09 Mar Root Cause Analysis of a Medication Error
In this short paper, you will use a root cause analysis to determine the reason a patient received the wrong medication, what should be done about this error, and how this type of error could be prevented in the future.
Directions
Root Cause Analysis of a Medication Error
At Imaginary Medical Center, a 69-year-old patient was inadvertently administered 100 milligrams of metoprolol instead of the prescribed 25-milligram dose. The error was discovered during routine vitals monitoring when the patient exhibited bradycardia and hypotension. The medication was entered correctly into the electronic health record (EHR), but the nurse retrieved the wrong dosage from the automated dispensing cabinet (ADC). No barcode scanning was performed before administration.
You are part of the hospital’s Quality and Safety Review Team. Your role is to conduct a root cause analysis (RCA) to understand the systemic breakdowns that led to this event and recommend improvements.
Specifically, you must address the following rubric criteria:
Adverse Event: Analyze the adverse event in detail and identify how the error occurred.
Include why you think the error was not intercepted.
Use the Five Whys method to trace the root cause.
Stakeholders: Identify at least four key stakeholders to be involved in the investigation and explain the role each stakeholder plays and why their perspectives are essential.
Stakeholders might include people such as nurse managers, pharmacy staff, IT and EHR specialists, and patient safety officers.
Communication, Technology, and Workflow: Analyze how problems in communication, technology, and workflow contributed to the error.
Consider latent conditions—for example, staffing levels, training gaps, and system alerts—that may have influenced the outcome.
Interventions: Propose three evidence-based interventions to reduce future medication errors and justify your recommendations using research or best practices.
Consider interventions such as barcode scanning compliance, ADC redesign, and simulation-based training.
Safety Culture: Explain how this case illustrates the importance of a safety culture and describe what you’ve learned that can be applied to your future practice.
What to Submit
Your submission should be a 2- to 3-page Microsoft Word document with double spacing, 12-point Times New Roman font, and one-inch margins. All citations and references should use the latest APA formatting.
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