Board releases first semiannual medication‑error summary and highlights joint forum on controlled‑substance access

The California State Board of Pharmacy’s executive officer presented the board’s first semiannual medication‑error report on Jan. 7, covering the initial months after mandatory outpatient medication error reporting began Sept. 1, 2025.

Staff said registration compliance was near 80% for entities required to report and emphasized that the dataset covers a short window (about six months) and will improve over time. Board staff noted the report shows room for increased compliance and for improved reporting completeness; they recommended continued education rather than immediate punitive action. ‘‘The mandatory reporting did not begin until September, so we don't have a full six months worth of data for this first report,’’ the executive officer said.

Members asked whether a dashboard and trend reporting would be available; staff replied the current contract provides reporting metrics and that both registrants and the board will eventually gain dashboard access, but the system is still in early development. The board discussed the statutory definition of medication error (BPC §4113.1) and clarified that reportable errors are those delivered to a patient and not corrected prior to dispensing.

Public commenters, including Monte Goddard and Kathy Gomeshi, praised the board’s effort and urged further synthesis and guidance for health system pharmacies and unregistered entities. Sean Kim of the California Pharmacists Association asked for transparency about the categories of errors being collected to aid understanding.

Separately, the executive officer updated members on a December joint forum on controlled substances and medications for opioid use disorder (MOUD) convened with five other healing‑arts boards. The forum combined presentations and breakout sessions to identify barriers to patient access; staff are synthesizing notes and will pursue follow‑up actions with partner boards.

What happens next: Staff plan continued education and targeted outreach to improve registration and reporting, development of reporting dashboards, and committee‑level review of trends to inform potential best practices or regulatory changes.