Pharmacy Errors: A Course in Quality-Related Events (Approved For Florida Board of Pharmacy “Misfill” Discipline)

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Intended Audience

ACPE Universal Activity Number

Kraig L. Schell, Ph.D.
Associate Professor of Psychology
Director, MS Program in Industrial-Organizational Psychology
Angelo State University
Member, Texas Tech University System

David B. Brushwood, R.Ph., J.D.
Associate Professor of Psychology
Professor of Pharmaceutical Outcomes & Policy
College of Pharmacy
The University of Florida

CE Hours


Dates Available
04/01/2015 to 04/01/2018

Activity Type



This program is designed to educate readers on the basic elements of human error and how they apply to the practice of pharmacy. Theories of human error are discussed, followed by a discussion of factors that can influence error capture, production and prevention and error analysis techniques like Root Cause Analysis (RCA). Finally, the course concludes with a summary of main ideas in order to become more “error-aware.”

All pharmacists will benefit from this course but it was developed for pharmacists who are required by the Florida Board of Pharmacy to take the Medication Errors (QRE) Course. Please note that this course does not fulfill the two (2) CE hours of Board-approved courses on medication errors required by many states for relicensure.


At the completion of this activity, the participant will be able to:

  • Outline what errors are, how they happen, and how we can study them
  • Characterize the essentials of attention and memory and how they affect pharmacy performance.
  • Describe the nature of expertise and how it plays into error capture and production
  • Define how an organization can facilitate or inhibit error capture and production
  • Analyze the immediate aftermath of an error and what the pharmacist can expect to experience.
  • Outline how to focus on patients first and how to address error issues with them
  • Describe tendencies to attribute blame for negative events and how those tendencies can inhibit learning from errors.
  • Explain how irrational thinking can cause a downward spiral of unrealistic expectations about errors.
  • Explain the history of how errors have been viewed in the health sciences and why that view is not conducive to performance improvement.
  • List three critical misconceptions about human error that can lead to inaccurate perceptions of why they occur.
  • Compare and contrast error management versus error prevention and define why both are necessary.
  • Outline possible ways to implement error management practices and training in the pharmacy.
  • Describe cases in which system failure has set up pharmacists to commit errors.
  • List the primary conclusions of the Institute of Medicine Report, To Err is Human.
  • Describe the steps necessary to establish a pharmacy CQI program in Florida.
  • Describe the best approach to conducting a pharmacy CQI meeting.


To receive credit for completing this course the participant must complete the readings, score a minimum score of 70% on the quiz, and submit a course evaluation. Credit will be posted to CPE Monitor and CE Broker where applicable.


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This course received no outside funding support.

ACPE LogoThe University of Florida College of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.