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Managing Medication Errors

Today’s healthcare system has a serious problem with medication administration safety. Since drug administration mistakes can significantly affect patients’ health and well-being, healthcare organizations must take all necessary precautions to guarantee that medications are given to patients safely and precisely (Page & McKinney, 2020). This root cause analysis and improvement plan will look into a problem or sentinel event linked to medication administration safety in a healthcare context and generate an improvement plan based on the analysis findings. The plan’s justification will be based on academic research, best practices, and the availability of resources in the particular healthcare context.

Analysis of the Root Cause

An error in medication administration was the primary contributor to this sentinel incident. The patient was given the wrong drug dosage, which caused an unfavourable outcome. Further examination revealed that the nurse did not adhere to the correct procedures and lacked the training to deliver medications. The leading causes of the drug error and the ensuing adverse reaction were a lack of training and protocol adherence. Further inquiry showed that the nurse needed to be adequately supervised when administering the drug and her lack of training and adherence to protocols. The likelihood of a medication error rose due to the further breakdown in quality control caused by this lack of supervision.

Additionally, there were no protocols to confirm the dosage before giving the drug. Because of the lack of a double-check method, there was no way to ensure that any potential mistakes would be caught, which raised the risk of a drug error. The nurse’s lack of training, adherence to procedures, lack of supervision, and lack of a double-check mechanism were all factors that led to the drug error and the ensuing bad response. A medication error was not only likely but almost inevitable due to the nurse’s lack of training and attention to protocols and the absence of a quality control system. Sentinel occurrences like this can only be avoided by implementing appropriate protocols, sufficient training and monitoring, and a system of double-checking.

Application of Evidence-Based Strategies

Concerns about medication delivery safety can be addressed using several evidence-based techniques. To ensure accuracy and reduce the possibility of human error, these tactics include double-checking procedures, which entail having two healthcare experts confirm each medicine order and administration (Leape et al., 2022). An improved nursing education and training program can help ensure that nurses have the knowledge and abilities to deliver drugs safely. The safe and accurate administration of pharmaceuticals can also be ensured by giving nurses dispensing them more oversight (Leape et al., 2022). The use of technology can assist in lowering the risk of medication errors in addition to these techniques. Barcode scanning ensures that the proper medication is administered to the right patient in the correct dosage. Like paper records, electronic health records (EHRs) can give a thorough overview of a patient’s medical history and current prescriptions, making it simple for medical practitioners to access and correctly determine a patient’s drug requirements (Williams et al., 2019). Using these technologies can not only lower the possibility of medication errors but also streamline the administration of medications.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The following evidence-based and best-practice techniques are included in the suggested improvement plan to lower the risk of medication errors:

Double-checking systems

The healthcare system should implement a double-checking system to guarantee that the patient is given the right drug in the correct dosage. Two nurses should be employed to verify the drug and dosage before administration. To further verify that the prescription and dosage are precise, this method should also include an additional verification stage by a third nurse (Schutijser et al., 2019). In order to track and monitor any potential errors, the system should also have a method for maintaining permanent records of each medication provided.

Enhanced education and training

According to the healthcare system, all nurses who give medication should get proper training and education in this domain. To make sure that nurses are knowledgeable about the most current best practices, this should include the utilization of regular training and education sessions. Topics covered in these meetings should include how much medication to administer, any possible adverse effects, and when to take it (Wondmieneh et al., 2020). Additionally, it is essential to urge nurses to attend conferences and seminars on administering medications to further their expertise.

Increased supervision

The healthcare system should ensure that nurses are adequately supervised while giving drugs. Guarantee that the medication is provided correctly; this should entail implementing a system in which two nurses are assigned to the same patient. The supervisor should keep a careful eye on the procedure and provide the nurses with comments on how they are doing. The supervisor should also regularly check the medication records to verify accuracy.


To reduce the likelihood of medication errors, the healthcare system should embrace technology like barcode scanning and electronic health data. To swiftly and precisely identify the patient and the drug and confirm that the right dosage is being provided, barcode scanning should be employed. Each patient’s medications should be tracked in their electronic health records, which can notify the medical staff when a medication is late, or a possible medication error is discovered (Wondmieneh et al., 2020). To further lower the danger of prescription errors, cutting-edge technology like artificial intelligence should be considered.

The healthcare system can lower the risk of medication errors and maintain patient safety by using these evidence-based and best-practice methods.

Existing Organizational Resources

The healthcare system already has personnel and resources available that might be used to enhance the suggested plan’s execution and outcomes. Nurses can receive frequent training on drug delivery from the system’s current education and training department. The training sessions would focus on any new rules or practices that needed to be introduced, as well as the proper use and storage of medications (Citron et al., 2019). A technology department that is already in place inside the system can be leveraged to implement the utilization of barcode scanning and electronic health records. Utilizing this technology would enhance patient data tracking and medication administration accuracy.

Additionally, it would enhance departmental collaboration and deliver more comprehensive patient care. To guarantee that the system is functioning correctly, the technology department could also help by offering technical support to nurses and other healthcare professionals (Citron et al., 2019). Additionally, the healthcare system already has a quality control unit that may be used to evaluate and track the performance of the proposed plan. Additionally, this department can offer opinions and recommendations on enhancing the strategy and guaranteeing better patient outcomes.


In conclusion, this root cause analysis and improvement plan has identified a problem or sentinel event linked to medication administration safety in a healthcare context and has generated an improvement plan based on the analysis findings. Utilizing systems for double-checking, improved education and training, better monitoring, and the use of technology are just a few of the plan’s evidence-based and best-practice initiatives. The healthcare system also has personnel and resources already in place that can enhance the plan’s execution and results.


Citron, I., Jumbam, D., Dahm, J., Mukhopadhyay, S., Nyberger, K., Iverson, K., … & Ulisubisya, M. (2019). Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania. BMJ global health4(2), e001282.

Leape, L. L., Berwick, D. M., & Bates, D. W. (2022). What practices will most improve safety?: evidence-based medicine meets patient safety. Jama288(4), 501-507.

Page, K., & McKinney, A. A. (2007). Addressing medication errors–The role of undergraduate nurse education. Nurse education today27(3), 219–224.

Schutijser, B. C. F. M., Jongerden, I. P., Klopotowska, J. E., Portegijs, S., de Bruijne, M. C., & Wagner, C. (2019). Double checking injectable medication administration: does the protocol fit clinical practice? Safety Science118, 853-860.

Williams, K., Lang, E. S., Panchal, A. R., Gasper, J. J., Taillac, P., Gouda, J., … & Hedges, M. (2019). Evidence-based guidelines for EMS administration of naloxone. Prehospital emergency care23(6), 749–763.

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing19(1), 1-9.


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