Root cause and corrective action: Prevent errors from repeating on you: pharmacists: on demand

Target Audience:

Pharmacists in community-based practice.

Universal program number: 0401-0000-17-058-H05-P
CE Broker tracking number: 20-600798

This program has been approved by the Florida Tripartite Committee as an option for the Florida Medication Errors requirement.

Activity type: Knowledge-based


To provide medication safety continuing education, utilizing RCA methodology, to pharmacists and technicians.


A root cause analysis is an effective tool to investigate an adverse event. RCA is a process for identifying the basic or casual factors that underlie variation in performance, including the occurrence or risk of occurrence of a sentinel event. RCA focuses primarily on systems and processes, not individual performance. Finding and identifying root causes during an investigation adds considerable value by pointing out significant, underlying, fundamental conditions that increase the risk of adverse consequences. They facilitate system evaluation, analysis of need for corrective action and tracking and trending. Targeting corrective measures at the identified root causes is the best way to ensure that similar problems do not occur in the future. This session will review RCA methodology that has recently been developed specifically for use in community pharmacy settings.

Learning objectives:
  1. Recognize factors in the practice environment that can contribute to the occurrence of medication errors.
  2. Utilize ISMP’s “Key Elements of the Medication Use System” to help identify and prevent  risk in daily practice.
  3. Describe how to analyze a medication error using a specific set of steps and associated tools to help the user identify the contributing factors and root causes of the event.
  4. Specify how to use information gathered during a root cause analysis to minimize the reoccurrence of medication errors.
  5. Select effective error reduction strategies that can prevent patient harm and engage in practices that assure patient safety.
  6. Prepare an action plan from the RCA, which includes risk-reduction strategies, communication, and implementation strategies as well as ways to measure effectiveness.
To obtain credit:

To complete the program and receive CPE credit, view all lesson content and complete the learning assessment by submitting answers online. A minimum test score of 70% is needed to obtain credit. After successfully completing the learning assessment, participants must complete a program evaluation and claim the available CPE credit. Participants also must verify personal information required by CPE monitor and/or CE Broker (for Florida license holders) prior to submitting CPE credit claims. Official statements of credit are available only through CPE Monitor located at

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Drug Store News is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This CPE activity is approved for pharmacists and is worth 2.0 contact hours (0.2 CEUs). The activity is available for CE credit through July 26, 2020.

Course summary
Credit hours: 
  • 2.00 Pharmacist
Course opens: 
Course format: 
On-demand Webinar
Course expires: 

Donna Horn, RPh, DPh, MS, director patient safety, Community Pharmacy ISMP

Donna Horn and the DSN editorial and continuing education staff do not have any actual or potential conflicts of interest in relation to this lesson.

Available Credit

  • 2.00 Pharmacist

Accreditation Period

Course opens: 
Course expires: 


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