Root Cause Analysis

FISH BONE : CAUSE-EFFECT DIAGRAM

HUMAN FACTORS PHARMACY EQUIPMENT & SUPPLIES

MEDICATION ERRORS

HUMAN FACTORS NURSING

PHARMACY TECH STRESS & BURNOUT

ERROR PHARMACISTS

NEED TO BE ON THE UNIT MORE OFTEN

PHARMACY KNOWLEDGE

DEFICIT: 7 RIGHTS

PHARMACISTS UNAVAILABLE

BY PHONE

SCANNERS FAIL TO SCAN

UNIT DOSE MACHINES ALWAYS

BREAKING DOWN

BARCODE LABELS ARE DEFECTIVE, SCANNERS

CAN’T READ THEM

LOOK-ALIKE MEDICATION

KNOWLEDGE DEFICIT: GENERIC VS. TRADE

NAMES

INADEQUATE STAFFING

KNOWLEDGE DEFICIT: NO RIGHTS OF MEDICATION

ADMINISTRATION

WORKAROUND: MANUAL ENTRY EIN