Incidents, near misses and complaints
What to do when something goes wrong or nearly does, how it's recorded and investigated, and how concerns are raised.
Version 1 · approved 23 Sept 2026 by Sam Nguyen
What to report
Plain-English meanings (the VPA does not define these terms): - **Incident**: something went wrong — for example, the wrong medicine or strength was supplied. - **Adverse event**: a patient was harmed while receiving a pharmacy service. - **Near miss**: something would have gone wrong but was caught in time — for example, a wrong medicine picked but noticed before it reached the patient. Every incident, adverse event and near miss should be recorded. Near misses are how problems get found before they cause harm.
Regulator guidance VPA Standard 1.5.2 · VPA Guidelines G1.5.2
When something goes wrong
1. Work out how serious it is. Can it be resolved here, or does the patient need medical attention? 2. Act straight away to prevent further harm — for example, get the correct medicine to the patient. 3. Record it as soon as possible, preferably by the pharmacist involved: what happened, who was affected, where and how. 4. Be open with the patient, or their family or carer, about what happened. 5. Tell the pharmacist in charge and the licensee (0413 662 907). 6. Investigate: what happened, how, why, and what will stop it happening again.
Regulator guidance VPA Guidelines G1.5.2
How deep the investigation goes
- Minor incidents and near misses: recorded and looked into locally. - Moderate incidents where a patient was harmed: usually an in-depth case review, led by a senior person such as the licensee or pharmacist in charge. - Serious incidents with significant harm: a root cause analysis, started as soon as possible.
Regulator guidance VPA Guidelines G1.5.2
The incident register
Every incident, adverse event and near miss should go into one dedicated incident register. We record complaints there too. Where it's kept: not yet recorded. Each record should show when it happened, who was involved, what happened, contributing factors, what the investigation found, the actions taken and follow-up, and who recorded it.
Regulator guidance VPA Guidelines G1.5.2 and Appendix 5 · VPA self-audit 1.5.2
Looking for patterns
Incidents should be reviewed regularly for trends and shared causes. Anything found should become an improvement action, recorded with who will do it and by when, and followed up.
Regulator guidance VPA Guidelines G1.5.1 and G1.5.2
Complaints
Listen, apologise where appropriate, and try to resolve it on the spot. Record every complaint in the incident register with what was done. The pharmacist in charge follows up any that aren't resolved.
Pharmacy's own choice VPA Guidelines G1.5.1
Raising a concern
Anyone can raise a concern about safety, practice or how the pharmacy is run — with the pharmacist in charge or directly with the licensee. We want people to speak up. Raising a concern in good faith is welcomed, not punished.
Regulator guidance VPA self-audit 1.2.3 and 1.5.1
Passing information between shifts
Anything the next pharmacist needs to know — owings, follow-ups, a patient to call back, a fault — is written in the handover log before the end of the shift, and read at the start of the next.
Pharmacy's own choice VPA self-audit 1.5.2
Checks that go with this policy
- Incident and complaint review — Monthly
PharmPolicy supports compliance. It is not legal advice, and it does not replace the licensee's own judgement or obligations under the Pharmacy Regulation Act 2010 and other laws.