Collaborate on Quality: Issue Analysis and Leadership Action Plan

Subject: Administration and Regulation
Pages: 8
Words: 2245
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8 min

Medication Errors

The issue of interest was a case of medication error in the medical ward. This case involved a wrongful administration of a high dose of morphine for pain control. The nurse in question administered 10mg of morphine instead of the prescribed 5mg per oral morphine. This error occurred during the issuing of drugs at the ward. In addressing the error, the nurse who made the error said she confused the two patients’ treatment sheets. Luckily, the patient affected by the error did not suffer from any adverse complications following the error. An analysis of the situation found that the incident occurred due to problems with following the standard operating principles for drug administration in healthcare. According to the standard regulations, the issuance of any medications to the patients should be counter-checked by two nurses to minimize the risk of unfair practices. There is a need for the hospital to institute mechanisms to lower the rates of medication errors as it is one of the major contributors to health complications, death, and hospitalizations of patients.

The goal of the management of medication errors is to promote the safety of patients and reduce the chances of reoccurrence of the problem in clinical practice. The significant issues to address in medication errors include the nurse-to-patient ratios, communication channels between healthcare personnel, and the availability of guidelines for drug administration (Gorgich et al., 2016). Disproportionate staffing of nurses to patients in the ward may result in a high workload affecting the optimal administration of drugs by nurses. The availability of effective communication channels in healthcare enhances the optimal correction of mistakes in the organization. Furthermore, the availability of guidelines gives nurses a framework to follow during prescription and medication administration. Medication errors occur due to several organizational and individual factors which need to be addressed by the policymakers.

IHI Triple Aim

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement (IHI) to identify new ways of maximizing the care of patients in hospitals. This strategy aims to enhance patient care, improve populations’ health, and reduce healthcare costs (Rodziewicz, 2021). This technique emphasizes promoting the well-being of hospitalized patients by lowering the chances of damage. Additionally, this concept calls the managers of institutions to encourage the reporting of medication errors by their subordinates and document them appropriately. The process of reporting errors needs to be shortened to enhance their practice. Reporting on the medication errors is necessary for the early institution of management plans.

Another element of the IHI triple aim applicable to medication errors is developing protocols for managing the adverse effects following drug administration. The side effects of drugs should be addressed first, as they may be the primary source of discomfort and poor health. Healthcare institutions can adopt trigger tools prepared by the IHI to investigate the adverse effects of mistakes by nurses. Additionally, hospitals should empower nurses to effectively administer drugs, prevent errors, enhance the patient’s safety and manage adverse effects. Empowerment may be in the form of education and increasing the staffing needs of nurses in the healthcare setting (Rodziewicz, 2021). Moreover, promoting the safety of patients by reducing the risk of harm is instrumental in decreasing healthcare costs. The health complications arising from the damages of medication errors may increase treatment costs for the patients. The IHI triple aim elements are essential in managing medication errors.


Culture is an important concept in healthcare organizations in the modern world. It refers to a complex set of values, beliefs, practices, and understanding of individuals about the world. Culture is a way of life of persons belonging to a particular social group or community, for instance, healthcare personnel. The cultural practices of members of an organization have significant impacts on their behaviors in the workplace. It also determines the goal achievement abilities of the organization (Rodziewicz, 2021). Culture is developed over a given period by the managers and the subordinates of a particular organization. These practices, attitudes, and beliefs are then passed down to new employees or clients in the institution. Therefore, adopting a positive culture is imperative in enhancing the success of the organizational goals and objectives.

Culture is an essential component of promoting safety and quality in an organization. For instance, in a healthcare organization, the culture of the healthcare providers is key in determining patient safety and the quality of care. Individual beliefs, attitudes, and practices are the major determinant of the effectiveness of the organizational goals. An effective culture promotes the corporate commitment to identifying, reporting, and analyzing medication errors. An effective culture for promoting safety and quality encourages its employees to speak up about workplace errors without fear of losing jobs. Nurses adhere to the standard operating procedures and the nursing process to enhance the safety of patients (Rodziewicz, 2021). Furthermore, applying evidence-based practice principles facilitates high-quality patient care and reduces incidences or errors in practice.

