Targeted Medication Safety Best Practices for Hospitals

With the release of the Root Cause Analysis Workbook for Community/Ambulatory Pharmacy, community pharmacies now have access to a coordinated, extensive set of tools designed to meet regulatory requirements in the full investigation of the causes of a sentinel event* (an unexpected occurrence involving death or serious physical or psychological injury or risk thereof) and identify and implement appropriate and effective strategies to prevent this or a similar occurrence. The RCA workbook is designed to help community pharmacies take a process-driven, system-based approach to address this critical issue.

At right are links to the RCA workbook, which contains appendices with sample forms that can be used during the process. Also provided are each of the appendix forms as a separate document with each column/field electronically fillable, so that you can personalize and use them for your specific organization.

The tools were developed by the Institute for Safe Medication Practices (ISMP) with grant support from National Association of Boards of Pharmacy Foundation.

*NOTE: any error not defined as a sentinel event should be investigated and analyzed using other internally available company tools or the ISMP Assess-ERR™ worksheet. See section titled: When is RCA necessary?

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