Comparative Pharmacy Medication Near-Miss Analysis using Root Cause Analysis (RCA) versus Human Factors Analysis Classification System (HFACS)
Care Process & Redesign
Singapore Healthcare Management Congress
SingHealth
31 December 2018
Classify medication near misses using RCA and HFACS methodologies, and evaluate the feasibility of a combined tool. A unified tool combining RCA and HFACS methodologies can provide comprehensive insights and improve patient safety.
Year Submitted: 2018
Published Date: 31 December 2018
Tags: Care Process ＆ Redesign, Value Based Care, Risk Management, Preventive Approach, Quality Improvement, Clinical Practice Improvement
About this Content
Aims
Classify medication near misses using RCA and HFACS methodologies, and evaluate the feasibility of a combined tool.
Background
Medication near misses lacked systematic analysis, limiting identification and mitigation of recurring issues.
Methods
Conducted retrospective and prospective analyses, interviewed staff, and used R programming for correlation analysis.
Results
Identified strong correlations between RCA and HFACS, enabling the formulation of a singular analytical tool.
Conclusion
A unified tool combining RCA and HFACS methodologies can provide comprehensive insights and improve patient safety.
Lessons Learnt
Structured methodologies enhance the identification of root causes and preventable factors in medication errors.
Additional Information
Recognized at SHM 2018 Risk Management Conference for its analytical rigor.
Keywords
Medication Safety, RCA, HFACS
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | KK Women and Children Hospital |
Platform(s) | Singapore Healthcare Management Congress |
Healthcare Professional Group(s) | Pharmacy |
Applicable Specialty or Discipline | Obstetrics and Gynaecology, Pharmacology |
Project Lead(s) | Eng Jing Jia |
Project Member(s) | Mohammed Nazri |
Connect with this contributor!
Eng Jing Jia - singaporehealthcaremanagement@singhealth.com.sg
Project Attachment
C267_KKH_Comparative_Pharmacy_Medication_Near_Miss_Analysis.pdf