ICHP Position Statement - Medication Error Reporting and Support for a Just Culture

The Illinois Council of Health-System Pharmacists (ICHP) supports the role of pharmacists and pharmacy technicians (hereafter referred to as "pharmacy staff")  as key participants in the identification, reporting, prevention, and management of medication errors and near misses. Pharmacy staff, in conjunction with other health care professionals, must continually collect data on and evaluate the medication use process as part of an ongoing quality improvement program  to minimize the risk of medication errors.

Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.  Such events may be related to professional practice, health care product, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.1

ICHP is committed to improving the quality of patient care and recognizes the identification of medication errors and near misses as an opportunity for improvement. ICHP supports the concept that errors occur due to a breakdown in systems and processes. ICHP encourages pharmacy staff to exert leadership in establishing a non-punitive reporting environment to encourage pharmacy staff and others to report actual and potential medication errors in a timely manner. In addition, ICHP encourages pharmacy staff to exert leadership in establishing a just culture in their workplace that supports staff involved with an adverse outcome by recognizing that:

  • Human error is not 100% avoidable
  • Transparent culture is essential for improvement
  • An emphasis on system opportunities rather than individual fault fosters voluntary reporting

A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control, and that many of these represent predictable interactions between human operators and the systems in which they work. However, a just culture does not tolerate conscious disregard of clear risks to patients or gross misconduct.2

The evaluation of medication use systems must employ continuous quality improvement techniques in conjunction with a fully utilized, non-punitive reporting mechanism and concurrent pharmacist intervention in the prescribing, dispensing, administering, and monitoring of medications. At a minimum, this includes appropriate review of medication orders by a pharmacist, ensuring that pharmacists are fully involved in drug treatment plans and pharmacist participation in nationally established medication error reporting programs. Further, ICHP encourages the use of automation such as robotics, other automated dispensing technology, bar coding, and computer technology for the purpose of alerting the pharmacy staff and other health care practitioners to prevent and/or minimize patient harm.


1. American Society of Health-System Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Heath-Syst Pharm. 2018; 1493-1517.

2. American Society of Health-System Pharmacists. ASHP Policy Positions 2009-2018 (with rationales): Medication Misadventures. Number 1115 Just Culture. Medication Safety Policy Positions (ashp.org

3. American Society of Health-System Pharmacists.  ASHP Statement on Reporting Medical Errors. 2000.  https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/reporting-medical-errors.ashx


Revised 9/2021