Dovetailing with the National Learning and Reporting System (NLRS), root cause analysis (RCA) provides a rigorous framework within which to reflect on an actual or potential safety incident, working back across the sequence of events. RCA is important, because it helps move thinking beyond the “who” to the “how”, by uncovering underlying, contributory and causal factors in systems and process failures, to prevent a recurrence.
We acknowledge that pharmacists already take patient safety extremely seriously, and trap a significant number of medication errors. But, in practice, things can and do go wrong despite high levels of professionalism in the field. For example, in primary care, an estimated 1 per cent to 11 per cent of all prescriptions are associated with some sort of error. However, there are few data on the type, frequency and provenance of errors, or how to prevent them, which is why RCA matters.
Various methods can be used for RCA:
