Root Cause Analysis

When an error occurs it is important not to concentrate on “who is to blame” but “how and why did it occur”.

Focusing on the factors that contribute to a medicines related incident enables pharmacy teams to take action to avoid recurrence of the incident.

This also encourages an environment of shared learning where factors that have contributed to errors can be shared with other healthcare professionals to reduce the risk of recurrence in another healthcare setting, thus improving patient safety faster.

Root cause analysis (RCA) is a systematic investigation of any underlying cause(s) of an incident. The root cause is defined as “the cause or causes that if addressed will prevent or minimise the chances of an incident recurring”.

There are 7 key stages to completing a RCA:

  • Identifying which incidents to investigate - community pharmacy should focus on incidents that reach the patient, focusing on incidents that did or could have caused patient harm.
  • Gathering information - all information that is relevant to the incident being investigated should be collected, examples of relevant information could include patient health records e.g. PMR, prescriptions, policies or procedures such as relevant SOPs, the incident report form, staff accounts of what happened and their specific action(s).
  • Mapping events - confirming the chain of events that resulted in a patient safety incident allows systems to be adapted to prevent a recurrence of the event.
  • Analysing information - looking at the collated information over what happened and why, and developing measures that will prevent the error happening again.
  • Barrier analysis - a barrier is a control measure put in place to prevent or reduce the risk of an error occurring. Failure of a barrier is likely to result in a patient safety event. Barrier analysis involves identifying barriers that should have been in place, why they failed and what could be done to prevent a recurrence.
  • Develop solutions and actions plan - this involves putting in place steps to prevent a repeat of the dispensing error.
  • Completing a report – it is important to maintain comprehensive records as evidence of investigations into dispensing errors and preventative measures taken to avoid recurrence of the same or similar error.

The RCA Five Whys Tool

By repeatedly asking the question 'why?' (using five as a rule of thumb), the layers of an issue can be peeled away which can lead to the root cause of a problem. The reason for a problem can often lead into another question; the question may need to be asked fewer or more than five times to get to the origin of a problem. The real key is to avoid assumptions and logic traps and to encourage the team to keep drilling down to the real cause.

Download the RCA Five Whys template

How to use it:

  • Write down the specific problem to help formalise the problem and describe it accurately
  • Use brainstorming to ask why the problem occurs and write down the answer
  • If the answer doesn't identify the source, ask 'why?' again and write the answer down
  • Loop back to the previous step until the team agrees that they have identified the problem's root cause

Once the RCA has been completed it is essential that an action plan is formulated to remove any factors identified as contributing to the error. The pharmacy team should be aware of the details included in the action plan and their individual responsibilities for achieving the plan.