ISMP Root Cause Analysis Workbook for Community/Ambulatory Pharmacy - Chapter 1 Introduction - Purpose and Tools

Sep 12, 2026

Upload by Elsa

ISMP Root Cause Analysis Workbook for community and ambulatory pharmacy guides users through a systematic RCA process to identify causal factors behind sentinel medication events. It frames why RCA is needed within Continuous Quality Improvement programs, explains core concepts emphasizing systems and processes over individual performance, and outlines investigation outputs such as action plan development and effectiveness measurement. The workbook also highlights common pitfalls and provides structured tools, templates, and example materials to support consistent analysis and safer risk control.

LanguageEnglish

CategoryPresentations

FormatPDF

Pages68

Reading Time24 min

AccessFree to download

Chapter 1. Introduction

Purpose of the Workbook and Associated Tools

Chapter 2. What is RCA?

Characteristics of a Thorough and Successful RCA

When RCA Is Necessary

Conducting RCA – An Overview

Conducting RCA – A Step-by-Step Approach

Chapter 3. Key Practice Points

Chapter 4. Conclusion

Appendix A. Glossary of Terms

Appendix B. Research Articles and Resources

Appendix C. Process Step Descriptions

Appendix D. Prescription Flow Chart

Appendix E. Common Pitfalls

Appendix F. Fact Gathering Worksheet

Appendix G. The Five Rules of Causation

Appendix H. ISMP Community Pharmacy Template for Root Cause Analysis and Action Plan

Appendix I. RCA Summary

Root Cause Analysis Workbook for Community/ Ambulatory Pharmacy Table of Contents | Chapter 1. Introduction
1.1 Purpose of the Workbook and Associated Tools | 3 3 | | --- | --- | | Chapter 2. What is RCA?
2.1 Characteristics of a Thorough and Successful RCA
2.2 When RCA Is Necessary
2.3 Conducting RCA – An Overview
2.4 Conducting RCA – A Step-by-Step Approach | 4 4
5 5
6 | | Chapter 3. Key Practice Points | 10 | | Chapter 4. Conclusion | 11 | | Appendix A. Glossary of Terms | 12 | | Appendix B. Research Articles and Resources | 15 | | Appendix C. Process Step Descriptions | 16 | | Appendix D. Prescription Flow Chart | 19 | | Appendix E. Common Pitfalls | 20 | | Appendix F. Fact Gathering Worksheet | 22 | | Appendix G. The Five Rules of Causation | 28 | | Appendix H. ISMP Community Pharmacy Template for Root Cause Analysis and Action Plan | 30 | | Appendix I. RCA Summary | 40 | Case Study 41 The Error 41 Fact Gathering Worksheet 42 Review of the Event: Process Flow/Steps (attach to RCA template) 50 ISMP Community Pharmacy Template for Root Cause Analysis and Action Plan 50 Root Cause Analysis Summary 66 ISMP—ROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY 2 Chapter 1. Introduction It is estimated that the overall dispensing accuracy rate in community pharmacy is 98 .3%(77 errors among 4,481 prescriptions) .1 This translates to about 4 errors per day in a pharmacy filling 250 prescriptions daily. Extrapolating these numbers could insinuate that an estimated 51.5 million errors occur during the filling of 3 billion prescriptions annually in America’s pharmacies. There is a need for every community/ambulatory pharmacy to find a way to control risk in order to prevent, identify and mitigate harm from these errors. To assist pharmacists in the process of minimizing the occurrence of medication errors, many state boards of pharmacy are contemplating or already requiring community pharmacies to have a Continuous Quality Improvement (CQI) program in place. Many of the state regulations require a Root Cause Analysis (RCA) in the case of a sentinel event. The Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury or risk thereof, and recommends completing RCA for all sentinel events that happen in healthcare organizations they accredit. RCA for sentinel events is required in the Center for Pharmacy Practice Accreditation’s (CPPA) standards developed by the National Association of Boards of Pharmacy (NABP), American Pharmacists Association (APhA) and American Health System Pharmacy Association (ASHP) . There are several programs and tools available for conducting RCA, but the majority of these focus on acute care settings. Until now, little information existed on how to perform a RCA in a community pharmacy and utilize the results for system improvement. 1.1 Purpose of the Workbook and Associated Tools 1. Describe the root cause analysis (RCA) process in community/ambulatory pharmacy, using a specific set of steps and associated tools, and help the user identify the primary causes of the sentinel event. 2. Prompt the users to create an action plan framework resulting from the RCA, including risk-reduction strategies, communication and implementation strategies, and measurement of effectiveness. 3. Describe common pitfalls when conducting RCA. 4. Provide example of the investigation and analysis of a sentinel event using RCA methodology and the newly developed ISMP Community Pharmacy Template for Root Cause Analysis and Action Plan. This RCA workbook is suitable for use in community pharmacy, mail order pharmacy or other ambulatory pharmacy practice settings that need to investigate a sentinel event. 1 Flynn et al. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc (Wash) . 2003 Mar-Apr;43 (2):191-200 . ISMP—ROOT CAUSE ANALY

FAQs

What is the purpose of this RCA workbook for community/ambulatory pharmacy?

It describes an RCA process using defined steps and tools, helps identify primary causes of sentinel events, and supports creation of an action plan with risk-reduction, communication, implementation, and effectiveness measurement strategies.

Why does the workbook emphasize RCA as a systems/process approach rather than individual performance?

RCA focuses on causal factors that contributed to the event, primarily within systems and processes. This supports deeper understanding of underlying conditions that increase risk and helps prevent similar problems in the future.

When is RCA necessary in healthcare settings according to the workbook’s framing?

RCA is required in the case of a sentinel event. The workbook aligns sentinel-event concepts with definitions such as unexpected occurrences involving death or serious injury or risk thereof and notes expectations for completing RCA for such events.

Sep 12, 2026

Upload by Elsa