Root-Cause Analysis and Safety Improvement Plan

Errors are a crucial part of human life. Most errors occur from a natural process of behavioral and cognitive adaptations. Medication errors have been the most common healthcare mistakes that influence patient care. Considerably, medication administration errors have been a global problem in healthcare settings since they have increased length of hospital stay, increased mortality rates, and related healthcare costs (Shahrokhi, Ebrahimpour & Ghodousi, 2013). Medication errors have remained a great problem since most nurses fail to report these incidents due to anticipations of negative responses from the nursing managers. This paper will focus on nursing medication errors at Boston Children’s Hospital, review the root cause, and develop a safety improvement plan.

Analysis of the Root Cause

Medication errors have been one of the leading causes of preventable death in the U.S. This has remained one of the critical patient safety risks that need to be focused on as the nursing profession evolves to support the nursing practice and improve patient care. Medication errors tend to influence patient safety, increase healthcare treatment costs, and lead to hazards to patient families (Abukhader & Abukhader, 2020). Ideally, providing medical care is among the crucial responsibilities of nurses since the consequential medical errors have severe and unintended costs on the patient. Medication errors can result in adverse outcomes such as increased stay in hospitals, high mortality, and huge medical expenses. The rates of nursing medication errors are high in both developing and developed countries.

Recently, Boston Children’s Hospital has had a steady ride in medication errors. The incident of increased medication rate within the healthcare facility has increased the request for a root cause analysis to determine the factors that have constituted the facility’s problem.

In 2017, Boston Children’s Hospital had three patients that encountered medication errors, involving a patient that had to wait for delayed medication for an antibiotic for more than 14 hours, after which the patient died. The medication errors were anesthetic Propofol and Zosyn (Leahy et al., 2018). A nurse administered Zosyn to a patient more than 12 hours late. Unfortunately, the patient developed an infection that later led to their death after two days. The patient was seriously ill when admitted to the hospital and required a breathing machine. The nurse in charge of the patient thought that the doctor had said not to give an antibiotic to the patient, which was not the case (Cureatr, 2021). The other two patients had an overdose of Propofol. The incidents were discovered through an inspection that was conducted at Boston Children’s Hospital.

In 2014, a medication error occurred at Vibra Hospital of Sacramento that claimed a patient’s life after excessive amounts of Levophed were administered (Cousins, 2021). A CDPH regulator statement indicated that the patient heart failed to function after the nurse administered excessive Levophed. Considerably, the medication was correct, but the nurse gave 3,000 to 8,000 times the prescribed dosage (Cousins, 2021). The excessive administration of the medication was attributed to factors such as lack of safeguards to drugs that have heightened risks to patients, the nurse administering lack of knowledge and enough understanding of Levophed, and lack of the second nurse to sign off on medication provision for the patient.

Inadequate work experience, poor working environment, and neglecting hospital medication due to extreme tiredness and lack of time are some of the factors related to medication errors. The hospital also lacked safeguards and strategies for high alert medications that would effectively notify the provider. Lack of appropriate communication between the nurses led to poor coordination of medication, thus translating to ineffective patient care.


Application of Evidence-Based Strategies

Health care professionals, especially nurses, are spending much of their time in the administration of medications. Ideally, precise and secure medication administration is influenced is by the nurses’ decisions, critical thinking, technical skills, and pharmacologic knowledge. Medication errors can result from systemic problems and human errors. Medication errors have been linked to poor communication, confusion over drugs with similar packaging and names, illegible handwriting, and wrong drug selection (Cheragi, Manoocheri, Mohammadnejad & Ehsani, 2013). For instance, incorrect doses such as extra dose, under-dose, and over-dose occur due to inappropriate medication that may lead to significant morbidity and mortality. Minimum staffing, skipping medical procedures and policies, and lack of inter-professional communication and collaboration are some of the factors that have resulted in medication errors within various hospital settings. For instance, minimum staffing has led to high workload, fatigue, and tiredness due to long working hours, which increase the chances of medication errors.

