Okotoks Pharmacy Replaces Blame With Learning to Strengthen Patient Safety

An Okotoks pharmacy is showing how patient safety can improve when practice incidents are treated as opportunities to learn rather than occasions to assign blame. In a September 22 profile, the Alberta College of Pharmacy (ACP) describes how licensee Yasmin Mohamed Essa led her team toward a just culture built on trust, fair treatment and professional accountability.

Patient safety comes first

Essa became the pharmacy’s licensee in February 2024 and identified a blame-and-shame culture as an early challenge. Her replacement process begins with checking on the affected patient and addressing immediate safety needs. The team then investigates what happened, discusses contributing factors, and documents and reports the incident or close call.

The emphasis is on understanding the system rather than naming an individual. Staffing, interruptions, workflow design, data entry and other conditions are considered alongside individual actions so the response can prevent recurrence.

Turning reports into workflow improvements

As part of Alberta’s CQI+ requirements, the pharmacy holds quarterly continuous quality improvement meetings to review incident and close-call trends. Weekly huddles give the team a more frequent place to discuss new requirements and safer ways of working.

One recurring problem involved immediate-release and extended-release versions of the same medication. After a pharmacy intern identified that a patient had received the wrong formulation, the team introduced tall-man lettering to make IR and XR distinctions more visible during data entry and verification.

The example illustrates what a just culture is—and what it is not. Open reporting does not remove accountability; it makes it easier to distinguish human error, risky processes and conduct that requires a different response.

Practice guidance for pharmacists

• Use a written incident-response sequence that starts with the patient’s immediate safety, communication and continuity of care.
• Encourage prompt reporting of both incidents and close calls, and separate initial fact-finding from blame or disciplinary assumptions.
• Examine system contributors such as staffing, interruptions, workload, software design, storage and data-entry conventions.
• Review patterns at scheduled CQI meetings and use brief team huddles to keep corrective actions visible between formal reviews.
• Assign an owner and follow-up date to each improvement, then confirm whether the change reduced recurrence while preserving appropriate accountability.