Patient and Medication Safety in the Pharmacy

Edited by Mirabella Chan

How can we analyze our mistakes and prevent them from happening again?

Have you ever made typos during order entry that weren’t caught? How about selecting the wrong drug off the shelf when compounding or filling? What about giving the wrong pick-up bag to a patient? These are just some of the incidents that can happen in community pharmacy, and they are vital to patient safety.

Thinking back to any incidents you’ve had in the past, I’d like you to ask yourself if you did anything about these mistakes to make sure they don’t happen again in the future. If you have, you might have unknowingly started a process called “Root Cause Analysis” (RCA).

RCA is an analytical process used to conduct a comprehensive, system-based review of critical incidents. RCA helps people gain an understanding of the factors that may have contributed to an incident, which is important to identify in order to develop solutions. RCA can be quite costly and time-consuming, so it is reserved for complicated and critical incidents that have the potential for or have caused major harm. There are 5 steps in this process that must be followed in a specific order to prevent jumping to conclusions.

Step 1: Determine if an RCA should be conducted.

Again, since RCAs can be resource-intensive and time-consuming, it’s important to reserve it for critical incidents. We can analyze if a particular incident requires an RCA by using a Safety Assessment Score that ranks incidents based on the probability of recurrence and severity (catastrophic > major > moderate > minor). Based on this assessment score, we can decide whether we need to conduct an RCA or not.

Step 2: Define your goals of analysis

It’s important to review the information, staff interviews, and timeline of events that lead up to the incident so that you can find factors that could potentially be contributing to the error. Some important questions to ask are: what was the environment like when this incident happened? What was a particular member of the pharmacy doing when this incident happened? What can we do to reduce the likelihood of this error from happening again?

Step 3: Create a constellation diagram

This constellation diagram is a visual of 5 different parts that are intended to help map out your ideas.

  1. In the center of the diagram, the incident and outcome is described.

  2. Potential contributing factors are identified and placed around the incident and outcome. Some contributing factors that are common the pharmacy include the work environment, the patient, the care team, and the equipment.

  3. Inter-relationships between the potential contributing factors are linked using arrows, which can indicate which factors are the most involved.

  4. The factors should be classified as either Preventative (factors that we can change that would prevent the incident from happening again), Incidental (even if you correct this factor, the incident would have still occurred), and Mitigating (factors that didn’t allow an incident to have more severe consequences).

  5. Confirm the findings with your team.

Step 4: Develop an action plan

This step entails creating solutions to directly address the Preventative factors. The solution-factor pairs should be prioritized and delegated to the staff members to implement.

Step 5: Implement the action plan

This last step is to implement the action plan and ensure that the actions offer long-term solutions versus temporary fixes for the problem. It’s important to continue to assess if the solution is working well or if a new solution should be formed to address a recurring issue.

Although the RCA is reserved for critical incidents, having an understanding the framework and line of questioning can help you identify root causes for any type of medication incident and ensure that your practice always puts patient safety first.

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  1. Beard P, Greenhall J, Hoffman CE, et al. Canadian Incidence Analysis Framework. Canadian Patient Safety Institute; 2012. Accessed February 22, 2021.

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