BOP Program Statement 6360.03 § 16

Reporting and evaluating medication errors and near misses are an essential function of a

successful healthcare system.

a. Definitions.

 Medication error is defined as “any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is the control of the

healthcare professional, patient, or consumer,” according to the National Coordinating

Council for Medication Error Reporting and Prevention.

 Except for errors of omission, the patient must receive the drug for the incident to be

classified as a medication error.

 Near miss is an error in prescribing, dispensing, or planned medication administration

that is detected and corrected through intervention, by another health care provider or the

patient, before actual medication administration.

 Documentation of instances in which an individual has prevented the occurrence of a

medication error will help identify system weaknesses and reinforce the importance

of multiple checks in the medication use system.

b. Applicability and Procedures. The monitoring and reporting of medication errors will be

conducted in a blame-free manner and focus primarily on systems and continuous quality

improvement activities rather than on individuals. The responsibility to detect and prevent

6360.03 5/7/2026 PROPERTY OF US GOVERNMENT 22

medication errors lies across the entirety of the health services operations and includes the

following:

 Sufficient personnel must be available to perform tasks adequately and a suitable work

environment must exist for preparing drug products.

 Lines of authority will be clearly defined for medication ordering, dispensing, and

administration.

 The institution supplement provides for efficient and safe distribution of all medications

and related supplies to inmates.

 Only abbreviations approved in the Program Statement Health Information

Management may be used.

 The telephone number of the local poison control center will be displayed prominently in

the pharmacy and readily available in areas where medications are

dispensed/administered.

 The pharmacy department, in conjunction with nursing, risk management, Quality

Improvement Program (QIP), and the medical staff, will conduct ongoing educational

programs to discuss medication errors, their causes, and methods to prevent their

occurrence.

c. Monitoring and Managing Medication Errors. The staff member identifying the error will

report near miss and actual medication errors using the system defined by Bureau Chief

Pharmacist. The Institution Chief Pharmacist or pharmacist designee will review the submitted

error and notify the physician when clinically indicated.

The Institution Chief Pharmacist will collaborate with the QIP coordinator and other stakeholders

to review, analyze, and classify the errors and near misses and develop process improvements.

This review will not identify those making the error by name. Reviews should focus on the

improvement of performance by recognizing errors and developing a plan to minimize future

errors.

Errors resulting in permanent harm or death (e.g., sentinel events) should be reported according to

the requirements in the Program Statement Health Services Quality Improvement.