TABLE 1.

Summary of the RCA Recommendations and Improvements Achieved.

Root‐cause analysis Recommendations	Improvements Achieved
Workflow
Develop a new workflow between the pharmaceutical care department, pharmaceutical planning, and the facility’s ER satellite pharmacy on requesting medications unavailable in the pharmacy main store.	The workflow of ordering and re-stocking antidotes between the pharmacy main store and the ER & ICU satellite pharmacy was developed.
Move all antidotes from the warehouse to the pharmacy main store immediately upon delivery (excluding antidotes with non-toxicological indications and regular consumption e.g. Calcium chloride).	All antidotes are now stocked in the pharmacy main store upon delivery (i.e. on-site).
Storage & Workspace
Dedicate a special area within the ER and ICU satellite pharmacies for stocking antidotes (antidote shelves), including designated shelves in the refrigerator for refrigerated antidotes.	We now have a specific area within the ER and ICU satellite pharmacies for storing antidotes. All antidotes are stored in a clear area on the antidote shelf in alphabetical order with an information sheet on the minimum quantity available for each antidot to be checked and verified by staff on each shift.
Expand the ICU satellite pharmacy to accommodate the huge service covered by the satellite.	Planned and under consideration.
Pharmaceutical Planning
Develop a task force to estimate the minimum quantity required for all antidotes, and provide that list to the planning department for procurement.	The team identified important antidotes that were not listed on the formulary. Overall, ten antidotes were evaluated and approved by the hospital’s pharmacy and therapeutics committee for addition. See table 2 for the list of antidotes added. The team developed the hospital's antidote list with the minimum quantity that should be stocked at the facility, utilizing published literature, real historical consumption data, the expertise of toxicologists dealing with toxicity cases, together with i
Education
Provide staff with easy access to antidote information (e.g. indication, dosing, and administration).	At the time of this publication, the team had developed 20 antidote data sheets, which include information about the antidote’s indication, adult and pediatric dosing, method of preparation, monitoring parameters, and administration. These data sheets were also posted on the hospital’s intranet to ensure rapid access to information, and are also accessible in hard copies on the antidote shelves.
Technical
To expedite and support the new electronic integrated pharmaceutical inventory module which will also be integrated with the CPOE system.	Under development.

CPOE: computerized physician order entry; ER: Emergency Room; ICU: Intensive Care Unit