Several cultural practices in this organization result in medication errors. First, there was a minimal collaboration between nurses in drug administration. Several patients were allocated to one nurse for meeting their needs, including administration of medications, due to few nurses. This negatively affects the ideal administration of drugs by nurses (Rodziewicz, 2021). Second, the nurses were adamant about reporting medication errors due to the risk of disciplinary actions and a perceived mild impact of the patient’s mistake. However, the nurses’ timely management of medication errors promotes the prevention of worsening harm to the patient.

Several evidence-based strategies exist to promote a culture for managing medication errors due to their adverse effects. These errors may result in an additional need for medical interventions, prolonged patient stay in hospitals, increased cost of treatment, and deaths. Some of the effective cultures for avoiding medication errors include encouraging adherence to the five rights of drug administration every time the nurse gives medications (Rodziewicz, 2021). These rights are the right patient, right drug, correct route of administration, right dose, and right time. Moreover, the organization needs to foster a culture that encourages nurses to stay informed about the therapeutic effects of drugs. This is imperative to determine the mode of action, adverse effects, and the potential interactions between drugs (Rodziewicz, 2021). Furthermore, the nurses should adopt a culture that enhances information provision to patients about the therapeutic effects and the potential effects of drugs. An influential cultural strategy is instrumental in preventing medication errors.


Effective multidisciplinary collaborations in the healthcare system are necessary for avoiding medication errors. Different departments are involved in the corrective process for these errors in the patient care. First, the nursing department needs radical changes because they are the major stakeholders in administering medications. Nurses should adhere to the five principles of drug administration, maintain current knowledge of drugs’ pharmacologic actions, and ensure counter-checking of drugs by two nurses during drug administration (Rodziewicz, 2021). Second, the medical practitioners’ departments are useful in correcting medication errors. Physicians need to follow the evidence-based regulations for suitable dosage and route of administration during prescription. Finally, pharmacists need to record the patient’s drug allergies to prevent adverse reactions during drug administration. Documentation of the patient’s medication is required of all departments involved in the prescription and administration of medication.

Clinical leaders help reduce the incidences of medication errors at the healthcare organization. Nurse managers are an example of leaders who are instrumental in managing medication errors. They are liable for ensuring that nurses uphold the principles of drug administration (Rodziewicz, 2021). The managers should encourage the junior nurses to seek further clarifications in cases where they are not conversant about the nursing implications of certain medications. Additionally, nurse managers should ensure that their subordinates practice adequate documentation of the medications administered to patients. Recording the nursing actions helps promote follow-up for medication errors. Finally, nurse leaders should agitate for effective staffing of nurses following the standard regulations to enhance safety during drug administration—the principles of effective delegation state that the nurse manager should delegate responsibilities effectively to avoid medication errors. The nurse retains accountability for the juniors’ performance.

The lack of engaging all the departments in the plans for avoiding medication errors may have grave implications for their success. Ineffective collaborations between healthcare personnel hinder goal attainment. Teamwork is required for the prevention of medication errors. Ineffective collaborations impact negatively the harmonious working of the healthcare professionals to reduce medication errors (Rodziewicz, 2021). Furthermore, collaborations among professionals promote effective communication about the adverse effects of the drugs, the allergies of the patients, and the patients’ drug history. This information is crucial in avoiding medication errors, and it is affected by ineffective collaborations. The nurse manager can create a meeting for all professionals involved in drug administration to inculcate a culture of proper drug administration.


Leadership is an inherent component of prevention strategies for medication errors. Some of the specific leaders who are important in achieving this goal include nursing officers, medical officers, pharmaceutical managers, and patient safety managers. These leaders are responsible for taking a role modeling task in agitating for proper practices in pharmacotherapy (Hertig et al., 2016). These leaders need to adhere to the five rights of drug administration to encourage their subordinates to follow their example in practice. Moreover, healthcare leaders should give inspirational talks to their junior employees to report medication errors for prompt management. They also need to foster interdisciplinary collaborations to reduce these mistakes.

