Medication Errors: Root-Cause Analysis and Safety Improvement Plan

Subject: Healthcare Institution
Pages: 4
Words: 1196
Reading time:
5 min


The problem of errors in prescribing and administering drugs remains relevant for many medical organizations throughout the country. Given that there have been cases of misuse of medications with adverse patient outcomes in Minnesota, a plan to improve the quality and safety of nursing services is required. The critical healthcare facility under consideration in the current study is Allina Health, located in Minnesota. There will be applied evidence-based and best-practice strategies to address the safety issue. A viable, evidence-based safety improvement plan will be created, and existing organizational resources will be estimated.

Analysis of the Root Cause

Nurses are doing everything possible to keep medical organizations operational during the coronavirus period. Even before the onset of this crisis, the number of nurses worldwide had not grown at a fast enough pace. As countries grapple with the challenges posed by the COVID-19 pandemic, the provision of a functional health care system with a qualified medical workforce becomes paramount. Medication errors are mainly related to whether an organization has a sufficient number of qualified nurses. In 2016, a nurse’s mistake in administering adrenaline to a patient led to his being in intensive care for three days (“CMS put Allina hospital in ‘immediate jeopardy’ for drug error during nurses’ strike,” 2016). In time, this event coincided with the passing six-week nurses’ strikes.

Shortly after this event, the agency adopted a remediation plan that involved adding a supervising nurse and retraining department staff when necessary. Every year in state hospitals, there are a total of about 5-6 cases of medication errors that lead to the death of patients or severe disability (Olson, 2016). In case studies related to the issue, it was noted that mistakes in the misuse of adrenaline can lead to the patient’s death (Akca et al., 201).

The incident sparked questions from major Minnesota media outlets about whether Allina Health will keep patient care at a high level amid multiple layoffs of nurses ((“CMS put Allina hospital in ‘immediate jeopardy’ for drug error during nurses’ strike,” 2016; Olson, 2016). Reducing nurses’ workload and improving their working conditions could have prevented what happened and the trend for an increase in the number of such errors.

It is important to note that the organization itself reported an error in the use of the drug. The situation that arose affected not only the woman patient herself but also all the clients of the Allina Health clinic, since the incident made them doubt that the nurses of the organization have sufficient qualifications. Human errors include responding late to an aggravated problem and ignoring the deterioration in the quality of services provided. Among the steps taken to address this issue, the signing of an agreement with the nursing union (Chaudhry, 2019), which provides a raise, overall improvement in working conditions, and staff recruitment should be highlighted. As a controllable factor, it should be noted the policy pursued by the clinic’s management regarding the recruitment of qualified nurses and the conduct of regular checks on their activities.

The inattention of the nurse during the procedure is an uncontrollable factor. Experts nevertheless state that a communication disruption primarily caused the mistake in taking medications. Accordingly, the reasons for the incident include nurses’ work overload, difficulties with communication, inattention, and lack of qualifications of the new nurse.

Application of Evidence-Based Strategies

To prevent a decline in the quality of care, it is necessary to analyze what circumstances cause this regression process and identify strategies to overcome it. Parenteral drug misuse is a severe problem in intensive care units, and its solution is recognized as a high priority for the healthcare system around the world (Li et al., 2020). It has been shown that errors are associated with additional morbidity and mortality among already critically ill patients (Rodziewicz et al., 2021).

The drug may be given to the wrong patient, at the wrong time, or the wrong injection method may be mistakenly prescribed. Some medications must be given slowly and intravenously; some cannot be entered simultaneously (Marsilio et al., 2016). Most errors do not occur in emergencies but during routine work by medical personnel. The cause of these errors can be found at any stage, from initial drug administration to drug injection.

The main reasons that increase the frequency of medical errors when working with drugs are the nurse’s workload, as well as the complexity of the organization of the clinic. To avoid medical mistakes in a medical institution or to minimize them, it is essential to properly organize the work of medical personnel with drugs and equipment and set specific requirements (Tariq et al., 2021). The more consistent security checks are implemented, the more secure the entire system becomes.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Nurses and patients should understand the mechanism of action of drugs and the importance of timing and regimen for the effectiveness of treatment and prevention of complications and adverse reactions. It is planned to create such a system for the drugs’ distribution to meet the time requirements for their administration. It is known that adverse side reactions of varying severity occur in every tenth patient receiving drug therapy (Coleman & Pontefract, 2016). That is why one of the critical requirements for drug safety is monitoring the condition of a patient receiving drug therapy. A more accessible working environment is guaranteed to improve the safety and quality of hospital care. The approximate time to implement the safety improvement plan is about three months. However, its development will presumably take less time, that is, approximately one month. It is assumed that the joint implementation of these measures will reduce the chance of medication administration errors.

Existing Organizational Resources

Allina Health is already striving to improve the quality of life and health of patients. The organization is taking action to address drug-related problems. Existing resources such as the availability of EHR systems and ongoing training activities for nurses can already be used to improve the quality of services. However, an increase in the number of nurses may be required, that is, the employment of new employees to reduce the burden on the current staff.


At the present stage of development of the health care system, skillful nursing specialists are being trained, new organizational forms and technologies of nursing care for the population are being developed. In addition, nursing administration is being optimized rather quickly. The role of nursing personnel is also increasing in organizing medical and social assistance, as well as in the management of health care organizations. Accordingly, the deterioration of the quality of patient care due to errors in the organization of the work of nurses is unacceptable.

In the course of writing this work, it was possible to create a safety improvement plan for Allina Health. At the same time, many factors were taken into account and assessed. These include available resources of the hospital, the proven successful experience of other organizations, and the causal relationship between the phenomena under consideration and its negative impact on the quality of care. The created plan, the implementation time of which will be about three months, is guaranteed to protect Allina Health from deteriorating care safety due to insufficient staffing.


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