Medical Errors: Root-Cause Analysis and Safety Improvement Plan

Subject: Nursing
Pages: 4
Words: 1226
Reading time:
5 min
Study level: Bachelor


Medication errors (MEs) seriously threaten patient health conditions and outcomes. Therefore, ME reporting is crucial for prevention efforts; healthcare personnel should report MEs routinely to improve patient safety and care quality. However, the real-life MEs reporting rate reaches only the 57-61% mark (Jember et al., 2018; Rishoej et al., 2018). This paper provides a root-cause analysis of ME non-reporting based on the community hospital nurses survey. In addition, evidence-based strategies to reduce ME non-reporting are discussed, and a reporting rate improvement plan is developed based on the strategies and available organizational resources.

Root-Cause Analysis of ME Non-Reporting

Despite the vital importance of proper ME reporting, nurses frequently show reluctance to report the cases. For instance, a study at federal hospitals in Addis Ababa, Ethiopia, by Jember et al. (2018) found that only 57,4% of 403 participants reported their own MEs or MEs made by their colleagues. According to Rishoej et al. (2018), only 60% of pediatric nurses and physicians in Southern Denmark deemed it necessary to self-report MEs to a national mandatory reporting system. In these examples, one can see that approximately 40% of MEs may remain unreported in hospital settings. As a result, hospitals cannot analyze MEs and implement the necessary changes. Therefore, ME non-reporting harms patients and healthcare organizations as the issue persists and endangers patient safety.

Considering the harmful implications of non-reporting, scholars attempted to reveal and analyze the underlying causes of the safety issue. Rutledge et al. (2018) surveyed 359 registered nurses at Magnet-accredited faith-based hospitals in California with a Medication Error Reporting Barriers (MERB) questionnaire. The participants evaluated 20 items using 5-point Likert scales to indicate the barriers that disrupt proper ME reporting procedure. The answers were described via the IBM SPSS software (Rutledge et al., 2018). Overall, ME non-reporting was associated with three primary factors: procedure complexity, fear, and awareness gaps.

Reporting Procedure Complexity

Procedure complexity was the most common barrier to ME reporting. In particular, 173 nurses, or 48,2% of total respondents, claimed that documenting MEs requires extra time (Rutledge et al., 2018). In addition, 129 nurses (35,9%) argued that forms used for ME reporting were too long and time-consuming to fill (Rutledge et al., 2018). As such, the complexity of the procedure can be considered a negative communication factor in ME non-reporting.


Nurses’ sense of fear was the second-most mentioned barrier to reporting. Fear manifested in various aspects — 123 (34,3%) of respondents expressed fear of lawsuits, 118 (32,8%) were afraid of being blamed and 104 (29%) were worried about potential disciplinary actions (Rutledge et al., 2018). In this regard, fear can be considered a substantial environmental factor of ME non-reporting. Nurses were inclined not to report MEs in order to avoid legal and professional repercussions.

Awareness Gaps

Lastly, the ME non-reporting was associated with awareness gaps in several domains. In particular, 82 respondents (22,8%) did not know that reporting MEs is useful (Rutledge et al., 2018). Additionally, 77 nurses (21,4%) lacked the knowledge of which MEs should be reported, and 75 (20,4%) could not recognize that ME had occurred (Rutledge et al., 2018). In this regard, the lack of education can be considered a severe human factor in ME non-reporting.

Application of Evidence-Based Strategies to Reduce ME Non-Reporting

Since procedure complexity was found to be the most prevalent root cause of ME non-reporting, simplifying the reporting procedure is highly recommended. Most importantly, this strategy will make ME reporting less time-consuming (Rishoej et al., 2018). In turn, the increase in report sending and processing speed may convince the nurses to report MEs. For example, procedure simplification increased incident reporting rates in intensive care units (Harris et al., 2007, as cited in Rishoej et al., 2018). In this regard, the administration should encourage ME reporting to a direct supervisor.

