Academic journal article American Journal of Pharmaceutical Education

A Root Cause Analysis Project in a Medication Safety Course

Academic journal article American Journal of Pharmaceutical Education

A Root Cause Analysis Project in a Medication Safety Course

Article excerpt


Approximately 100,000 people die each year as a result of preventable medical errors. (1) This is more than the number of deaths caused by motor vehicle accidents, breast cancer, and acquired immune deficiency syndrome combined. These deaths result in more than $30 billion in direct healthcare expenses and indirect income losses each year. (1) As a result of these statistics, hospitals and regulatory agencies, such as The Joint Commission, have reevaluated the importance of patient safety in healthcare. Also, these agencies have recommended that medication and patient safety principles be introduced early in the education of healthcare professionals. (2) For example, the Institute of Medicine, the Association of American Medical Colleges, the American Association of Colleges of Nursing, and the Accreditation Council for Pharmacy Education (ACPE) have all advocated for and emphasized greater inclusion of patient safety principles and competence in the curriculums of their academic institutions. (3-6) The ACPE's accreditation guidelines, in particular, stress patient and medication safety as core elements of pharmacy education and specifically state in Standard 9 that a pharmacy curriculum must prepare graduates to ensure optimal patient safety. (3)

As a means to fully address ACPE accreditation standards and prepare students to be proficient in the skills of patient safety, the Jefferson School of Pharmacy developed a required medication safety course for second-year doctor of pharmacy (PharmD) students. This course is designed to establish the principles of medication safety through classroom lectures and out-of-class readings, as well as to facilitate the application of newly learned skills in teams using structured root cause analysis activities. A root cause analysis is an essential tool for evaluating safe medication use in healthcare settings and can be used to analyze and identify faulty medication-use systems implicated in errors using a systematic approach. In the medication safety course at the Jefferson School of Pharmacy, the root cause analysis also serves as a measure of students' comprehension and ability to apply essential medication and patient safety skills. This article describes the design and implementation of a root cause analysis activity in a required medication safety course.


Medication Safety is a 2-credit course required for second-year PharmD students delivered in 12 weekly 2-hour class sessions in the fall semester. The first part of the course (classes 1-5) was designed to introduce students to essential medication safety principles, including the culture of medication safety, agencies dedicated to safe medication practices, drug safety legislation, error-reporting systems, and common errors associated with poor packaging and labeling, inappropriate dose expressions, and unapproved abbreviations. These concepts were reinforced as students were asked to complete out-of-class reading assignments from the current medication safety literature and answer open-ended questions in online quizzes that were designed to assess students' ability to apply baseline medication safety knowledge to contemporary issues. The delivery and reinforcement of these principles were necessary to prepare students for the second part of the course (classes 6-12) in which the model for evaluating individual medication errors or root cause analysis was emphasized.

The root cause analysis used in this course followed the approach described by the Institute for Safe Medication Practices (ISMP), (7) which emphasizes that the cause of a medication error is rarely the fault of a single person practicing within the vast and complex medication-use process. Rather, medication errors are often the result of a breakdown of at least 1 of 10 key elements that affect medication use. These key elements are interrelated subprocesses of the 5 core steps in the medication use process: medication prescribing, order processing, dispensing, administration, and monitoring. …

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