A root cause analysis project in a medication safety course.

Jason J. Schafer

Commentary

A root cause analysis project in a medication safety course.

September 12, 2012

Schafer JJ. Am J Pharm Educ. 2012;76(6):116.

View more articles from the same authors.

This commentary describes an initiative to integrate development of root cause analysis skills into a pharmacy curriculum to ensure safe medication use.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.

April 25, 2012

Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers.

April 17, 2019

Disclosing adverse events to patients.

March 6, 2005

Measures and measurement of high-performance work systems in health care settings: propositions for improvement.

February 9, 2011

Team-based intervention to reduce the impact of nonactionable alarms in an adult intensive care unit.

November 6, 2019

Barriers to speaking up about patient safety concerns.

November 22, 2017

Team-based approach to improving medication reconciliation rates in family medicine residency clinics.

October 7, 2020

Measurement as a performance driver: the case for a national measurement system to improve patient safety.

April 26, 2017

Without question.

July 20, 2022

Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human–computer interaction.

June 6, 2012

Sleep deprivation: a call for institutional rules.

September 25, 2013

An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit.

January 8, 2020

Do patient safety indicators explain increased weekend mortality?

September 2, 2015

The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU.

April 18, 2012

Neonatal intensive care unit safety culture varies widely.

October 26, 2011

Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals.

April 28, 2010

Error disclosure: a new domain for safety culture assessment.

May 23, 2012

Barriers to reporting medication errors: a measurement equivalence perspective.

October 6, 2010

Principles of automation for patient safety in intensive care: learning from aviation.

June 6, 2018

Factors affecting incident reporting by registered nurses: the relationship of perceptions of the environment for reporting errors, knowledge of the Nursing Practice Act, and demographics on intent to report errors.

December 12, 2007

Racial and ethnic disparities in the treatment of chronic pain.

December 29, 2020

The science of human factors: separating fact from fiction.

May 22, 2013

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications.

October 21, 2009

When clinicians drop out and start over after adverse events.

March 14, 2018

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections.

October 26, 2016

Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior.

July 10, 2019

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

April 3, 2013

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

November 30, 2016

Assessing medical students' perceptions of patient safety: The Medical Student Safety Attitudes and Professionalism Survey.

January 29, 2014

Do older patients' perceptions of safety highlight barriers that could make their care safer during organisational care transfers?

January 30, 2005

Applying lessons from social psychology to transform the culture of error disclosure.

June 7, 2017

Potential consequences of patient complications for surgeon well-being: a systematic review.

April 17, 2019

COVID-19 and patient safety: time to tap into our investment in high reliability.

May 12, 2021

Responding to unprofessional behavior by trainees - a "just culture" framework.

March 11, 2020

Safety culture across cultures.

January 8, 2020

Technology-enhanced simulation for health professions education: a systematic review and meta-analysis.

September 14, 2011

Utilising improvement science methods to optimise medication reconciliation.

April 13, 2011

Patient safety in emergency medical services: a systematic review of the literature.

December 21, 2011

Exploring barriers and facilitators to the use of computerized clinical reminders.

April 21, 2005

Doing well by doing good: evaluating the influence of patient safety performance on hospital financial outcomes.

May 31, 2017

Hospital credentialing and privileging of surgeons: a potential safety blind spot.

April 15, 2015

A simulation-based approach to training in heuristic clinical decision-making.

June 19, 2019

Returning to the roots of culture: a review and re-conceptualisation of safety culture.

June 5, 2013

The eNOTSS platform for surgeons’ nontechnical skills performance improvement.

March 4, 2020

Improving communication and resolution following adverse events using a patient-created simulation exercise.

January 25, 2017

Impact of an antiretroviral stewardship strategy on medication error rates.

July 18, 2018

Clinically inconsequential alerts: the characteristics of opioid drug alerts and their utility in preventing adverse drug events in the emergency department.

December 16, 2015

Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic.

March 1, 2017

Structuring patient and family involvement in medical error event disclosure and analysis.

January 22, 2014

Pediatric trainees' speaking up about unprofessional behavior and traditional patient safety threats.

September 30, 2020

Medication safety pharmacy technician in a large, tertiary care, community hospital.

March 30, 2016

Who is responsible for the safe introduction of new surgical technology? An important legal precedent from the da Vinci Surgical System Trials.

May 10, 2017

Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives.

August 20, 2014

The influence of organizational factors on patient safety: examining successful handoffs in health care.

August 27, 2014

Systematic review of the impact of physician work schedules on patient safety with meta-analyses of mortality risk.

August 16, 2023

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

January 18, 2006

Impact of patient safety mandates on medical education in the United States.

