When an error occurs it is important not to concentrate on “who is to blame” but “how and why did it occur”.

Focusing on the factors that contribute to a medicines related incident enables pharmacy teams to take action to avoid recurrence of the incident.

This also encourages an environment of shared learning where factors that have contributed to errors can be shared with other healthcare professionals to reduce the risk of recurrence in another healthcare setting, thus improving patient safety faster.

Root cause analysis (RCA) is a systematic investigation of any underlying cause(s) of an incident. The root cause is defined as “the cause or causes that if addressed will prevent or minimise the chances of an incident recurring”.

The NPSA RCA tool[1] details 7 key stages to completing a RCA:

  • Identifying which incidents to investigate - community pharmacy should focus on incidents that reach the patient, focusing on incidents that did or could have caused patient harm.
  • Gathering information - all information that is relevant to the incident being investigated should be collected, examples of relevant information could include patient health records e.g. PMR, prescriptions, policies or procedures such as relevant SOPs, the incident report form, staff accounts of what happened and their specific action(s).
  • Mapping events - confirming the chain of events that resulted in a patient safety incident allows systems to be adapted to prevent a recurrence of the event.
  • Analysing information - looking at the collated information over what happened and why, and developing measures that will prevent the error happening again.
  • Barrier analysis - a barrier is a control measure put in place to prevent or reduce the risk of an error occurring. Failure of a barrier is likely to result in a patient safety event. Barrier analysis involves identifying barriers that should have been in place, why they failed and what could be done to prevent a recurrence.
  • Develop solutions and actions plan - this involves putting in place steps to prevent a repeat of the dispensing error.
  • Completing a report – it is important to maintain comprehensive records as evidence of investigations into dispensing errors and preventative measures taken to avoid recurrence of the same or similar error.

Once the RCA has been completed it is essential that an action plan is formulated to remove any factors identified as contributing to the error. The pharmacy team should be aware of the details included in the action plan and their individual responsibilities for achieving the plan.

Use the concise investigation report template when reporting errors. It will help with any investigation carried out by the GPhC, the NHS or other health body.

Download Concise Investigation Report template