[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-243623-105":53,"doc-detail-243623-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","ismp-community-pharmacy-template-root-cause-analysis-and-action-plan","ISMP Community Pharmacy Template - Root Cause Analysis and Action Plan","","ISMP Community Pharmacy Template for Root Cause Analysis and Action Plan provides a structured workflow to organize and display RCA steps for community or ambulatory pharmacies. It guides teams to define the event scope and problem statement, document what happened, and build a time-series flowchart without assumptions. The template then prompts identification of proximate factors, root causes, and contributing factors with clear “Yes/No” check-offs, and links each confirmed cause to a risk-reduction action plan.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ismp-community-pharmacy-template-root-cause-analysis-and-action-plan/243623/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ismp-community-pharmacy-template-root-cause-analysis-and-action-plan/243623.png","ImageObject",442,249,{"name":88,"@type":89},"Aran","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-14","2026-09-12",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is needed in Step 1 for the RCA worksheet?","Question",{"text":109,"@type":110},"Record the RCA title and the date/time range of the event, then list team members including a team leader, individuals with event knowledge, frontline staff familiar with the process, and an optional RCA expert.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should Step 2 “What Happened” be completed?",{"text":114,"@type":110},"Document when the event occurred and provide a detailed, complete description of the event details, focusing on factual findings.",{"name":116,"@type":107,"acceptedAnswer":117},"What does Step 4 require for identifying root causes and contributing factors?",{"text":118,"@type":110},"For each proximate factor finding, answer whether it is a root cause or a contributing factor using the “Yes/No” columns and determine whether a risk-reduction action can be assigned, with emphasis on process and system vulnerabilities rather than individuals.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},243623,1790018809,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":40,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":141},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","ISMP Community Pharmacy Template for Root Cause Analysis and Action Plan  \nThis template is provided as an aid to organizing/displaying the steps in a RCA. Not all possibilities and questions will apply in every case, and there maybe others that will emerge in the course of the analysis. However, all possibilities and questions should be fully considered in your quest to identify root causes, contributing factors and associated risk reduction strategies.  \nStep 1-RCA Title:  \nDate/Time Range of Event:  \n\n| Problem Statement:\u003Cbr>\u003Cbr>Team Members\u003Cbr>Team leader: |\n| --- |\n| Individual with knowledge about the event: |\n| Frontline worker familiar with process (but not directly involved with the event): |\n| RCA expert (optional: someone who works in medication safety such as a risk manager, an outside consultant or a respected pharmacist from another pharmacy who can look at the event objectively to properly guide this process): |\n\nISMP—ROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY Community Pharmacy Template for Root Cause Analysis and Action Plan, page 1 of 12  \nStep 2-What Happened  \n\n| Question\u003Cbr>When did the event occur? (e.g., time period—date(s), day of week, time of day) | Finding |\n| --- | --- |\n| What are the details of the event? (i.e., full event description) |  |\n\nOVERFLOW PAGE NEEDED  \n> GO TO OVERFLOW PAGE  \nISMP—ROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY Community Pharmacy Template for Root Cause Analysis and Action Plan, page 2 of 12  \nStep 3 – Flowchart Steps in the Process  \nDevelop a flowchart to illustrate the process steps involved in the event. Construct a basic “time series” of the steps/facts beginning with the initial cue to fill the prescription and then recording all steps leading up to and including the adverse outcome.  \nTip: When developing the flowchart of events, do not jump to conclusions. It is essential to stay focused on what actually happened – not what the team thinks happened.  \n\n| \u003Cbr>Question Finding |  |\n| --- | --- |\n| What was the actual sequence | Create own flow chart |\n| of events? (complete a flowchart) | Ask why for key findings on the flowchart |\n| What events were involved in (contributed to) the event?\u003Cbr>Why did it happen? | Determine which steps were involved or directly contributed to the adverse outcome |\n\nOVERFLOW PAGE NEEDED  \n> GO TO OVERFLOW PAGE  \nISMP—ROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY Community Pharmacy Template for Root Cause Analysis and Action Plan, page 3 of 12  \nStep 4 – Identify Proximate (Primary Contributing) Factors and Root Causes  \nAs an aid to avoiding “loose ends,” the last three columns on the right are provided to be checked off for later reference:  \n• “Root Cause?” should be answered “Yes” or “No” for each finding. Each finding that is identified as a root cause should have an assigned action plan (Step 6 on this form) . Number each finding that is identified as a root cause so that it can be correlated to specific strategies.  \n• “Contributing Factor?” should be answered “Yes” or “No” for each finding. Consider how it relates to the event and create action plans as appropriate.  \n• “Take Action?” should be answered “Yes” for each finding of a root cause or contributing factor that can reasonably be assigned a risk reduction strategy.  \nTip: Root causes and contributing factor statements must clearly address why something has occurred and there must be a clear focus on process and system vulnerabilities, never on individuals.  \n\n| Proximate Factor Questions\u003Cbr>I. Patient Information\u003Cbr>Was the patient correctly identified?\u003Cbr>Was critical patient information available? | Findings/Proximate Factors | Root Cause?(If yes, assign \\#) | Contributing Factor? | Take Action? |\n| --- | --- | --- | --- | --- |\n\nOVERFLOW PAGE NEEDED  \n> GO TO OVERFLOW PAGE  \nISMP—ROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY Community Pharmacy Template for Root Cause Analysis and Action Plan, page","cbCaiu56RumKfdtt","https://ap.wps.com/l/cbCaiu56RumKfdtt","pdf",246273,"English","# Step 1 - RCA Title\n# Step 2 - What Happened\n# Step 3 – Flowchart Steps in the Process\n# Step 4 – Identify Proximate (Primary Contributing) Factors and Root Causes\n## I. Patient Information\n## II. Drug Information\n## III. Communication of Drug Orders\n## IV. Drug Labeling, Packaging, and Nomenclature\n## V. Drug Standardization, Storage and Distribution\n## VI. Medication Device Acquisition, Use and Monitoring\n## VII. Environmental Factors, Workflow and Staffing Patterns","[{\"question\":\"What information is needed in Step 1 for the RCA worksheet?\",\"answer\":\"Record the RCA title and the date/time range of the event, then list team members including a team leader, individuals with event knowledge, frontline staff familiar with the process, and an optional RCA expert.\"},{\"question\":\"How should Step 2 “What Happened” be completed?\",\"answer\":\"Document when the event occurred and provide a detailed, complete description of the event details, focusing on factual findings.\"},{\"question\":\"What does Step 4 require for identifying root causes and contributing factors?\",\"answer\":\"For each proximate factor finding, answer whether it is a root cause or a contributing factor using the “Yes/No” columns and determine whether a risk-reduction action can be assigned, with emphasis on process and system vulnerabilities rather than individuals.\"}]","ISMP Community Pharmacy Template - Root Cause Analysis and Action Plan | PDF",1789206412,6]