In the busy world of pharmacy, medication incidents can happen even to the most diligent professionals. Understanding the root cause of these incidents is essential for preventing them in the future. When we identify the underlying causes of medication errors, we can implement changes that improve patient safety, enhance workflow efficiency, and boost overall pharmacy performance. Isolated errors can often mask deeper issues, and without thorough investigation, these problems may persist.

There are a variety of tools available for pharmacists to analyze errors and make process improvements to enhance patient safety. Here, we review three popular quality improvement tools that can help you identify the root cause of medication errors and implement effective solutions.

The 5 Whys method is a simple yet powerful problem-solving tool, used to explore the cause-and-effect relationships underlying a particular problem. 

The technique involves repeatedly asking “why” to drill down to the root cause of a problem. By repeatedly asking why a problem occurred, you uncover layers of issues that contributed to the incident. 

Despite its name, you shouldn’t always stop asking ‘why?’ after you’ve asked five times. For this method to work, you must ask ‘why?’ as many times as is required until you’ve identified the true root cause of a problem.

Remember that each “why” is intended to drill deeper. Ask why something occurred. Formulate the answer, then ask why that thing occurred. Continue that process until you’re confident you have reached the true root cause of the problem. For example, if you deduce an error occurred because a process or policy was not followed, don’t stop there. Keep asking why until you uncover why the process wasn’t followed.

Implementing the 5 Whys in Pharmacy

Imagine a situation where a patient receives the wrong dose of a medication. Start by asking why the error occurred. Perhaps the answer is that the prescription was misread.

1. Why did the patient receive the wrong dosage of medication?
The dosage was incorrectly labelled on the medication bottle.

2. Why was the dosage incorrectly labelled on the medication bottle?
The pharmacy technician selected the wrong dosage strength when preparing the medication.

3. Why did the pharmacy technician select the wrong dosage strength?
The prescription was not clearly written, leading to confusion.

4. Why was the prescription not clearly written?
The physician’s handwriting was difficult to read.

5. Why was the physician’s handwriting difficult to read?
The physician was in a rush and did not take the time to write clearly.

By the fifth “why,” you might identify that unclear handwriting was the root cause of the error, but is that truly the root cause of the issue? It’s important to drill down further to determine why the medication was given to the patient if the pharmacy technician could not confidently read the physician’s handwriting. 

What process should they have followed to ensure the correct dosage was given? This insight can lead to solutions like implementing electronic prescriptions that eliminate the need to read handwriting.

Benefits of the 5 Whys

  • Simplicity: Easy to implement without requiring extensive training.
  • Depth: Uncovers multiple layers of contributing factors.
  • Focus: Keeps the investigation targeted on the specific problem.

Also known as a cause-and-effect diagram, the fishbone diagram is a visual tool that helps identify various potential causes of a specific problem. Named for its fish-like shape, this diagram helps cluster buckets of contributing factors, making it easier to analyze complex issues.

How to Create a Fishbone Diagram

The Head (Effect): This is the problem you are trying to solve.

The Spine: A straight line that leads to the head, representing the problem.

The Bones (Causes): Major categories of potential causes branch off from the spine. These categories can vary but typically include Man, Material, Method, Measurement, Machine, and Mother Nature.

Sub-Causes: Branches off the main bones to identify more specific causes within each category.

Implementing the Fishbone in Pharmacy

Let’s use our example of a patient receiving the wrong dose of their medication. In this example, your fishbone diagram might look like this:

  • Man: Inadequate training, poor handwriting, fatigue, miscommunication
  • Material: Incorrect labelling, similar packaging
  • Method: Flawed prescription process, lack of double-checks
  • Measurement: Inaccurate scales, improper measuring tools
  • Machine: Faulty equipment, outdated software
  • Mother Nature: Environmental distractions, poor lighting
Illustration of fishbone diagram

By using a fishbone diagram, your pharmacy team can systematically analyze the potential causes of medication errors and implement targeted solutions to prevent future occurrences. This structured approach helps ensure that all possible factors are considered and addressed.

Advantages of the Fishbone Diagram

  • Comprehensive: Addresses multiple facets of a problem.
  • Visual: Makes it easier to understand and communicate findings.
  • Organized: Helps structure complex issues into manageable categories.

The Plan-Do-Study-Act (PDSA) is a four-step model for testing changes and implementing improvements. It involves planning a change, executing it, studying the results, and acting on what is learned, eventually leading to successful improvements. This iterative process ensures continuous improvement.

Applying PDSA in Pharmacy

Suppose you want to reduce the incidence of medication errors. Your PDSA cycle might look like this:

  • Plan: Introduce a double-check system for all prescriptions.
  • Do: Implement the system for one month.
  • Study: Review the number of errors before and after implementation.
  • Act: If errors decreased, expand the system pharmacy-wide; if not, revise the plan and test again.

Benefits of PDSA

  • Dynamic: Allows for ongoing refinement and improvement.
  • Evidence-Based: Relies on data to guide decisions.
  • Scalable: Can be applied to large or small changes.

Integrating These Tools In Your Pharmacy

Combining Methods

While each tool is powerful on its own, combining methods can provide a more comprehensive analysis. For example, start with the 5 Whys to identify the root cause, use a fishbone diagram to explore related factors, and then apply PDSA cycles to test and implement solutions.

Continuous Improvement

Remember that quality improvement is an ongoing process. Regularly review and update your analysis and solutions to ensure they remain effective over time. Encourage a culture of continuous improvement within your pharmacy to maintain high standards of patient safety and care.

Building a Culture of Safety and Improvement

Engaging Staff

Effective root cause analysis requires the involvement of your entire pharmacy team. Encourage open communication and create an environment where staff feel comfortable reporting incidents in Pharmapod and suggesting improvements. Regular training sessions can help reinforce the importance of quality improvement.

Monitoring Progress

Implementing changes is just the beginning. Continuously monitor the impact of your solutions and make adjustments as needed. 

Celebrating Success

Recognize and celebrate the achievements of your team. Positive reinforcement can motivate staff to continue striving for excellence and contribute to a culture of safety and continuous improvement.

Medication errors can have serious consequences, but with the right tools and approach, pharmacists can identify and address the root causes of these incidents and prevent them from reoccurring. Using the Pharmapod platform to report medication errors and good catches makes it easier to drill down into your data and identify where improvements can be implemented. 

Ready to improve patient safety in your pharmacy? Request a custom demo of the Pharmapod platform today.