Several changes in organizational culture can modify the fear factor. Most importantly, the hospital should offer mental support and counseling to nurses. According to Robertson and Long (2018), physicians who make medical errors usually wish to discuss their experiences. Therefore, a hospital can increase ME reporting rates by replacing the blame culture with a more supportive approach. Nurses should be convinced that MEs do not automatically render them unprofessional. In contrast, MEs should be perceived as learning opportunities to enhance patient safety.

Finally, the awareness gaps can be addressed only through additional education and timely feedback from the hospital administration. All nurses should undergo ME reporting training to learn why MEs reporting is beneficial and what defines a ME. In addition, the supervisors must provide the nurses with timely feedback once MEs are reported (Rutledge et al., 2018). In the end, a nurse cannot be expected to report MEs reliably if they cannot recognize one or doubt whether it should be reported.

Improvement Plan

The plan to improve ME reporting rates within the hospital contains two main parts. Firstly, the organizational improvement part consists of streamlining the MEs reporting procedure to make it less burdensome for nurses and addressing the fear-induced reluctance to report MEs. Rishoej et al. (2018) suggest simplifying reporting process, which can be achieved by encouraging the nurses to report MEs directly to a specifically designated supervisor. As a result, time will be saved on filing the report and receiving feedback, which would incline the nurses to report MEs more frequently. The fear-based reluctance can be addressed by adding the elements of support and understanding to the existing organizational culture of fear and perfectionism. Counseling and open discussion would help the nurses overcome the fear of being blamed and persecuted for errors (Robertson and Long, 2018). Consequently, the ME reporting rates would increase since nurses would stop fearing legal persecution and professional status loss.

Secondly, the human factor stemming from awareness gaps can be modified through additional education. In particular, Rutledge et al. (2018) recommend training sessions within the hospital in order to increase the organization-wide understanding of the ME concept. In particular, nurses must be taught a clear ME definition and know which cases must be reported (Rutledge et al., 2018). As a result, nurses would understand what constitutes MEs and why it is helpful to report and openly discuss them. Overall, changes associated with both parts of the improvement plan can be implemented within several months.

Existing Organizational Resources

In general, the MEs reporting improvement plan can be implemented without significant expenditures. Both organizational and human factors parts would largely depend on the skills and knowledge of existing staff members. Hiring extra staff members might be necessary only on two occasions. Firstly, training sessions and education on MEs would occupy the time of nurses and trainers. Secondly, designated supervisors would have to review an increased number of ME reports. Therefore, hiring extra nurses might be necessary to spread the workload more efficiently and avoid such adverse effects as fatigue and emotional burnout.


ME non-reporting is a significant patient safety issue since it hinders error analysis and subsequent correction. Three primary root causes are responsible for ME non-reporting — procedure complexity, fear, and awareness gaps. The two-pronged safety and quality improvement plan can address these causes. Firstly, organizational improvement requires simplifying the ME reporting procedure and shifting organizational culture from blame to support. Secondly, nurses should be provided with additional education in order to bridge awareness gaps. In the end, the ME reporting rates should increase as the nurses’ knowledge and confidence surge.


Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). The proportion of medication error reporting and associated factors among nurses: a cross-sectional study. BMC Nursing, 17(1), 1-8.

Rishoej, R. M., Hallas, J., Juel Kjeldsen, L., Thybo Christesen, H., & Almarsdóttir, A. B. (2018). Likelihood of reporting medication errors in hospitalized children: A survey of nurses and physicians. Therapeutic Advances in Drug Safety, 9(3), 179-192.

Robertson, J. J., & Long, B. (2018). Suffering in silence: Medical error and its impact on health care providers. The Journal of Emergency Medicine, 54(4), 402-409.

Rutledge, D. N., Retrosi, T., & Ostrowski, G. (2018). Barriers to medication error reporting among hospital nurses. Journal of Clinical Nursing, 27(9-10), 1941-1949.