Significant event audit
Another technique that is slightly less intensive than the RCA, but can be used in a similar manner, is the significant event audit (SEA). This differs from RCA in that it analyses events that stand out from daily practice – both positively and negatively.
It is less involved than a complete RCA and may be better suited for working through the day-to-day things that happen in pharmacy practice.
There are three basic steps to an SEA:
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Describe what happened and any issues arising from the significant event.
This can include positive things, such as the accurate dispensing of a complex prescription, an error-free day, or any event for which you’ve had positive feedback. By analysing why something went well, it can be repeated, just as analysing why something went badly can help in ensuring it is done differently in the future.
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Describe what went well, what went less well and what could be done differently next time.
Think about how you, as an individual, contributed to the outcome of the event and how your systems contributed to this outcome. As a result, what would you do next time? Would you do the same thing or something different?
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Describe what you’ve learnt from the event.
How would adjust your performance if a similar situation arose again? Think about how you would apply the factors that contributed to the outcome of other situations in your workplace. If this was successful, what might you take from this experience to use on other occasions?
Getting into the habit of doing a quick SEA as part of the working week should contribute to establishing a safer workplace, as it gives people the opportunity to learn from errors more rapidly, therefore helping to move towards a learning culture where incidents can be prevented.
Learning campaign
- Access the CPPE patient safety campaign for more information
- Sign up for CPPE’s Patient safety: an anticoagulant case study workshops
- Share how the patient safety campaign is influencing your practice on Facebook, Twitter and Instagram using the hashtag #CPPEPS.