The Institute for Safe Medication Practices Canada (ISMP Canada), the Canadian Institute for Health Information, and Health Canada are the three collaborating parties in the development and implementation of the Canadian Medication Incident Reporting and Prevention System (CMIRPS). These organizations are working with the Canadian Patient Safety Institute and an advisory committee to strengthen Canada’s ability to effectively manage and coordinate information about medication incidents. One of ISMP Canada’s roles in the CMIRPS is to assist with root cause analysis (RCA) for selected medication incidents. (For information on ISMP Canada’s other roles in the CMIRPS, see the CMIRPS web page).

To provide a standardized approach to the retrospective analysis of critical incidents and near-miss events in health care, ISMP Canada, Saskatchewan Health, and the Canadian Patient Safety Institute worked together to develop a Canadian Root Cause Analysis Framework. The Framework has been updated in 2012 and is entitled Canadian Incident Analysis Framework. The Framework is an analytic tool for performing a system-based review of incidents, including but not limited to medication incidents. It utilizes well established methods for analysis designed to help determine the root causes and contributing factors that led to an event and to identify strategies for implementing system improvements.

The goals of root cause analysis are to determine

• What happened?
• How and why it happened?
• What can be done to reduce the likelihood of recurrence and make care safer?
• What was learned?

RCA often reveals underlying system deficiencies that are not obvious, as well as issues that have become so familiar to those working in a particular environment that they are not identified as risks. RCA does not assign blame and is outcome directed, with emphasis on specific, high-leverage actions that take into account human factors engineering principles and the need to design systems with integrated safeguards.

Canadian health care providers are gaining knowledge and understanding about the impact of underlying system factors and the latent conditions that can increase the risk of incidents. ISMP Canada shares learning from incident analysis in the ISMP Canada Safety Bulletins and SafeMedicationUse.ca newsletters and alerts for consumers.

ISMP Canada provides educational workshops on RCA and can also be contracted to assist with analysis of sentinel events. For more information, send an email message to info@ismp-canada.org, call 416-733-4158, or call toll free 1-866-544-7672.

Download a copy of the most recent version of the Canadian Incident Analysis Framework (PDF).

ISMP Canada Publications on Root Cause Analysis:

Root Cause Analysis of Medication Incidents. ISMP Can Saf Bull 2005; 5(10).

Greenall J, Senders JW. Root Cause Analysis: Learning from Adverse Events and Near Misses. Medication Safety Alerts. Can J Hosp Pharm 2006; 59 (1): 34-36.

Wichman K, Greenall J. Using root cause analysis to determine the system-based causes of error. CPJ 2006; 139(3): 63-65.

Greenall J, U David. Root Cause Analysis: A patient safety tool. Hospital News, December 2005.

Examples of Root Cause Analyses Conducted by ISMP Canada:

Fluorouracil Incident Root Cause Analysis

Event Analysis Report: Hydromorphone/Morphine Event

(Links published with permission.)

Root Cause Analysis conducted by ISMP (US):

Shaping systems for better behavioral choices: lessons learned from a fatal medication error (in which an epidural pain medication was administered intravenously)