Root Cause Analysis Design and Its Application to Pharmacy Education

Abstract

Objective. To evaluate third-year pharmacy students' ability to effectively design and apply root cause analysis (RCA) to a sentinel event and to analyze student responses for areas of proficiency and deficiency. Methods. This study involved a comprehensive review of RCA key assessments from 82 students in spring 2014. The performance assessments consisted of a review of each student's RCA worksheet and flow diagram as well as the 1-2 page narrative reflection. Results. The majority of students were able to successfully design an RCA, but had challenges with 3 components: fact-finding session, disclosure plan, and a flow diagram. Several students perceived challenges to conducting a formal RCA in certain health care settings, which included assembling an RCA team and gathering relevant facts, a lack of transparency/safe environment within organizations, and creating a plan for multiple/sequential errors. Conclusion. Most students were able to design an RCA process, but encountered difficulty with some components. Students also identified challenges in applying the approach in certain health care arenas.