title: Root Cause Analysis, Part 1: Nonsterile Compounding.
abstract: When an adverse event or near miss occurs in a pharmacy, eliminating the root cause to prevent recurrence is critically important. We occasionally see pharmacies address deviations in a manner that only superficially addresses the adverse event, but does not address the root cause of the problem, thereby putting patients and the pharmacy at risk of a recurrence. This article proposes a method for performing Root Cause Analysis.
authors.forename: Joe
authors.initials: J
authors.lastname: Cabaleiro
authors.forename: Kathleen
authors.initials: K
authors.lastname: Jackson
mesh_terms: D011232:Chemical Precipitation; D002626:Chemistry, Pharmaceutical; D004304:Dosage Forms; D004339:Drug Compounding / Q000379:methods / Q000592:standards*; D005421:Flavoring Agents / Q000592:standards; D006801:Humans; D000067491:Near Miss, Healthcare / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care; D004364:Pharmaceutical Preparations / Q000592:standards*; D011340:Problem Solving; D011786:Quality Control; D018570:Risk Assessment; D012307:Risk Factors; D060891:Root Cause Analysis
chemical_list: D004304:Dosage Forms; D005421:Flavoring Agents; D004364:Pharmaceutical Preparations