Root-Cause Analysis and Safety Improvement Plan

Root-Cause Analysis and Safety Improvement Plan

Medication Errors Root Cause Analysis and Safety Improvement Plan

Root cause analysis (RCA) is a tool used to investigate and understand the underlying causes if patient safety incidents such as medication errors (Ahmed et al. 2019). It helps in problem identification so that health practitioners can introduce changes that improve care quality and patient experience. Medication errors is a typical incident that requires an RCA that will ultimately produce various recommendations to reduce medication errors and improve patient safety.

The application of RCA to medication errors within a clinical care setting is especially important considering the alarming numbers of increased length of stay, hospital injuries and death that adverse events have caused in American hospitals (Gates et al. 2019). For instance, according to Mazer and Nabhan (2019), at least 200,000 deaths are attributable to medication errors yearly, indicating that there are various root cause factors that play a role in those events, and that are worth exploring. This report covers an RCA of ten hospitals in the US, analyzing and describing the fundamental causes and major contributors to medication errors, as well as an evidence-based plan and resources for improving patient safety.


Root Causes Of Medication Errors And Evidence-Based Solutions

When nurses, pharmacists of physicians offer any type of healthcare service to patients, they can unknowingly inflict injury on the patient or cause adverse events such as medication errors or misdiagnosis. As per Gates et al. (2019) 10-20% of medication orders contain medication errors depending on the adverse event, for instance delayed medicine administration.

However, Gates et al. (2019) also found out that serious medication errors make up 5% of medication administrations in the US.  In the case of Delaware Community clinic, the management reports collected ever the past 30 days indicated that for every 100 medication administration cases, seven of errors are experienced. This number is above the acceptable rate of medication errors.

The data was collected through direct and non-participant observations of medication preparation and delivery. The non-participatory observation of medication errors yielded important information about medication errors. For example, it was observed that distractions and secondary events were among the direct cause of medication errors in the Delaware Community clinic.

While most medication errors are preventable, they cause an array of adverse events such as triggering new health conditions patient injury, or in worst cases, death (Ibrahim et al. 2020). Medication errors also lengthen hospital stay, increases cost of healthcare, and inflicts psychological or physical pain to the patient and their families. Regarding healthcare organizations, medication errors reduce patient satisfaction and ultimately contributes to trust issues towards the nurses, physicians, and entire health organization.

The RCA was conducted by a team of six practitioners including a clinician, a supervisor, two quality improvement personnel and two nurses. Through nurse observations, the medication errors were recorded with an emphasis on medication ordering and administration services. The error cases were categorized under prescription omission, wrong timing, improper usage, dose preparation and dosage, medication administration errors including extra dosage and giving the to the wrong patient.

The observed incidences revealed that time, unauthorized administration, and dosage errors were the most prevalent, accounting for 17, 10 and 18 percent of the medication errors respectively. The observations also indicated that the errors occur during the periods of high activity, for instance during shift changes and during emergency calls. The RCA also showed that staff-related causes of medication errors were attributable to inadequate pharmacological knowledge.

For instance, it was observed that nurses who lacked the ideal knowledge of the ideal medication administration route were likely to cause incidences of intravenous injections. The errors were also observed to be highly associated with poor knowledge of drug pharmacological properties as well as excessive dosage. These errors were observed to be primarily caused by the complex nature of intravenous medication, which require vast experience to deliver the drug as optimally as possible.

Particularly, the nurses who made these mistakes showed a lack of in-service training among newer staff, which constrain them of the necessary knowledge needed to prepare and deliver the drugs. as recommended by Mazer & Nablan (2019), in-service training on pharmacology and administration of complex medicine could be a good approach to reducing such medication errors.

The second root cause of medication errors in the Delaware Community clinic was a shortage of nurses, which increased the workload of nurses needed at one point in time. Interviewed nurses revealed that medication errors were highly attributable to understaffing because nurses were under pressure to cover all the workload. Therefore, some evidence-based solution to understaffing is employing more nurses, ensuring a smoother change of shifts, and supporting the nursing staff as much as possible (Mazer & Nabhan, 2019).

For instance, during the root cause analysis, it was observed that some laboratory staff could call the physicians to physically collect the lab results, yet the results could easily be transmitted to the physician using electronic medical records system (EMRs). Rezaei (2019) recommends that EMRs can reduce medication errors by facilitating fast, efficient, and reliable transmission of patient information between nurses, pharmacists, laboratory technicians and the patient. Using technology to transmit important information such as lab reports could help minimize the pressure that comes with physically handling the data.

Improvement Plan

The improvement plan following this RCA will take two approaches namely improvement of staffs’ skills and knowledge and making the necessary environmental changes to minimize medication errors. The first item of the plan is to improve the hospital’s medication monitoring system to improve staff coordination and enhance prescription accuracy through various cross-checking points and communication among staffs. The second improvement plan will be to train the staff on how to prevent medication errors, especially when administering complex medications such as intravenous injections. The training should improve the nurses’ pharmacological knowledge especially on new drugs, contraindications, dosages, and proper administration.


Medication errors are associated with lengthened hospital stays, injury, increased care costs and even death. An RCA of the factors contributing to medication errors revealed important information on some of the leading causes as well as their potential solutions. The report indicated that nurse lack of skills and knowledge, followed by poor communication and distractions are the most common cause of medication errors. Some of the evidence-based strategies for addressing the problem include improvement of staffs’ skills and knowledge and making the necessary environmental changes to minimize medication errors. These two solutions will provide a ground approach to minimizing medication errors in Delaware Community hospital.

Root-Cause Analysis and Safety Improvement Plan References

Ahmed, Z., Saada, M., Jones, A.M., & Al-Hamid, A.M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14.

Gates, P.J., Baysari, M.T., Mumford, V., Raban, M.Z. & Westbrook, J. I. (2019). Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931-939.

Ibrahim, O.M., Ibrahim, R.M., Meslamani, A.Z.A., & Mazrouei, N.A. (2020). Dispensing errors in community pharmacies in the United Arab Emirates: investigating incidence, types, severity, and causes. Pharmacy Practice (Granada), 18(4), 2111.

Mazer, B.L., & Nabhan, C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267.