Intended Audience/User Role: | Staff identifying and reporting events Staff responsible for Case Management and Continuous Quality Improvement |
Region: | All Regions |
Updated Date: | February 2026 |
After an event is submitted, it can be subsequently viewed and edited as new information may arise during the post event analysis. Users who have permission to edit events can do so by clicking on the Event ID, most commonly from the CM Queue open events.
Opening an event
Clicking on the Event ID will open the event Summary Page
Summary page
Managing the event from the summary page
A. Summary Page options
Learning points are lessons uncovered during the post event analysis which should be shared with the relevant stakeholders.
Adding an event to the watchlist notifies the Pharmapod system administrator, e.g., Designated Manager/Owner, and notifies them when the event is updated. They can also track the event from their dashboard (see “Dashboard: Tracking and Searching Events”). This is useful for flagging important events, such as those with a high risk level.
Event details from the original form can be edited by the original submitter or other staff working on the case as new information is uncovered.
Event drafts can be discarded, removing all traces of the event draft. Submitted events can be misrecorded, preserving a trace, but excluding the data from reporting and data analysis.
Users can close an event which triggers data from data sharing agreements to be sent to regional or national data bases.
Users can reopen closed cases using this button
Reviewing the event summary
B. Event Details. The left side of the page displays the factual details related to the event itself as submitted by the user.
Linked facilities are facilities that may be related to the event. E.g. central fill site, care home, hospital
Staff involved are any staff who are involved in the event, directly or indirectly (such as a witness). These users may not be responsible for the event workup but may have valuable information.
Informed/Notified is an area to note individuals who were notified of the event with details. E.g. dates and document notes from the conversations such as disclosure to a patient, physician, family, hospital, manager (regional regulations dictate who needs to be notified)
Audit trail displaying the different versions of the event. Once edited and resaved, different versions of the event can be accessed via the summary page.
A summary of all the information reported about the event.
Performing a post event analysis using Continuous Quality Improvement (CQI) tools. The right side of the page focuses on post event analysis using different CQI tools that may or may not be needed during the post event analysis.
C: Assigned staff are those that are responsible for the event CQI post event analysis.
D: Collaborators are individuals that can support the post event analysis. The event is shared with these users who may not be responsible for the event workup but may have valuable information.
E: The Risk matrix is a built in score that is calculated based on the risk of harm and the risk of likelihood of recurrence as documented in the event report. It's a mechanism to increase the visibility of risks and to assist management decision-making. During post event analysis, new information can come to light and changes to the matrix answers may be done using the edit function. Eg. The patient was hospitalized days after the event was reported.
Calculation: After answering the required questions in the original event form, a score from 1-25 is autocalculated and assigned to the event (1 being low risk to 25 being high risk)
F: Contributing Factors: Allows users to identify variables, conditions, or situations that play a role in causing or influencing an incident or good catch, making it more likely to happen or affecting its result, though not necessarily being the sole or primary cause.
Multiple factors can be selected. Multiple factor category and subcategory options that help specify the situation. Tip: factors that never would apply in your organization may be removed as options. Eg. eMAR factors. See “Form Settings (All Functionalities)”
The search function allows users to find their choices of factors using the search at the top of the page. Once completed, select Save (green button) at the bottom of the page.
G: Root Cause Analysis (RCA): A tool to improve system reliability and reduce risk by identifying why an event happened, not just what happened. The focus is to move beyond blaming individuals and identify flaws in systems, processes or procedures. It utilizes evidence-based, data driven approaches to trace issues back to their origin. Equally, it can be used to identify why a process went well and an error was caught resulting in a successful outcome. This positive approach is known as SCA or Success Cause Analysis. Success stories help to improve staff engagement and build "psychological safety" by focusing on positive reinforcement and learning from best practices.
Allows users to examine the core issue(s) that led to the event. Pharmapod uses the 5 Why's method to establish the cause and effect of events, often reaching the root cause in five or fewer steps.
