Application of system-level root cause analysis for drug quality and safety problems: a case study

Research in Social & Administrative Pharmacy : RSAP
Brian C Sauer, Charles D Hepler

Abstract

Automated surveillance indicators are used to identify problems with drug therapy. A previous study automated 39 indicators of possible drug-related emergency department visits and hospitalizations. These indicators were used to investigate the quality and safety of drug use in a large health care coalition in Florida. This study describes a method of capturing this input with an aim of applying it to a root cause analysis (RCA), which may be useful for improving system-level flaws and weaknesses in medication use. To apply results of a computerized surveillance system containing selected indicators of potential drug-related emergency department and hospital admissions to an RCA for evaluation. Such evaluation might prove effective in determining criteria useful in improving the quality and safety of systemic responses to individual types of drug therapy problems. This was a case study that brought together a study group of 6 coalition stakeholders to evaluate findings from 4 indicators. The indicators represented problems in the prescribing, adherence, and monitoring steps in the ambulatory care medication use system. The RCA included the following procedures: brainstorming of possible system failures, organizing proposed syst...Continue Reading

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Citations

May 18, 2020·Medical Principles and Practice : International Journal of the Kuwait University, Health Science Centre·Jimmy Martin-DelgadoJosé Joaquín Mira

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