June 4, 2008

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

Safety considerations in learning new procedures: a survey of surgeons.

January 31, 2018

Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals.

September 2, 2009

Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey.

July 15, 2009

Patients as partners in learning from unexpected events.

November 9, 2016

Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care.

March 9, 2016

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial.

September 16, 2015

Color-coded prefilled medication syringes decrease time to delivery and dosing error in simulated emergency department pediatric resuscitations.

March 25, 2015

Examining medical office owners and clinicians perceptions on patient safety climate.

November 7, 2018

How differences between manager and clinician perceptions of safety culture impact hospital processes of care.

February 14, 2018

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

June 7, 2017

The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates.

July 14, 2021

Disaster ergonomics: human factors in COVID-19 pandemic emergency management.

August 19, 2020

Spike in fatal medication errors at the beginning of each month.

March 6, 2005

The safety of warfarin therapy in the nursing home setting.

June 13, 2007

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

October 26, 2016

Healthcare professional and patient codesign and validation of a mechanism for service users to feedback patient safety experiences following a care transfer: a qualitative study.

October 5, 2016

Countering cognitive biases in minimising low value care.

June 7, 2017

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study.

July 26, 2023

Prevalence and characteristics of interruptions and distractions during surgical counts.

July 28, 2021

Classification of adverse events occurring in a surgical intensive care unit.

September 5, 2007

Medication dosing errors for patients with renal insufficiency in ambulatory care.

September 14, 2005

Origins of and solutions for neonatal medication-dispensing errors.

January 27, 2010

PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety.

December 7, 2016

March 28, 2018

Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a three year, multi-phase study.

April 27, 2016

What causes adverse events in prehospital care? A human-factors approach.

September 19, 2012

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

July 11, 2012

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.

June 19, 2019

Patients' conceptualizations of responsibility for healthcare: a typology for understanding differing attributions in the context of patient safety.

June 5, 2019

Closing the loop: a process evaluation of inpatient care team communication.

January 11, 2017

Fundamentals of diagnostic error in imaging.

October 10, 2018

Implementing a survey for patients to provide safety experience feedback following a care transition: a feasibility study

October 9, 2019

Variation in quality of urgent health care provided during commercial virtual visits.

April 20, 2016

PCA safety data review after clinical decision support and smart pump technology implementation.

June 12, 2013

Regional variations in diagnostic practices.

May 12, 2010

Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.

November 22, 2017

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

June 1, 2011

Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in obstetrics.

September 23, 2020

Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.

February 24, 2016

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

October 5, 2011

Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care

October 2, 2019

Related Resources

Medication guides: patient medication information. A proposed rule by the Food and Drug Administration.

June 28, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology.

May 4, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Medication safety issues with newly authorized PAXLOVID.

January 12, 2022

Patient Safety Primers

Deprescribing as a Patient Safety Strategy

October 27, 2021

Use of therapeutic outcomes monitoring method for performing of pharmaceutical care in oncology patients.

April 28, 2021

WebM&M Cases

The Impact of Communication on Medication Errors

March 15, 2021

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

Medication errors: the year in review.

October 23, 2019

A lethal hidden curriculum—death of a medical student from opioid use disorder.

September 4, 2019

Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC).

May 15, 2019

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

December 19, 2018

How to prevent the top 4 medication errors.

October 17, 2018

Fixed-dose combination antihypertensives and risk of medication errors.

October 3, 2018

Themed Issue on Innovations in Medication Safety.

August 22, 2018

Board of pharmacy practices related to medication errors and their potential impact on patient safety.

August 1, 2018

Impact of an antiretroviral stewardship strategy on medication error rates.

July 18, 2018

The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials.

July 11, 2018

Necessity for a pathway for "high-alert" patients.

May 23, 2018

Implementation of a mock root cause analysis to provide simulated patient safety training.

December 20, 2017

Errors originating in hospital and health-system outpatient pharmacies.

July 19, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.

May 17, 2017

The effects of bar-coding technology on medication errors: a systematic literature review.

April 19, 2017

All consumer medication information is not created equal: implications for medication safety.

April 19, 2017

A patient-centered prescription drug label to promote appropriate medication use and adherence.

January 18, 2017

Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.

November 2, 2016

Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications.

August 24, 2016

Perspective

Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective

June 1, 2016

See More About The Topic

Pharmacists

Educators

Pharmacy

Medication Errors/Preventable Adverse Drug Events

Root Cause Analysis

A root cause analysis project in a medication safety course.

Deprescribing as a Patient Safety Strategy

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A root cause analysis project in a medication safety course.

Deprescribing as a Patient Safety Strategy

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site