Root Cause Analysis Flashcards
Components of Incident Analysis
- Gather information
- What happened - Analyze the information
- Why did it happen - Identify root and contributing causes
- Why did it happen - Action plan for change
- How can we prevent it
Root Cause vs Contributing Cause
THIS is the stem of the incident
Series of actions that led from the root cause to the incident
Types of Analysis
Concise
Comprehensive
Mult-Incident
Types of Analysis
- Concise
Fastest
1-2 Reviewers
Low to moderate risk of harm to the patients / staff / property
Types of Analysis
- Comprehensive
Significant time requirement
Large committee of reviewers
Major harm
Types of Analysis
- Multi-Incident
Groups several incidents together
Usually for low to moderate harm
Can group consider or comprehensive analysis
Team Based Approach
- Perspectives
Try to involve multiple direct care providers and variety of team members
- Increases the number of different perspectives
Try to include patient perspectives (not the one involved as their feelings are involved)
Team Based Approach - Meetings
- Confidentiality
Meetings and deliberations should be kept individual
- We should be more focused on the system rather than the individual
Exceptions: Malicious acts or impaired judgements
Initial Understanding
Section in the drug incident report form
1. Document the known facts
- Obtain additional information
- Walk through of the incident
- Review of policies
- Patient records, prescriptions
- Interview with individuals involved
- Patient outcomes
Final Understanding
A detailed timeline of the incident
- Include times (estimate if needed)
- What occurred (actual)
- Source of information
How to conduct Root Analysis
Focus on system, not on individuals (do not name names)
- Determine a starting point and then work backwards (Why? What caused it?)
- Tree diagrams work quite well
Casual Chains
- What is it?
Start with the error the follow the contributing factors to lead to the Root Cause
Casual Chains
- Action vs Condition
Action (Short lived event)
- Ex. Interrupted by a customer when checking prescription
Condition (Something that exists over a long period of time)
- Only staff member in the dispensary
Root Cause
- What is it?
Used to help identify what the pharmacy can do to prevent the same error from happening again
Casual Statement
- What is it?
A problem statement
A - Antecedent (Cause)
B - Bridging (Increased / Decreased chances of consequence)
C - Consequences (Outcome)
Action Plan
- What is it?
What can be changed to eliminate / decrease likelihood of a repeated incident
- Use casual statement to create action items for implementation
Hierarchy of Effectiveness
- High Leverage
Computer Assisted
Constraints
- Password bypass
Automation
- Robotic dispensing
Hierarchy of Effectiveness
- Medium Leverage
Standardization
- Checklist
Independent Double Checks
- Does not have to be a pharmacist
Reminders
- Pop ups
Hierarchy of Effectiveness
- Low Leverage
Policies and Procedures
Training
Communication
Implementation
- How will we know we achieved our goal
Plan - Do - Study - Act
- Measures effectiveness of changes
- Test changes and adapt if necessary
Set SMART Goals
SMART Goals
Specific
Measurable
Assignable
Realistic
Time-Related
