The Utility of Root Cause Analysis and Failure Mode and Effects Analysis in the Hospital Setting

This activity is for pharmacists and is sponsored by Postgraduate Healthcare Education, LLC (PHE).
There has been no commercial support for this activity.


Jennifer Gibson, PharmD
Medical Writer
President of Excalibur Scientific

Marsha K. Millonig, MBA, BPharm
Medical Writer
President & CEO, Catalyst Enterprises, LLC

Editorial Note:
Contributions to educational materials: Material released January 30, 2019 through January 30, 2022 under ACPE 0430-0000-18-077-H05-P developed and written by Jennifer Gibson, PharmD. Updated with additional writing and references in 2022 by Marsha K. Millonig, MBA, BPharm.

The original clinical review was completed by Laura Stinson. Clinical reviewer for updated material completed by L. Michael Posey, BSPharm, MA.


Jennifer Gibson, PharmD, and Marsha Millonig, MBA, BPharm have no relevant affiliation or financial relationship or relationship to products or devices with a commercial interest related to the content of this activity to disclose.

The following reviewers, Laura Stinson and L. Michael Posey, BSPharm, MA, have  no relevant affiliations or financial relationships or relationships to products or devices with a commercial interest related to the content of this activity to disclose.

Susanne Batesko, RN, BSN, Mary Camillo, and the planners, managers, and other individuals, not previously disclosed, who are in a position to control the content of Postgraduate Healthcare Education (PHE) continuing education (CE) activities hereby state that they have no relevant conflicts of interest and no financial relationships or relationships to products or devices during the past 12 months to disclose in relation to this activity. PHE is committed to providing participants with a quality learning experience and to improve clinical outcomes without promoting the financial interests of a proprietary business.


acpePostgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-22-022-H05-P
Credits: 2.0 hours (0.20 ceu)

Type of Activity: Knowledge
Media: Internet

Fee Information: $7.95
Estimated time to complete activity: 120 minutes

This course is approved by the Florida Board of Pharmacy, provider number 50-17869. CE Broker Course ID: 20-895882.
Postgraduate Healthcare Education, LLC reports registered course completions by Florida license holders to the CE Broker System.


February 3, 2022


February 3, 2025


This accredited activity has been designed for pharmacists.


During the period February 3, 2022, through February 3, 2025, participants must 1) read the learning objectives and faculty disclosures; 2) study the educational activity; and 3) complete the post-test and the evaluation form. To answer the questions, click on your selected choice for each answer then proceed to the next question. Once completed, click on Grade Exam at the bottom of the page. Your post-test will automatically be graded. If you successfully complete the post-test (score of 70% or higher), your statement of participation will be made available immediately. Click on the View Statement of Participation link and print the statement for your records. If you receive a score lower than 70%, you will receive a message notifying you that you did not pass the post-test. You will have 2 opportunities to pass the post-test. To receive Credit, you must provide your date of birth and NABP number. All Credit information will be uploaded into CPE monitor within 30 days.


Identifying and preventing medication errors is a significant challenge in all healthcare settings. Pharmacists and pharmacy technicians must understand common methodologies for detecting sources of risk in order to participate in error and risk investigations and to implement changes in pharmacy practice.


Upon completion of this program, participants should be better able to:

  • DISCUSS the prevalence and causes of medication errors in the United States
  • DESCRIBE the utility of root cause analysis in the healthcare setting
  • OUTLINE the steps involved in a failure mode and effects analysis
  • SUMMARIZE the benefits of drawing from a multidisciplinary team to complete patient safety evaluations
  • LIST 4 strategies that can be employed in the pharmacy to help reduce medication errors


Please ensure the computer system you plan to use meets the following minimum requirements:

  • Operating System: Windows 98 or higher & Macintosh 2.2 or higher
  • Internet Browser (Mac & Windows): Internet Explorer 6.0 or higher, Google Chrome, Safari 5.0.6 or higher, Firefox 3.0.3 or higher, & Opera 5 or higher
  • Broadband Internet connection: Cable, High-speed DSL & any other medium that is internet accessible
  • Peripherals: Computer speakers or headphones
  • Monitor Screen Resolution: 320 x 480 or higher
  • Media Viewing Requirements: Adobe Reader, Microsoft PowerPoint, Flash Player & HTML5

Disclosure of Unlabeled Use and Disclaimer

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of Postgraduate Healthcare Education, LLC. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions, and possible contraindications on dangers in use, (review of any applicable manufacturer's product information) and comparison with recommendations of other authorities.

The author, sponsor, and publisher of this continuing education activity have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. However, because information regarding drugs (their administration, dosages, contraindications, adverse reactions, interactions, special warnings, precautions, etc.) is subject to constant change, the reader is advised to check the manufacturer's package insert for information concerning recommended dosages and potential problems and cautions prior to dispensing or administering the drug. Special precautions should be taken when a drug is new, or highly toxic, or is unfamiliar to the dispenser or administrant. This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the U.S. Food and Drug Administration (FDA). Neither the publisher nor sponsor promotes the use of any agent outside of approved labeling. Statements made in this activity have not been evaluated by the FDA. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

Purchase Options

Single Course
The Utility of Root Cause Analysis and Failure Mode and Effects Analysis in the Hospital Setting
Amount to be charged: $7.95
Single Course
Pharmacist CE Library
This single course is included in the Pharmacist CE Library. This library provides 1 year unlimited access to 50 ACPE credit hours and a minimum of 1 Live CE Webinar per month.
Amount to be charged: $99.00
Pharmacist CE Library
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*Credits purchased through premium pharmacist course bundles can only be used for individual courses priced at $7.95 and cannot be used for Live Webinars. Once a course bundle is purchased, access to premium courses will be automatically granted, and your credits will be reduced as they are used. Once all credits are used, premium course access will require payment.