Background It has been found that around 70% of medication errors (MEs) have been corrected by pharmacists; however, the pharmacists did not report the MEs to the safety reporting system. When we analyzed the existing data, we noticed that the current reporting of MEs by pharmacists was zero, even though the benchmark for the 8-hour shift is estimated to report at least five MEs per day. Thus, we decided to develop an improvement project aiming to increase the number of MEs reported to 64 by November 2018 in Al-Wazarat Primary Healthcare Pharmacy of Prince Sultan Military Medical City (PSMMC).

Methods This quality improvement project was done at Al-Wazarat (Primary Healthcare Pharmacy) at PSMMC. The Quality Team (QT) has been formulated and started analyzing the reporting data available in the pharmacy department. Data showed there is a huge gap between the number of MEs corrected by pharmacists and their reporting behavior. Then the QT conducted several sessions using quality tools, such as process mapping, brainstorming, and cause-effect techniques, to explore the possible factors causing pharmacists to not report MEs. Several PDSA (plan-do-study-act) cycles were used to test ideas for change, including redesigning the ME form to simplify and standardize the reporting process of MEs. The impact of such an intervention had been assessed using the process and outcomes measures. The final results have been analyzed and presented using a run chart.

Results The implementation led to remarkable improvement. In November, 130 MEs had been reported by pharmacists, which exceeded our goal for ME reporting in the Al-Wazarat Primary Healthcare Pharmacy. The number of MEs reported increased from zero in October (before the intervention) to between five and ten MEs reported per day during the month of November after the intervention. Also, the percentage of pharmacists who became active in reporting MEs improved after several PDSA cycles had taken place.

Conclusion Simplification and standardization of the ME form has led to an increase in the reporting of MEs among primary healthcare pharmacists. However, such an intervention might not be sufficient to sustain the pharmacists’ new reporting behavior without making such change a part of the pharmacy management safety system. Thus, before spreading these initiatives to another primary healthcare pharmacy, further testing among other pharmacies in a different setting is highly recommended.