In a descriptive study that focused on 150 nurses at Qazin Medical University teaching hospitals, it was clear that factors effective to medication errors are management related, nurse related, and environment-associated factors (Teixeira & Cassiani, 2010). Therefore, strategies to eliminate medication faults and enhance quality care should focus on three categories. Nurse staffing is a vital health policy, and a great deal of consensus on quality health care and safety. High nurse staffing levels have indicated a positive influence on patient outcomes and care. The management leaders should focus on review the nurses’ staffing levels, which is a contributing factor to quality care.

To protect patients against medication errors, the nurses have to implement appropriate procedures and policies for medical administration. For instance, the nurses should adhere to the procedures such as two nurses checking the medication orders before dispensing medication. Training and education programs that focus on reducing medication errors should be emphasized within the facility to ensure accurate administering and dispensing process that prioritizes the safety of patients. Certainly, the utilization of information technology to computerize medical procedures and orders can improve the patient’s health due to eliminating medication errors, especially those that happen due to reading and prescription writing (Wang et al., 2015).

Improvement Plan with Evidence-Based and Best-Practice Strategies

The improvement plan involves two major goals; reduce medication errors and enhance follow-up procedures. The improvement plan will be developed and implemented within six months to evaluate the quality and patient safety initiatives. The improvement plan will focus on a comprehensive intervention that includes information technology, organizational, education, and process optimization-based measures.

The health facility will develop an electronic medication tracing system that will be used in process management in handling orders since it will record the patient’s name, drug information, and warnings to enhance the safety of medication administration. The organization will implement a training program that will educate nurses on the rights of medication administration to help prevent errors. The organization will also ensure that nursing staffs are aware and knowledgeable of the policies and procedures of medication administration to ensure that all treatments and medications are administered per the procedures and policies.


Existing Organizational Resources

            The health facility management team, nurse managers, and nursing administrators can help improve the plan’s implementation to achieve better outcomes. Ideally, they play an essential role in eliminating medication errors since they can recommend changes in nursing practices that will eliminate increased patient risks during medication administration. The in-service education programs can also help eliminate medication errors through educational interventions.


Patient safety remains a priority in all healthcare settings worldwide since it is the cornerstone of high-quality care. The prevalence of medication errors has led to the demand for safe nursing practices. Regarding the root cause analysis conducted at Boston Children’s Hospital, medication errors result from various factors that are nurse-related, environmental, and management-related. Various strategies such as in-service education programs, policies, and procedures, technologies such as electronic medication tracing systems, and inter-professional collaboration and communication are recommended. Evidence from previous studies reveals that these practices are effective in reducing medication errors and improving patient safety.




Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal of Biosciences and Medicines8(6), 135-147.

Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian journal of nursing and midwifery research18(3), 228.

Cousins, D. H. (2021). Medication errors. In Paediatric clinical pharmacology (pp. 245-264). CRC Press.

Cureatr. (2021). Six medication error stories that made headlines. Available at:

Leahy, I. C., Lavoie, M., Zurakowski, D., Baier, A. W., & Brustowicz, R. M. (2018). Medication errors in a pediatric anesthesia setting: Incidence, etiologies, and error reduction strategies. Journal of clinical anesthesia49, 107-111.

Shahrokhi, A., Ebrahimpour, F., & Ghodousi, A. (2013). Factors effective on medication errors: A nursing view. Journal of research in pharmacy practice2(1), 18.

Teixeira, T. C. A., & Cassiani, S. H. D. B. (2010). Root cause analysis: evaluation of medication errors at a university hospital. Revista da Escola de Enfermagem da USP44(1), 139-146.

Wang, H. F., Jin, J. F., Feng, X. Q., Huang, X., Zhu, L. L., Zhao, X. Y., & Zhou, Q. (2015). Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. Therapeutics and clinical risk management11, 393.

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