(1) Continuous Quality Improvement Program Requirements. Each pharmacy shall establish a Continuous Quality Improvement (CQI) Program for the purpose of detecting, documenting, assessing and preventing Quality Related Events (QREs). At a minimum, a CQI program shall include provisions to:

1. (a) designate an individual or individuals responsible for monitoring CQI Program compliance with the requirements of 247 CMR 15.00;
2. (b) identify and document QREs;
3. (c) minimize impact of QREs on patients;
4. (d) analyze data collected in response to QREs to assess causes and any contributing factors;
5. (e) use the findings of the analysis to formulate an appropriate response and develop pharmacy systems and workflow processes designed to prevent QREs; and
6. (f) provide ongoing education at least annually in the area of CQI to pharmacy personnel.