In every community pharmacy, close calls happen. These are the moments when an error is caught just in time—before it reaches the patient. A technician notices a wrong strength. A pharmacist spots a look-alike/sound-alike mix-up. A patient questions a label that seems “off.”
A single close call can be a warning.
But recurrent close calls?
That’s a signal—one that no pharmacy can afford to ignore.
Close calls are not harmless coincidences. They are early alerts that reveal vulnerabilities within workflow systems, communication processes, storage setups, staffing patterns, or technology use. Under Alberta’s CQI+ model, pharmacies are expected to treat close calls seriously, study them thoughtfully, and use them to strengthen safety culture.
This article explores why recurrent close calls occur, what they indicate about pharmacy systems, and how PhIX, PharmaSafe’s CQI+ platform, helps pharmacies prevent these near-misses from becoming actual practice incidents.
Understanding Close Calls in Pharmacy Practice
A close call (also called a near-miss) is an event that could have caused inappropriate drug use or patient harm, but was caught before the medication reached the patient.
Examples include:
- Selecting the wrong drug or strength but catching it at verification
- Misinterpreting a poorly written prescription and correcting it before dispensing
- Discovering duplicate therapy during counseling
- A wrong patient label attached and noticed before handout
- A stock bottle placed on the wrong shelf, almost leading to an error
Although no harm reached the patient, a close call reveals that the system allowed risk to progress.
When close calls repeat, the pharmacy must assume:
“If it almost happened again, it can eventually happen for real.”
Why Recurrent Close Calls Are a Red Flag
Close calls often share patterns:
- Always during peak busy times
- Always involving certain medications
- Always in specific workflows (e.g., order entry, filling, checking, pick-up)
- Always involving certain team communication gaps
Recurrent close calls indicate deeper issues such as:
1. Workflow Bottlenecks
Rushed processes lead to shortcuts—and shortcuts create risk.
2. Storage or Layout Problems
Look-alike/sound-alike drugs, similar packaging, or cluttered shelving can cause repeated selection errors.
3. Communication Breakdowns
Incomplete handoffs, unclear verbal orders, or assumptions between team members can make errors more likely.
4. Training Gaps
New staff or inconsistent processes can cause the same type of close calls across multiple shifts.
5. Technology Misuse or Underuse
Missing alerts, poor system routing, or improper documentation may allow the same mistake to surface repeatedly.
6. Cognitive Overload
High workload, fatigue, and multitasking increase the likelihood of repeated near-misses.
The danger is not the close call itself—it’s what it reveals.
From Close Call to Practice Incident: The Risk
Research and safety literature confirm that close calls are often the first stage in a chain of events that leads to a serious incident. The Canadian Patient Safety Institute (CPSI) and ISMP Canada emphasize that recurrent close calls require structured analysis and follow-up.
Without intervention, a close call can eventually become:
- A dispensing error
- A mislabeled medication
- An administration mistake
- A dangerous drug interaction missed
- A case of duplicate therapy
- A high-risk medication error
Preventing close calls is one of the most effective strategies for preventing patient harm.
Turning Recurrent Close Calls Into Pharmacy Improvements
Instead of viewing close calls as “lucky saves,” pharmacies should see them as data—data that can guide improvement.
1. Track and Categorize Every Close Call
Consistent documentation reveals frequency and patterns.
2. Identify Root Causes
Use structured questioning:
- What was happening at the time?
- What step allowed the close call to occur?
- What system contributed to the risk?
3. Develop Targeted Action Plans
Action plans may involve:
- Reorganizing shelves
- Adding double-check steps
- Improving lighting or signage
- Standardizing workflows
- Enhancing training
- Using alerts or flags more effectively
4. Communicate Findings to the Whole Team
Everyone must understand:
- What happened
- Why it happened
- How to prevent recurrence
5. Reassess and Monitor
After implementing changes, confirm whether the close calls have decreased—or if new patterns emerge.
6. Celebrate Close Call Reporting
Team members who report close calls are helping protect patients. Recognizing this builds a strong safety culture.
How PhIX Helps Pharmacies Manage and Prevent Recurrent Close Calls
PhIX is designed specifically to help Alberta pharmacies meet CQI+ expectations and convert close calls into meaningful improvements. Instead of letting near-misses go untracked, PhIX provides a structured, streamlined, and efficient approach.
PhIX Services and Capabilities
1. CQI+ Compliant Close Call Reporting
Capture near-misses quickly on any device.
Smart categorization ensures proper labeling of close calls vs. practice incidents.
2. Trend and Pattern Recognition
Dashboards highlight recurring close calls, helping teams quickly identify system vulnerabilities.
3. Contributing Factor Analysis
Built-in tools guide teams through ISMP- and ACP-aligned contributing factor categories.
4. Improvement Initiative Tracker
Assign owners, timelines, and follow-up tasks.
Track the progress of action plans in real time.
6. CQI Meeting & Safety Huddle Tools
Attach close calls to meeting agendas and document team discussions seamlessly.
7. SPPSA included
Connect self-assessment findings with recurrent close call patterns.
8. Analytics and Risk Heatmaps
Visual tools help identify high-risk workflows and repeated system failures.
9. Role-Based Access Control
Ensures privacy and compliance while supporting team accountability.
10. PIA & IMA Included
Pharmacies onboard quickly with all regulatory documentation ready.
PhIX transforms “we almost made a mistake” into “we solved a system problem.”
Building a Culture Where Close Calls Are Valued
Recurrent close calls are not evidence of failure—they are evidence of a pharmacy’s ability to catch and learn from risks. A strong safety culture views close calls as:
- Early warnings
- Learning opportunities
- Indicators of system gaps
- Essential components of prevention
Encouraging reporting, removing blame, and acting on close call data leads to fewer incidents and safer patient care.
Final Thoughts
Close calls happen in every pharmacy—but when they happen repeatedly, they signal system vulnerabilities that must be addressed. By documenting, analyzing, and responding to near-misses, pharmacies prevent harm long before a practice incident occurs.
PhIX gives Alberta pharmacies the tools they need to capture close calls easily, identify patterns quickly, and implement effective improvements confidently.
Recurrent close calls aren’t just near-misses—they’re near-messages.
Pharmacies that listen and act build safer teams, stronger workflows, and better patient outcomes.
