear small, routine, or harmless—yet they reveal system vulnerabilities that can lead to significant patient harm if left unaddressed. One of the most commonly overlooked examples is missing a refill that a patient is due for.
At first glance, it may seem like a minor oversight. But under Alberta’s CQI+ expectations, missing a clinically important refill can absolutely be considered a close call because it indicates that an error almost affected patient therapy but was caught before harm occurred.
Close calls are not limited to selection or labeling errors. They also include communication failures, omissions, workflow oversights, and administrative lapses—especially when they have the potential to result in inappropriate drug therapy or patient harm.
This article explains why missing a refill counts as a close call, how similar situations should be captured, and how PhIX, PharmaSafe’s CQI+ platform, helps pharmacies identify, document, and learn from these events.
Why Missing a Refill Is Considered a Close Call
A close call (near miss) is any event that could have reached the patient and caused harm or inappropriate medication use—but did not, because someone or something caught the issue in time.
Missing a refill meets this definition because:
- It can cause interruption of therapy, especially for chronic or high-risk medications
- It often indicates a system or workflow issue
- It reveals gaps in prescription assessment or communication
- It requires pharmacist intervention before a lapse in therapy occurs
When a patient comes in expecting their refill, and the team discovers the medication was not processed, not noticed, or not proactively monitored, this becomes an opportunity to understand why the oversight occurred.
For example:
- A refill was due for metoprolol, but no one noticed the refill request in the queue
- A prescriber sent an electronic refill, but it was missed in the system
- A refill autorenewal failed because of expired benefits and no one followed up
- A pharmacist caught the issue during counseling and prevented a delay in therapy
In all of these cases, the patient was at risk, and the issue was intercepted before harm occurred—making it a close call.
Common Examples of Close Calls in Pharmacy Practice
To strengthen CQI culture, pharmacies must recognize the wide range of events that qualify as close calls. Here are categories and examples relevant to Alberta’s medication-use process.
1. Assessment & Clinical Review Close Calls
- Missing a required refill for a chronic medication (hypertension, diabetes, asthma)
- Overlooking a drug–drug interaction but catching it during the final check
- Missing a duplicative therapy until the pharmacist notices
- Overlooking an important lab result until last-minute review
- Patient reveals an allergy that was not documented
2. Prescribing & Order-Entry Close Calls
- Incorrect prescriber selected (but caught before dispensing)
- Wrong patient profile accidentally opened but caught early
- Incorrect SIG entered but corrected before labeling
- Entering wrong medication due to look-alike/sound-alike names
- Typo in quantity or directions caught before handout
3. Product Selection Close Calls
- Pulling the wrong strength from the shelf
- Selecting the wrong formulation (e.g., XR vs. IR)
- Grabbing the wrong brand due to similar packaging
- Picking the wrong medication placed in the wrong bin
- Filling from the wrong stock bottle but catching it at verification
4. Labeling & Packaging Close Calls
- Attaching the wrong label to a vial but catching it before handout
- Printing instructions incorrectly but correcting before counseling
- Almost handing out a medication missing auxiliary warnings
- Barcode mis-scan that was corrected before sealing the bag
5. Distribution & Pick-Up Close Calls
- Wrong patient receives a bag—but the error is caught at checkout
- Delivering to the wrong address but intercepted before dispatch
- Providing the wrong blister pack week but caught during final check
- A medication almost given to the wrong caregiver
6. Administration & Education Close Calls
- Patient misinterprets dose instructions until corrected during counseling
- Patient attempts to inject insulin using outdated technique but is corrected
- Patient brings OTC supplements that reveal a hidden interaction
- Confusion between daily vs. weekly doses discovered during discussion
7. Documentation Close Calls
- Missing refill authorization not noticed until last minute
- Faxed prescriber note misfiled but found before release
- A DUR alert initially ignored but flagged on final check
- A pharmacist signs off on an unclear verbal order but immediately verifies details
Why Identifying Close Calls Matters
Close calls are the “early warning signs” of the pharmacy system. They help teams uncover:
- Workflow inefficiencies
- Knowledge or training gaps
- Environmental distractors
- Poor storage or layout design
- Inadequate documentation practices
- Staff communication breakdowns
- Technology configuration problems
Pharmacies that analyze close calls are far safer than those that only track actual incidents.
By addressing risks early, pharmacies prevent:
- Dispensing errors
- Duplications
- Missed therapies
- Adverse drug events
- Patient harm
Alberta’s CQI+ model relies on this proactive, learning-focused approach.
How PhIX Helps Pharmacies Capture and Learn from Close Calls
PhIX is designed specifically to support ACP-required CQI+ workflows. It simplifies identifying, documenting, analyzing, and acting upon close calls—including those involving missed refills.
PhIX Services & Capabilities
1. Streamlined Close Call Reporting
Staff can record close calls—including missed refills, wrong prescriber selections, wrong strengths—within seconds on any device.
2. Automatic Categorization
PhIX separates close calls from practice incidents, ensuring correct documentation for compliance.
3. Contributing Factor Analysis
Guided selection of contributing factors helps uncover root causes, including workflow gaps, communication issues, and process failures.
4. Analytics & Trend Dashboards
Identify patterns such as repeated missed refills, recurring prescriber selection errors, or frequent look-alike/sound-alike issues.
5. CQI Meeting & Safety Huddle Tools
Add close calls directly to meeting agendas and maintain a traceable record of discussions and follow-ups.
6. Improvement Initiative Tracker
Create, assign, and monitor action plans to address systemic issues.
8. SPPSA Integration
Link close call patterns to broader system vulnerabilities and improvement opportunities.
9. Role-Based Access Controls
Ensure confidentiality while maintaining team-wide learning.
10. PIA & IMA Documentation Included
Pharmacies onboard quickly with all privacy and regulatory requirements completed.
PhIX helps pharmacies transform scattered close calls into actionable quality improvements.
Final Thoughts
Missing a refill is more than a minor oversight—it is a close call that signals system vulnerabilities. When analyzed properly, it becomes an opportunity to strengthen processes, enhance communication, and protect patients.
Close calls are not accidents avoided—they are accidents predicted.
Pharmacies that take them seriously create safer systems, stronger teams, and better patient outcomes.
PhIX gives Alberta pharmacies the tools they need to capture, analyze, and respond to close calls with confidence—and to make improvements that last.