WHEN and WHAT fields pull information from the completed event form, eliminating double documentation.
"What normally happens" and "What is supposed to happen" should also be included in the discussion of What actually happened so that gaps in process can be identified.
WHY field pulls information from the previously completed contributing factors tool. Users can also add them directly from this window.
The Root Cause Analysis 5 Why’s technique helps teams identify the original reason for a problem by repeatedly asking "Why?" (usually about five times) until they get past symptoms and identify the root cause. Root Causes are often a result of systems, policies or decisions. Note that this is a “dig deeper” exercise. Q1: Why did this happen?
A1: Because of X.
Q2: Why did X happen?
A2: Because of Y.
Q3: Why did Y happen?
And so on until you find the root issue. It should not be a blame exercise because if one person can make the error, multiple people can make the same error.Users can add multiple root causes if needed.
Interventions that need to be made to address the identified root cause(s) are documented.
ACTIONS (subsequent CQI tool) can be created based on the identified interventions. Direct access to the ACTIONS tool is available here by checking the box.
H: Learning Points: Allows users to document lessons learned from the event and identify key opportunities for improvement, which helps prevent similar events from reoccurring.
Dropdown with pre-defined learning points. Dropdown configuration is explained in “Form Settings (All Functionalities)”.
Free text field that populates with the chosen dropdown option that users can further add information specific to this event.
I: Actions: Allows users to document quality improvement plans or pre-defined organizational actions with the goal to properly resolve the event and prevent further events.
The action owner is the staff member responsible for the completion of the action. This field can be updated as needed.
Assigned users receive in-app notifications and emails to remind them of the outstanding item.
Actions can be tracked on the users dashboard
Due date can be set from a dropdown (e.g., a week from creation date) or manually set.
SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) action plans are intended to drive quality improvement and are more flexible, allowing users to define the action plan themselves. SMART action plans and desired outcomes are to be documented in the text box ensuring there are defined items to measure to show improvement. If the user is not familiar with creating a SMART action plan, the “i” tooltip explains the theory behind the acronym and a worked example.
Corrective (reactive) actions seek to fix existing, root-cause issues and address the event that occurred. When selected, users will see only one field for SMART Goal/Action.
Preventative (proactive) actions seek to eliminate potential causes to prevent events from occurring in the future.
Preventative Action sub-categories allow users to more precisely define the nature of the preventative action. They are ranked in descending order of the Hierarchy of Intervention Effectiveness (HIE) (a human factors framework). The HIE asserts that system-focused changes (e.g., forcing functions, automation and computerization, or simplification and standardization) are more effective at addressing contributory factors than people-focused changes (e.g., education and training, rules and policies, reminders, checklists, or double checks).
Artificial Intelligence (AI) SMART action plan suggestion generation and refinement (may not be available at your organization).
Required Action Toggle if toggled, requires the action to be marked as completed in order for the event to be closed. Tip: best to use toggle for people-focused action plans so events can be closed in a timely manner. Actions requiring system-focused changes, may take longer and can be tracked on the Dashboard.
Pre-defined Action/Goals allow users to select from a predefined list.
i. Dropdown list of available options in your organization.
ii. Notes field for additional information provided by the user.
J: Documents: Allows users to upload all documents relevant to the event into the Pharmapod platform. This reduces the need to pull documents from other sources when performing the post event analysis. Multiple file types and document types are supported. Caution should be taken with uploading personal health information and each organization’s guidelines should be observed.
File type dropdown.
File upload: drag/drop or click to select the desired file on your computer.
K: Recent Activities: Allows users to see all the automated notifications and edits made by individuals to an event in chronological order.
Activity description.
Activity time/date.
L: Comments: Allows users to add a comment (up to 255 characters) to an event e.g. planning to include this event in the next staff CQI meeting.
Comment field
Submission button
Comment history