So far, in our series about the five key activities of ACP’s new continuous quality improvement program—CQI+—we have explored Prevent and Respond. In this article, we’ll take a closer look at the third key activity: Analyze.
Analyze is where pharmacy teams work to identify contributing factors and root causes of practice incidents and close calls when they occur. This analysis allows the pharmacy team to move beyond what happened and focus on why it happened. Each member of the pharmacy team should have an opportunity to contribute to the analysis, as everyone will have a different experience of the systems and processes in the pharmacy and may identify unique risks and contributing factors within their own role. Remember, open and honest communication about safety concerns is a hallmark of a positive safety culture.
Where possible, pharmacy teams are also encouraged to involve patients and/or their caregivers in the analysis of practice incidents. Patients may provide valuable insight into the best course of action to address the contributing factors and root causes of the practice incident. This will also validate the patient’s experience and maintain (or re-build) trust through accountability and transparency.
One method of analyzing practice incidents and close calls is diagramming. Diagramming involves asking “why” to visualize the relationship between contributing factors and the outcome being analyzed, such as patient harm, or potential patient harm in the case of a close call.
Diagramming supports pharmacy teams in engaging their curiosity to really think about all of the potential contributing factors to the incident. Please visit the CQI+ Resources page for tools to help your pharmacy team identify contributing factors and root causes of practice incidents and close calls. Importantly, your pharmacy’s practice incident management platform will include various options to analyze practice incidents and close calls, streamlining your documentation and analysis. Remember, results of your team’s analyses must be documented and used to create action plans to address the risks identified.
Action plans are one component of Improve, the subject of the next article in our series. Stay tuned!
