A Root Cause Analysis Project in a Medication Safety Course
A Root Cause Analysis Project in a Medication Safety Course
Ensuring safe medication use is a critical role of pharmacists. However, formal courses dedicated to the principles of medication safety and error prevention are not present in all pharmacy college and school curricula. A 2001 survey found little structure or uniformity in the delivery of medication safety principles among US colleges and schools of pharmacy. They also found that in many cases there was no instruction provided on identifying several major safety elements such as human errors, medical errors, and medication errors. Furthermore, only 38% (13/34) of respondents provided instruction on evaluating medication errors using root cause analysis, and most of those (9/13) occurred through classroom lecture rather than through applied skills training. A 2007 study of the integration of the "science of safety" into pharmacy curriculums found that basic medication error principles are not taught consistently to pharmacy students. The document also identifies several gaps in safety education including medication error identification, the application of error-evaluation skills using root cause analysis, and discussion of medication safety organizations such as ISMP.
Given the important role pharmacists play in medication safety, gaps present in the education of pharmacy students should be addressed. The medication safety course described in this paper addresses these gaps and more specifically facilitates the application of essential medication safety skills using root cause analysis assignments. Both root cause analysis assignments were designed to challenge students to critically evaluate the causes of medication errors using the systematic approach outlined by ISMP. The second root cause analysis also allowed for the synthesis of new information as students developed a plan to prevent error recurrences. These skills are essential to pharmacists and help students newly introduced into pharmacy practice better understand the medication use system. Understanding the key elements to safe medication use and medication error prevention enhances a student's ability to ensure safe medication practice now and after graduation and licensure.
The root cause analysis assignments were structured activities that placed students in the role of a pharmacist on a medication safety team. The structure of the activity combined with prompt assessment and feedback from instructors contributed to effective learning and retention of information and skills. In addition, students learned to communicate effectively and work within a team. While this strategy attempted to mimic "real world" medication safety practice, all of the students were pharmacy students, as opposed to the more common multidisciplinary medication safety committees found in healthcare settings.
Overall, students performed well on root cause analysis assignments and rated the activities high on course evaluations. While limited by the retrospective design of a final course evaluation, the findings demonstrate a consistent appreciation for the opportunity to apply safety knowledge and prevention skills to real medication error cases. In fact, the inability to apply safety skills to real error cases was a limitation to a previously described patient safety course. In contrast, placing students in a community or health-system pharmacy to conduct medication error reduction projects has had some success.
It is difficult to assess the overall impact this course will have on students' ability to contribute to medication safety as practicing pharmacists. While the course does provide a comprehensive overview of several essential principles and facilitates the application of error evaluation and prevention skills, its overall application is limited by the inclusion of only pharmacy students. Medication safety is a multi-disciplinary practice and future courses should seek to include medical students as well as other health professions students.
Discussion
Ensuring safe medication use is a critical role of pharmacists. However, formal courses dedicated to the principles of medication safety and error prevention are not present in all pharmacy college and school curricula. A 2001 survey found little structure or uniformity in the delivery of medication safety principles among US colleges and schools of pharmacy. They also found that in many cases there was no instruction provided on identifying several major safety elements such as human errors, medical errors, and medication errors. Furthermore, only 38% (13/34) of respondents provided instruction on evaluating medication errors using root cause analysis, and most of those (9/13) occurred through classroom lecture rather than through applied skills training. A 2007 study of the integration of the "science of safety" into pharmacy curriculums found that basic medication error principles are not taught consistently to pharmacy students. The document also identifies several gaps in safety education including medication error identification, the application of error-evaluation skills using root cause analysis, and discussion of medication safety organizations such as ISMP.
Given the important role pharmacists play in medication safety, gaps present in the education of pharmacy students should be addressed. The medication safety course described in this paper addresses these gaps and more specifically facilitates the application of essential medication safety skills using root cause analysis assignments. Both root cause analysis assignments were designed to challenge students to critically evaluate the causes of medication errors using the systematic approach outlined by ISMP. The second root cause analysis also allowed for the synthesis of new information as students developed a plan to prevent error recurrences. These skills are essential to pharmacists and help students newly introduced into pharmacy practice better understand the medication use system. Understanding the key elements to safe medication use and medication error prevention enhances a student's ability to ensure safe medication practice now and after graduation and licensure.
The root cause analysis assignments were structured activities that placed students in the role of a pharmacist on a medication safety team. The structure of the activity combined with prompt assessment and feedback from instructors contributed to effective learning and retention of information and skills. In addition, students learned to communicate effectively and work within a team. While this strategy attempted to mimic "real world" medication safety practice, all of the students were pharmacy students, as opposed to the more common multidisciplinary medication safety committees found in healthcare settings.
Overall, students performed well on root cause analysis assignments and rated the activities high on course evaluations. While limited by the retrospective design of a final course evaluation, the findings demonstrate a consistent appreciation for the opportunity to apply safety knowledge and prevention skills to real medication error cases. In fact, the inability to apply safety skills to real error cases was a limitation to a previously described patient safety course. In contrast, placing students in a community or health-system pharmacy to conduct medication error reduction projects has had some success.
It is difficult to assess the overall impact this course will have on students' ability to contribute to medication safety as practicing pharmacists. While the course does provide a comprehensive overview of several essential principles and facilitates the application of error evaluation and prevention skills, its overall application is limited by the inclusion of only pharmacy students. Medication safety is a multi-disciplinary practice and future courses should seek to include medical students as well as other health professions students.
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