Business and Professions Code (BPC) § 4113.1 established requirements for a community pharmacy to report medication errors to an entity approved by the California State Board of Pharmacy (“Board”) within 14 days of discovery. The Board approved Institute for Safe Medication Practices (“ISMP”) as the entity to receive and review medication error reports under BPC § 4113.1.
ISMP mailed registration cards at the end of April, 2025. If you haven’t received one, you can obtain it on the BOP’s website or register by going to the ISMP registration page.
According to ISMP, all community pharmacies must be registered by July 24, 2025 in order to be ready for reporting by the BOP’s required date of September 1, 2025.
The BOP’s guidance includes non-resident and outpatient hospital pharmacies within the definition of community pharmacy. However, pursuant to BPC § 4113.1(e), an outpatient hospital pharmacy shall not be required to report a medication error that meets the requirements of an adverse event that has been reported to the State Department of Public Health.
The term “medication error” includes any variation from a prescription drug order not authorized by the prescriber, including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong directions, the wrong preparation, or the wrong route of administration, but does not include any variation that is corrected prior to dispensing to the patient or patient’s agent or any variation allowed by law.
In addition to reporting any medication errors to ISMP, pharmacies are also required to continue documenting errors as part of their Quality Assurance.