Improvement Plan Tool Kit

Medication administration errors are leading causes of death and unnecessary injury in healthcare institutions. They are a leading cause of unintentional injury and death, causing over 7000 deaths annually. In addition, they cost the healthcare system over $20 billion annually in addition to morbidities such as amputations, blindness, hearing loss, cardiac injury, and acute kidney injury.

Improvement Plan Tool Kit

When preparing and considering a safety improvement plan, there are various themes that a healthcare provider must address. These factors include medication error causes, evidence-based strategies to manage medication errors, and barriers to medication error identification and reporting. These factors form the three essential themes under which this paper will provide detailed annotated bibliographies of articles with relevant information on the various themes.

Theme 1: Causes of Medication Administration Errors

Zarea et al. (2018) conducted a cross-sectional descriptive-analytical study using 225 nurses in various hospitals to study the causes of medication errors and their related factors. The study showed that among the significant errors by nurses include administering oral medications together despite their drug interactions, administering analgesics postoperatively without a prescription, and wrong timing of medications constituted familiar nurses’ medication errors.

The study also analyzed causes/ factors leading to medication errors among nurses. According to this study, the most common factors are a low nurse-to-patient ratio, high workload and urgency (such as in emergency departments), and fatigue from the high workload. The study notes that nurses fear reporting medication errors because of legal consequences. Zarea et al. (2018) also note that nurses should base their interventions around these factors, such as increasing the number of staff, increasing nurses’ knowledge, and modifying staff workload.

Intravenous medication errors contribute to a significant percentage of medication administration errors. Kuitunen et al. (2021) conducted a systematic review to evaluate the systemic causes of intravenous medication administration errors. According to the study, the systemic causes of medication administration errors were insufficient guidelines on handling high-alert medications, LASA drug confusion, lack of medication knowledge, failure in double-checking procedures, calculation problems, poor CPOE standardization, CDSS systems failure, and communication errors.

Frequency/calculation errors, failure to secure high-alert medications, and lack of knowledge were identified as the leading causes of medication errors. The study also notes that healthcare providers must address prescribing and preparation errors to protect patients due to their high vulnerability to infusion medication errors.

Izadpanah et al. (2018) conducted a cross-sectional descriptive study to evaluate the causes and frequency of medication errors in the pediatric and emergency wards of Hospitals affiliated with Tehran University. The study randomly selected 24 hospitals and focused on their pediatric units.

The data from the study showed that the hospital units had an average of 41.9 medication errors in one month, showing that their prevalence is high. The study identified the most common type of medication errors: wring time drug administration, incorrect dosage, forgetting dosage, administering more dosages than prescribed, wrong patients, and following verbal orders.

The study identified the most common causes of medication errors: illegible prescriptions, staff shortage, high workload, lack of physician knowledge, LASA drugs confusion, lack of appropriate formulations for children, and inadequate nurse training on medication administration. Some of these results are synonymous with Kuitunen et al. (2021).

Hammoudi et al. (2018) conducted a descriptive cross-sectional study using 367 nurses. The study cut across two themes; causes/factors associated with medication errors and barriers to reporting. The study results showed that significant factors associated with medication errors are medication packaging, poor nurse-physician communication, flawed pharmacy processes, poor transcribing processes, and nursing shortage.

The study showed that the significant barriers to medication error reporting were administrative responses and fear of discrepancies in the definition of errors. Thus, healthcare leaders should focus on developing less stringent policies that clearly define medical errors and promote reporting with fewer repercussions to the nurses.

The study also evaluated the rate of medication error reporting; about 58% of the nurses confessed to reporting less than 20% of medication errors. Thus, medication errors are a potentially more significant problem that requires strict attention.

Tawfik et al. (2018) emphasized the importance of understanding medication error causes to enhance the development of interventions that address the root causes, hence effectively addressing the healthcare problem of medication error. Tawfik et al. (2018) conducted a broad study to evaluate medical errors and the contribution of physician burnout, well-being, and work unit safety.

Medication errors are the most common medical errors, hence the significance of this study. The study results showed that care providers reporting suicidal ideations and signs of burnout were more likely to be involved in medication errors.

