title: Root Cause Analysis Design and Its Application to Pharmacy Education.
abstract: Objective. To evaluate third-year pharmacy students' ability to effectively design and apply root cause analysis (RCA) to a sentinel event and to analyze student responses for areas of proficiency and deficiency. Methods. This study involved a comprehensive review of RCA key assessments from 82 students in spring 2014. The performance assessments consisted of a review of each student's RCA worksheet and flow diagram as well as the 1-2 page narrative reflection. Results. The majority of students were able to successfully design an RCA, but had challenges with 3 components: fact-finding session, disclosure plan, and a flow diagram. Several students perceived challenges to conducting a formal RCA in certain health care settings, which included assembling an RCA team and gathering relevant facts, a lack of transparency/safe environment within organizations, and creating a plan for multiple/sequential errors. Conclusion. Most students were able to design an RCA process, but encountered difficulty with some components. Students also identified challenges in applying the approach in certain health care arenas.
authors.affiliation: University of New Mexico College of Pharmacy, Albuquerque, New Mexico.
authors.forename: Mark T
authors.initials: MT
authors.lastname: Holdsworth
authors.affiliation: University of New Mexico College of Pharmacy, Albuquerque, New Mexico.
authors.forename: Rucha
authors.initials: R
authors.lastname: Bond
authors.affiliation: University of New Mexico University Hospital, Albuquerque, New Mexico.
authors.forename: Saumeel
authors.initials: S
authors.lastname: Parikh
authors.affiliation: University of New Mexico College of Pharmacy, Albuquerque, New Mexico.
authors.forename: Bahie
authors.initials: B
authors.lastname: Yacop
authors.affiliation: University of New Mexico College of Pharmacy, Albuquerque, New Mexico.
authors.forename: Kristina M
authors.initials: KM
authors.lastname: Wittstrom
mesh_terms: D003695:Delivery of Health Care; D004512:Education, Pharmacy / Q000379:methods*; D004521:Educational Measurement / Q000379:methods*; D006801:Humans; D060891:Root Cause Analysis; D013339:Students, Pharmacy
keywords: pharmacy students; root cause analysis; sentinel events