BACKGROUND: To increase disclosure of errors and lead to system improvements, publications recommend a nonpunitive approach to medication errors. To our knowledge there is no published information regarding the extent or bases on which boards of pharmacy invoke punitive action against pharmacists involved in medication errors. OBJECTIVE: To determine how often and on what bases boards of pharmacy determine punitive action to be taken against pharmacists involved in medication error events. METHODS: The policies, procedures, and practices regarding medication errors by pharmacists for 49 of the 50 US boards of pharmacy were reviewed by pharmacy students at the University of New Mexico as a Safe Medication Practices class assignment. RESULTS: Most boards of pharmacy invoke punitive action against pharmacists involved in medication errors. Most states do not have specific rules or regulations that stipulate errors as actual violations and most determinations are made on a case-by-case basis. The major determinants of punitive action were error severity, actual patient injury, patient complaints, and factors related to the pharmacist. The most common types of punitive action include license suspension, probation, or revocation, and fines. In at least 17 states, incarceration was also a possible punitive action. The most common bases for punitive action were to address public safety/health and public complaints. CONCLUSIONS: Despite the fact that punitive action is not recommended as best practice for addressing medication errors made by health care practitioners, most state boards of pharmacy use punitive measures against pharmacists involved in medication errors. Based on current recommendations, such actions would not be expected to lead to improvements in the health care system.
BACKGROUND: To increase disclosure of errors and lead to system improvements, publications recommend a nonpunitive approach to medication errors. To our knowledge there is no published information regarding the extent or bases on which boards of pharmacy invoke punitive action against pharmacists involved in medication errors. OBJECTIVE: To determine how often and on what bases boards of pharmacy determine punitive action to be taken against pharmacists involved in medication error events. METHODS: The policies, procedures, and practices regarding medication errors by pharmacists for 49 of the 50 US boards of pharmacy were reviewed by pharmacy students at the University of New Mexico as a Safe Medication Practices class assignment. RESULTS: Most boards of pharmacy invoke punitive action against pharmacists involved in medication errors. Most states do not have specific rules or regulations that stipulate errors as actual violations and most determinations are made on a case-by-case basis. The major determinants of punitive action were error severity, actual patient injury, patient complaints, and factors related to the pharmacist. The most common types of punitive action include license suspension, probation, or revocation, and fines. In at least 17 states, incarceration was also a possible punitive action. The most common bases for punitive action were to address public safety/health and public complaints. CONCLUSIONS: Despite the fact that punitive action is not recommended as best practice for addressing medication errors made by health care practitioners, most state boards of pharmacy use punitive measures against pharmacists involved in medication errors. Based on current recommendations, such actions would not be expected to lead to improvements in the health care system.