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Running Head: Medication Errors

Root Cause Analysis

Dana L. Yurkon
Bon Secours Memorial College of Nursing
I Pledge

Running Head: Medication Errors

Approximately 100,000 people die each year as a result of preventable medical errors. This is
more than the number of deaths caused by motor vehicle accidents, breast cancer, and acquired immune
deficiency syndrome combined. These deaths result in more than $30 billion in direct health care
expenses and indirect income losses each year. As a result of these statistics, hospitals and regulatory
agencies, such as The Joint Commission, have reevaluated the importance of patient safety in health
care. ("JAMA Network | JAMA | Medication Errors and Adverse Drug Events in Pediatric Inpatients,"
Along with the administration of medication, there is an entire behind the scenes that goes on
before the medication is even given to a patient. A medication error is defined as errors in drug
ordering, transcribing, dispensing, administering, or monitoring. ("JAMA Network | JAMA |
Medication Errors and Adverse Drug Events in Pediatric Inpatients," 2001) There are many tasks that
must be undertaken by physicians, pharmacy, nurses, and interdiciplinary staff members for medication
administration. Along with personale, there is technology that plays a role in today's health care. There
are five categories which harbor the root cause to medication errors; they are technology, the workplace
environment, the physician/nurse team, the patient, and the nurse.
Technology is always evolving within the health care setting. It can be used for plenty of
positive impacts, however there are times that it can actually help cause errors. With technology and
The complexity of the hospital workplace, limitations in the number of care components that can be
automated, and the technologies' interaction with human factors can determine their success or failure.
If a technology is not used as intended, increased inefficiency and medical errors may result.
(American Journal of Health System Pharmacy, 2003) Although physicians enter their orders via a
closed computer system, this is not fool proof. Like any other form of technology, mistakes can be
made whether it is a decimal point in a dosage, one syllable difference in a medication, or a weight that
was entered incorrectly for a pediatric patient. All of these minimal or minute numbers or letters can

Running Head: Medication Errors

make the difference of life of death of a patient. A lack of education of the technological system
can also cause errors. Technology can not be trusted alone, one hundred percent.
The work place environment has an impact on medication errors as well. This is yet a form of
the root cause. For instance, the emergency department is very fast aced and often times, short staffed.
Short staffing means that nurses have difficulty to handle the overload of patient visits. As a result,
care is fragmented and methods designed to support patient safety are compromised. The most
frequently reported error in emergency department care is medication error. ("Medication errors from
an emergency room setting: safety solutions for nurses. - PubMed - NCBI," 2010)
This brings forth the physician and nurse team. The emergency room is a very hectic and fast
paced environment for a team on most days. Distractions and interruptions can contribute to
medication errors, the environment also must be considered. But nurses alone cannot resolve
environment-related medication safety issues. They must find solutions that require hospital policy
changes.(Elssvier, 2012) When a team is distracted, as well as having a heavy work load, little to no
support from managers or nursing supervisors, no time for continuing education, or they are pressured
to perform against high acuity and patient volume, medication errors are par for the course.
The last two root causes are the patient and the nurse. Patients are of high demand. They
expect everything and anything under the sun from perfect, timed out health care to warm blankets and
all of their other needs catered too. Along with the high demand, patients can be a demand due to their
specialized care. Critical patients, ones with many intravenous lines, central catheters, medications,
endotracheal tubes, and such can be extremely taxing of nurses. This can lead to the medication errors
as well while trying to perform daily duties with utmost quality and care.
Lastly, nurses as whole have a responsibility to continue their education, to ask questions, and to
be advocates. Emergency departments are seeing more influx of volumes and less experienced staff.
Errors are more likely to occur when nursing staff inexperience is combined with staff shortage,

Running Head: Medication Errors

inadequate supervision and high unit activity. When rostering or employing staff, nurse
managers and educators must consider the special requirements of inexperienced nurses.("effects of
nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs. - PubMed NCBI," 2001)
Although these are only a select few root causes to medication errors, they play a major role in
our health care system today. Filling the gaps and avoiding the holes in the swiss cheese can help keep
nurses, physicians, staff, and most importantly patients safe.

Running Head: Medication Errors


Workplace Environment

Technology not
used as intended

Fast paced
Short staffed

Nurse/Phyisican Team
Heavy workload

Not a fool proof


Overload of patients
Little support
Fragmented care

Lack of education
of technological systems

No continuing education

---------------------------------------------------------------------------------------------------------- Medication



High demand

No continue education

High acuity

No time to ask questions


Running Head: Medication Errors


American Journal of Health System Pharmacy. (2003). Impact of Emerging Technologies on

Medication Errors. Retrieved from
The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in
ICUs. - PubMed - NCBI. (2001, August 14). Retrieved from
Elssvier. (2012, August 22). Clinical Reasoning Can Prevent Medication Errors | Elsevier Nursing
Solutions. Retrieved from
JAMA Network | JAMA | Medication Errors and Adverse Drug Events in Pediatric Inpatients. (2001,
April 25). Retrieved from
Medication errors from an emergency room setting: safety solutions for nurses. - PubMed - NCBI.
(2010, June 22). Retrieved from