Medication Errors in Downsized Hospital Environments

Subject: Nursing
Pages: 2
Words: 395
Reading time:
2 min
Study level: College

Nurses have many responsibilities within a hospital as they assist doctors in procedures and monitor patient’s condition during the entirety of their stay in the hospital. One of their primary responsibilities is delivering medication, and failure to administer it is among the most severe mistakes a nurse can make. This essay will discuss medication omission during a shift change and the investigation procedure into the error.

Investigation into Failure to Deliver Medication

A downsized work environment in a hospital can affect patients’ health and well-being. Research shows that understaffing in a hospital leads to multiple adverse outcomes, including administering the wrong medicine, the wrong dosage, delivering the dose later than needed, or failing to provide it (Glette et al., 2017). Depending on the patient’s condition and medicine that needs to be given, failure to deliver the dose can lead to critical danger to their health.

The nursing supervisor should be responsible for investigating the circumstances behind the failure to administer medication to the patient during the shift change. Several steps should be taken during the inquiry into the mistake. First, the supervisor needs to establish who was the senior staff member during each shift and which nurses were assigned to the patient in question. These persons need to provide additional information on the shift and what happened during it. The staff’s recollections will help gain insight into the events of the shift change and help identify the circumstances behind the mistake.

Second, the nurse-to-patient ratio in the ward should be established. The supervisor needs to clarify how many cases each nurse was assigned to and their severity. If the staff members accountable for the person who was not given medicine were responsible for more than four people overall, the medication error could be attributed to understaffing (Glette et al., 2017). However, if the nurse in question was charged with fewer than four cases, the mistake can be attributed to them.


In conclusion, the omission of medication is a severe mistake and, in some cases, can be attributed to the downsized work environment. When investigating, the supervisor should consult the senior staff members on the shifts and all the nurses assigned to the patient who did not receive their medication. Furthermore, the nurse-to-patient ratio during the shifts should be examined to understand the nurses’ workload and whether understaffing is the primary cause of the error.


Glette, M. K., Aase, K., & Wiig, S. (2017). The relationship between understaffing of nurses and patient safety in hospitals—A literature review with thematic analysis. Open Journal of Nursing, 07(12), 1387-1429. Web.