Root-Cause Analysis of
Medication-Related Sentinel Events
Based on our extensive knowledge of the system-based causes of medication errors, strategies for error prevention, and our experience with proactive failure mode and effects analysis (FMEA), ISMP is in a unique position to assist your designated team in investigating the root-causes of your stated variance. Using ISMP's Key Elements of the Medication Use Process, our consultants can help your team formulate an action plan for process improvement that is specific to the needs of your organization and meets the regulatory requirements of accrediting agencies.
The interdisciplinary consulting team for this visit typically consists of two or three experienced practitioners. The length of the visit may vary from one to two days, based on the size of the facility, amount of preparatory work done by the facility, and number of departments involved in the investigation process. A detailed written report summarizing priority recommendations for improvement is provided following the visit. ISMP recognizes the highly sensitive nature of this type of consultation visit, and maintains strict confidentiality at all times.