A Root Cause Analysis Project in a Medication Safety Course
Objective. To develop, implement, and evaluate team-based root cause analysis projects as part of a required medication safety course for second-year pharmacy students.
Design. Lectures, in-class activities, and out-of-class reading assignments were used to develop students' medication safety skills and introduce them to the culture of medication safety. Students applied these skills within teams by evaluating cases of medication errors using root cause analyses. Teams also developed error prevention strategies and formally presented their findings.
Assessment. Student performance was assessed using a medication errors evaluation rubric. Of the 211 students who completed the course, the majority performed well on root cause analysis assignments and rated them favorably on course evaluations.
Conclusion. Medication error evaluation and prevention was successfully introduced in a medication safety course using team-based root cause analysis projects.
Approximately 100,000 people die each year as a result of preventable medical errors. 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. 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. 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. 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.
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.
Abstract and Introduction
Abstract
Objective. To develop, implement, and evaluate team-based root cause analysis projects as part of a required medication safety course for second-year pharmacy students.
Design. Lectures, in-class activities, and out-of-class reading assignments were used to develop students' medication safety skills and introduce them to the culture of medication safety. Students applied these skills within teams by evaluating cases of medication errors using root cause analyses. Teams also developed error prevention strategies and formally presented their findings.
Assessment. Student performance was assessed using a medication errors evaluation rubric. Of the 211 students who completed the course, the majority performed well on root cause analysis assignments and rated them favorably on course evaluations.
Conclusion. Medication error evaluation and prevention was successfully introduced in a medication safety course using team-based root cause analysis projects.
Introduction
Approximately 100,000 people die each year as a result of preventable medical errors. 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. 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. 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. 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.
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.
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