Text

Background: CIRS-NRW is a regional and interprofessional implementation of a Critical Incident Reporting System used in healthcare settings across North Rhine-Westphalia, Germany. Its primary goal is to enhance patient safety by systematically collecting, analyzing, and learning from critical incidents, near misses, and errors in clinical practice. Since 2019, the Chambers of Pharmacists of North Rhine and Westphalia-Lippe have been official partners in CIRS-NRW. Medication errors represent one of the most critical areas in the field of patient safety. Critical Incident Reporting Systems have been transformative in high-risk industries, especially in civil aviation.

Materials and Methods: In CIRS-NRW, the process begins when healthcare professionals access and fill out electronic incident report forms. These forms are submitted to a central office, where they are reviewed and anonymized to protect the identity of the individuals and institutions involved. Reports submitted by pharmacists or concerning incidents in pharmacies — such as medication errors — are specifically handled by staff members of the Pharmacists Chambers of North Rhine and Westphalia-Lippe. These experts review and publish the reports.

Results: CIRS-NRW has led to a range of impactful initiatives aimed at improving patient safety and reducing medication errors, particularly in pharmacy practice: Regular seminars are held on medication safety, helping healthcare professionals enhance their situational awareness and discuss measures for safer practices. Both Pharmacists' Chambers of North Rhine and Westphalia-Lippe have integrated a Room of Horrors pharmacy simulation into their preregistration training courses. In collaboration with Federal Association of Health IT (bvitg), CIRS-NRW published a position paper addressing risks in Methotrexate dosing, recommending improvements to electronic medication plans and alert systems. Medication errors reported through CIRS-NRW not only contribute to a recurring article series in the Deutsche Apotheker Zeitung, where real-world cases and practical insights are shared, but also serve as a valuable foundation for health services research. One first project focused on the imprinting of tablets and capsules and its potential to cause dosing errors.

Conclusion: CIRS-NRW represents a promising approach to strengthening patient safety through collaboration among various self-administration organizations. Its structured reporting and analysis of medication errors not only support professional education and healthcare research but also foster a culture of transparency and continuous improvement. Looking ahead, stronger cooperation with other organizations that collect medication error data — such as the Drug Commission of German Pharmacists could further enhance the system’s impact and contribute to a more comprehensive understanding of medication safety.