In addition, care providers in units reporting poor safety grades were more likely to be involved in medical errors. The study introduced a vital factor to consider in medication errors: the care provider’s well-being. Thus, interventions to prevent medication errors should also focus on the care providers well-being and environmental safety.

Theme 2: Evidence-Based Strategies in Preventing Medication Errors

Misasi and Keebler (2019) note that verification processes are associated with a reduction in medication errors. Professionals can verify, especially ‘the seven rights of medication administration. Human factors engineering is a promising technology that can improve the verification process and produce better outcomes, especially in the outpatient department.

Misasi and Keebler (2019) evaluated an HFE-driven process for reducing medication errors in the emergency department. The study collected and analyzed data for 54 months, showing a decreased average monthly error rate of 49.0% on all medications administered post-implementation. For specific medications, the rate of fentanyl medication errors, a common analgesic, was reduced by 71.1%.

This study shows the effectiveness of team-based cross-checks systems in reducing medication errors. Healthcare institutions’ departments should also adopt compatible systems to reduce medication errors within their institutions.

Gohari et al. (2021) conducted a systematic review to evaluate the effects of CPOE and CDSS, leading prescription and guidance systems, on reducing adverse drug events in the emergency department. The study results showed that CPOE and CDSS could significantly reduce adverse drug events, excessive dosing, and inappropriate prescribing. Studies report varying effectiveness of the technologies, synonymous with the results of Misasi et al. (2019).

Thus, organizations should evaluate available technologies for their feasibility with the organization before implementing them. They should also consider improving some features for more specific results within their organization. The study also notes that these technologies are promising, and more studies are required to determine their effectiveness in reducing other errors in the emergency department.

Mieiro et al. (2019) conducted a timeless search of articles to evaluate the various strategies nurses use to minimize errors in emergency care. The main strategies from the search were educational, organizational, and new technologies. Educational strategies include staff training and workshops, campaigns, and interdisciplinary teams responsible for preventing and reducing medication errors and adverse drug events.

Organizational strategies include changes in processes, policies, guidelines, and meetings. New technologies include prescribing technologies such as unit doses, barcoding, CPOE, and CDSS systems. The study showed that emergency department nurses employ various strategies that are feasible for their department. These

Nguyen et al. (2018) conducted a systematic review to determine the effectiveness of medication errors in neonatal care. The study analyzed interventions from 102 studies and classified these interventions into six themes: organizational, personnel, pharmacy, risk analysis, technology, and multifactorial interventions. Multifactorial interventions were associated with higher effectiveness in reducing medication errors.

Most studies showed that >90% of the interventions reduced medication errors. The study recognizes the importance of implementing medication error prevention interventions depending on their feasibility with the organization. The study results also showed that no single intervention was superior to others, and these interventions address specific errors in the medication administration process (prescribing, transcribing, dispensing, and administering processes).

Theme 3: Barriers to Medication Error Identification and Reporting

Nurses play a vital role in error identification and reporting to enhance the prevention of medication administration errors. Errors must be identified and reported to provide the data required to drive change. Failure to identify and report these errors leads to inaccurate data and poor decision-making. Poor identification and reporting of these errors is thus a considerable barrier to medication error prevention.

Dirik et al. (2019) conducted a descriptive survey to investigate the involvement of nurses in medication error identification and reporting. However, Dirik et al. (2019) note that underreporting is a significant barrier to the success of efforts in medication error prevention. As identified earlier, the major contributing factor to underreporting is fear of legal and disciplinary implications such as lay-offs, lawsuits, and pay cuts.

Rutledge et al. (2019) also note that most medication error events go unreported, leading to poor preparation and less effort than needed to prevent medication errors. The researchers conducted a descriptive study to report the barriers to report medication errors at a faith-based community hospital in California.

The study’s results showed features that reduce medication error reporting, including the time-consuming nature of medication error reporting and fear of severe repercussions. Thus, medication errors go majorly unreported, and most available data on these medication errors is not representative of the current situation of medication errors.

