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

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