Additionally, healthcare leaders should attain the role of mentors for good drug therapy. Providing supportive supervision to the new nurses promotes the reduction of the incidence of medication errors in practice. The leaders should allocate junior healthcare providers to more experienced personnel to improve their drug management practices. Furthermore, the leaders should take up the role of clinical educators (Hertig et al., 2016). They need to instruct their workmates on the importance of giving information to patients on the action of medications. The leaders should also remind the other healthcare personnel of the clinical implications of the various medication classes of interest (Hertig et al., 2016). Adequate knowledge of the actions of drugs is key to the prevention of medication errors.

Strategies exist for enlisting the effort of leaders in reducing medication errors. First, the leaders should occasionally meet to address the progress made in reducing mistakes in healthcare. Effective collaborations between professionals promote improvements in lowering errors in practice. The leaders need to advocate for the employment of additional healthcare personnel to improve drug therapy. The leaders should collaborate with other policymakers at the national and regional levels to address pertinent policy issues affecting proper drug administration.

The hospital governing board has several roles in promoting quality and safety in patient management. First, they provide the goals and objectives for healthcare personnel to follow to enhance the safety of patients and quality of care. These plans guide the action of the subordinates in striving to reduce the incidence of medication errors (Hertig et al., 2016). Second, the governing board has a role in providing the required pharmacological options. They ensure that protocols are guiding clinicians and nurses in drug issuance and prescribing. Nevertheless, the board of management collaborates with the national policymakers to address the effects of causes of medication errors (Hertig et al., 2016). The governors need to know that a disproportionate nurse to patient ratio impacts proper drug therapy.

Leadership Action Plan

Evidence-based techniques are recommended for solving medication errors by leaders in the hospital. First, the leaders need to encourage the healthcare personnel to counter-check the drugs before administration. Two nurses must ensure that it is the appropriate drug for the patient (Gorgich et al., 2016). They should also make sure that the drug is issued in the right dosage, frequency, and route of administration. Second, nurse leaders should encourage nurses to utilize the three names of the patients to enhance the identification of the right patient. The names should be read out loud in the ward to identify the correct patient. Third, the nurses should document drug administration, including any adverse effects following the treatment plan. This provides a framework for the interventions to address this problem.

There are techniques for addressing medication errors at the organizational level. First, the healthcare organization needs to practice the proper allocation of the adequate number of nurses per shift. This is important in enhancing the optimal drug administration mechanisms in the ward to reduce errors (Gorgich et al., 2016). Second, the organization needs to encourage effective multidisciplinary collaborations between the healthcare personnel. Good communication enhances the ideal drug administration by nurses. Third, the effective management of patients can be improved by focusing on medication errors in the hospital’s units. Timely interventions help promote patients’ safety and reduce the harm arising from medication mistakes (Gorgich et al., 2016). All levels of the hospital management team have a role in reducing the number of cases of medication errors.


Medication errors are a major cause of injuries and death to patients. Effective collaborations between healthcare practitioners are instrumental in improving preventative plans. The leaders of the hospitals should encourage the juniors to adhere to the standard protocols for drug administration. Managing this problem of medication errors in healthcare requires a collaborative effort between the management and the junior employees. Healthcare practitioners, including nurses, should adhere to the five principles of drug administration to reduce the chances of mistakes. The hospital administration needs to advocate for appropriate staffing of nurses. Timely management of errors is imperative in enhancing the safety of patients.


Gorgich, E. A., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 54448.

Hertig, J. B., Hultgren, K. E., & Weber, R. J. (2016). Using new leadership skills in medication safety programs. Hospital Pharmacy, 51(4), 338–344.

Rodziewicz, T.L., Houseman, B. & Hipskind, J.E. (2021). Medical error reduction and prevention. PubMed.