ISMP to develop first community pharmacy medication error reporting programme for the State of California

The Institute for Safe Medication Practices (ISMP), a world leader in improving medication safety, is building a medication error reporting program and portal for community pharmacies licensed by the California Board of Pharmacy. This will be the first state-mandated medication error reporting program in the nation focused specifically on community pharmacy.

The creation of the California Medication Errors Reporting Program is a result of the enaction of Assembly Bill 1286 (Haney, Chapter 470, Statutes of 2023) in 2023 to improve patient safety and address staffing and workplace conditions in community pharmacies.

ISMP has decades of experience collecting and analysing medication error reports to identify risks and guide safety improvements across care settings. ISMP runs the only national voluntary, practitioner-based reporting system, the ISMP National Medication Errors Reporting Program, as well as the ISMP National Vaccine Errors Reporting Program and ISMP Consumer Medication Errors Reporting Program. 

Building upon the experience with existing ISMP reporting programmes, analysis, and error prevention efforts, ISMP will use submitted medication error reports to identify key trends, patterns and safety issues. ISMP will also provide the California Board of Pharmacy with an annual report based on aggregate data that includes reduction strategies and other actionable recommendations for safety improvements.

“The California Medication Errors Reporting Program will produce data-driven insights about preventable adverse events that can drive broad systemic change,” says Rita K. Jew, president of ISMP. “Reporting errors and near misses is essential to ensure the success of efforts to reduce risk in the community pharmacy setting. We applaud California for being a national leader in taking this forward-thinking step to safeguard patients and hope other states will implement similar programs.”

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Source: ECRI, 8 May 2025