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Root Cause Analysis Design and Its Application to Pharmacy Education.

Mark T Holdsworth1, Rucha Bond1, Saumeel Parikh2

  • 1University of New Mexico College of Pharmacy, Albuquerque, New Mexico.

American Journal of Pharmaceutical Education
|May 12, 2016
PubMed
Summary

Third-year pharmacy students effectively designed root cause analysis (RCA) but struggled with specific components like disclosure and flow diagrams. Challenges also arose in applying RCA in real-world healthcare settings.

Keywords:
pharmacy studentsroot cause analysissentinel events

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Area of Science:

  • Pharmacy Education
  • Patient Safety
  • Healthcare Quality Improvement

Background:

  • Root Cause Analysis (RCA) is crucial for investigating sentinel events in healthcare.
  • Evaluating the effectiveness of pharmacy student training in RCA is essential for improving patient safety.

Purpose of the Study:

  • To assess third-year pharmacy students' proficiency in designing and applying RCA to sentinel events.
  • To identify specific areas of strength and weakness in student RCA performance.

Main Methods:

  • A comprehensive review of RCA assessments from 82 third-year pharmacy students was conducted.
  • Assessments included RCA worksheets, flow diagrams, and narrative reflections.

Main Results:

  • Most students successfully designed an RCA process.
  • Key challenges were identified in fact-finding sessions, disclosure planning, and creating flow diagrams.
  • Students reported difficulties applying RCA in certain healthcare settings due to team assembly, organizational culture, and error complexity.

Conclusions:

  • Pharmacy students demonstrate foundational ability in RCA design but require further training in specific analytical and practical components.
  • Barriers to implementing RCA in practice settings were recognized by students, highlighting the need for systemic support.