Rutledge et al. (2018) note that organizations ought to develop interventions that simplify the medication error reporting tools and ease the severe repercussions for nurses and other healthcare providers involved in medication errors. These two steps will improve the reporting process, help provide data representative of the organization’s safety state and aid in implementing interventions promoting patient safety.

Jember et al. (2018) note that medication error reporting shows responsibility and appreciation of the impact of medication errors on the patient and other stakeholders. Jember et al. (2018) conducted a cross-sectional study with 397 nurses to investigate the proportion of medication errors that were reported and associated factors.

The study reported a high medication error-reporting rate (57.4%) than other studies. The factors associated with reporting included sex, marital status, being involved in a medication error, and having experience in medication error reporting.

The study recommends that all nurses report medication errors to improve patient safety and improve patient outcomes. In addition, the study recognized that there lacks a succinct medication error reporting system that allows tracking of these errors hence missed opportunities.


Here are various issues of interest in medication errors. The annotated bibliography addressed various themes, including causes, evidence-based strategies, and barriers to identifying and reporting these errors. The causes are many and are not limited to knowledge gaps, care provider errors, failures in communication, work overload, fatigue and burnout, and nurses shortage.

The type of errors revolves around the rights of medication administration. The significant barriers to reporting medication errors are discrepancies in medication error definitions, time-consuming medication error reporting process, fear of legal and organizational consequences, and lack of a precise and elaborate system for reporting these medication errors.

The strategies used in medical error prevention are varied and target errors in prescribing, transcribing, dispensing, and administration. These strategies can be educational, organizational, or technological. These interventions show varied efficacy and no superiority because they address varied errors. Healthcare institutions should assess their needs and implement suitable strategies that meet their specific needs.


  • Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing28(5-6), 931-938.
  • Gohari, S. H., Bahaadinbeigy, K., Tajoddini, S., & Kalhori, S. R. N. (2021). Effect of Computerized Physician Order Entry and Clinical Decision Support System on Adverse Drug Events Prevention in the Emergency Department: A Systematic Review. The Journal of Pharmacy Technology: jPT: Official Publication of the Association of Pharmacy Technicians37(1), 53.
  • Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal of Caring Sciences32(3), 1038-1046.
  • Izadpanah, F., Nikfar, S., Imcheh, F. B., Amini, M., & Zargaran, M. (2018). Assessment of frequency and causes of medication errors in pediatrics and emergency wards of teaching hospitals affiliated to Tehran University of Medical Sciences (24 hospitals). Journal of Medicine And Life11(4), 299.
  • Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and associated factors among nurses: a cross-sectional study. BMC Nursing17(1), 1-8.
  • Kuitunen, S., Niittynen, I., Airaksinen, M., & Holmström, A. R. (2021). Systemic causes of in-hospital intravenous medication errors: a systematic review. Journal Of Patient Safety, 17(8), e1660.
  • Mieiro, D. B., Oliveira, É. B. C. D., Fonseca, R. E. P. D., Mininel, V. A., Zem-Mascarenhas, S. H., & Machado, R. C. (2019). Strategies to minimize medication errors in emergency units: an integrative review. Brazilian Journal of Nursing, 72, 307-314.
  • Misasi, P., & Keebler, J. R. (2019). Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Therapeutic Advances in Drug Safety, 10, 2042098618821916.
  • Nguyen, M. N. R., Mosel, C., & Grzeskowiak, L. E. (2018). Interventions to reduce medication errors in neonatal care: a systematic review. Therapeutic Advances In Drug Safety, 9(2), 123-155.
  • Rutledge, D. N., Retrosi, T., & Ostrowski, G. (2018). Barriers to medication error reporting among hospital nurses. Journal of Clinical Nursing27(9-10), 1941-1949.
  • Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., … & Shanafelt, T. D. (2018, November). Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. In Mayo Clinic Proceedings (Vol. 93, No. 11, pp. 1571-1580). Elsevier.
  • Zarea, K., Mohammadi, A., Beiranvand, S., Hassani, F., & Baraz, S. (2018). Iranian nurses’ medication errors: A survey of the types, the causes, and the related factors. International Journal Of Africa Nursing Sciences, 8, 112-116.