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**Root Cause Analysis of Wrong Medication Administration Incident** **Introduction** Medication errors are a significant threat to patient safety and can lead to severe consequences. In this case, a patient at the local hospital was administered the wrong medication. This paper uses a root cause analysis (RCA) to determine what happened, why it happened, and recommends strategies to prevent such errors in the future. **Event Description** The event involved a patient receiving the wrong medication during a routine medication round. The error was identified when the patient experienced unexpected side effects, prompting a review of the administered drugs. **How and Why the Error Happened** Upon investigation, it was found that a nurse, while preparing medications, misread a physician’s handwritten order. The similar appearance of two medication names and inadequate double-checking contributed to the error. Additionally, the barcode scanning system was not used due to a technical malfunction. **Key Stakeholders for Investigation** The following stakeholders should be involved in investigating this case: 1. **Nursing Staff:** Directly involved in medication administration and can provide insights into workflow and challenges. 2. **Pharmacists:** Responsible for dispensing medications and ensuring correct labeling. 3. **Physicians:** Write medication orders and can address clarity and legibility issues. 4. **IT Department:** Manages electronic health record and barcode scanning systems. 5. **Quality Improvement/Risk Management Team:** Specializes in analyzing incidents and developing safer processes. Involving these stakeholders ensures a comprehensive understanding from all angles, enabling systemic solutions rather than individual blame (Institute for Safe Medication Practices, 2022). **Comparing the Five Whys of Medication Administration** The Five Whys technique is a tool for identifying root causes by repeatedly asking "Why?" until the underlying issue is revealed (Serrat, 2017). 1. **Why was the wrong medication given?** - The nurse misread the medication order. 2. **Why did the nurse misread the order?** - The physician’s handwriting was unclear, and two medications had similar names. 3. **Why was there no double-check of the medication?** - The barcode scanner was not used due to a technical problem, and there was no manual verification process in place. 4. **Why was the barcode system not functioning?** - There is a lack of regular maintenance and contingency plans for system failures. 5. **Why is there no backup procedure when technology fails?** - Staff have not been adequately trained in manual verification processes. Addressing these questions systematically helps unearth the process and system failures that led to the error, rather than attributing blame to individuals (Institute for Healthcare Improvement, n.d.). **Prevention of Future Medication Errors** To prevent future incidents, the following measures are recommended: - **Implement Electronic Prescribing:** Reduces errors from illegible handwriting. - **Regular Maintenance of Technology:** Ensures barcode scanners and other safety systems are operational. - **Double-Check Protocols:** Establish mandatory manual verification when technology is unavailable. - **Staff Training:** Ongoing education on medication safety and error reporting. - **Improve Communication:** Standardize medication naming and labeling to reduce look-alike/sound-alike errors. **Conclusion** A root cause analysis reveals that medication errors often result from multiple system failures. By involving key stakeholders, applying the Five Whys, and implementing comprehensive preventive strategies, hospitals can significantly reduce the risk of medication errors and enhance patient safety. **References** Institute for Healthcare Improvement. (n.d.). *Root Cause Analysis*. http://www.ihi.org/resources/Pages/Tools/RootCauseAnalysis.aspx Institute for Safe Medication Practices. (2022). *Strategies to reduce medication errors*. https://www.ismp.org/ Serrat, O. (2017). *The Five Whys Technique*. In *Knowledge Solutions* (pp. 307-310). Springer. --- *Formatting: Double-spaced, 12-point Times New Roman, one-inch margins, APA citations included.*

**Root Cause Analysis of Wrong Medication Administration Incident** **Introduction** Medication errors pose a serious threat to patient safety and can result in adverse health outcomes. The recent incident at the local hospital, where a patient was given the incorrect medication, underscores the importance of systematic investigation. Conducting a root cause analysis (RCA) helps identify underlying issues contributing to the error, enabling healthcare providers to implement effective prevention strategies. **Event Description** The incident involved a nurse administering the wrong medication to a patient during a routine medication round. The mistake was identified when the patient developed unexpected side effects, prompting clinicians to review the medications administered. The root cause was linked to misreading the physician’s handwritten order, leading to the wrong drug being given. **How and Why the Error Happened** Investigation revealed that the nurse misread the handwritten prescription due to illegible handwriting and the similarity in the appearance of medication names. Additionally, the barcode scanning system, which could have served as a safeguard, was not utilized because of a technical malfunction. The lack of a manual double-check process further facilitated the mistake. These systemic issues contributed to the error rather than individual negligence alone. **Key Stakeholders for Investigation** Involving a diverse group of stakeholders is critical for a comprehensive investigation. Nursing staff are directly responsible for medication administration and can provide insights into workflow challenges. Pharmacists play a vital role in dispensing and labeling medications correctly. Physicians are responsible for writing clear, legible orders and can address communication issues. The IT department manages electronic health record systems and barcode technology, and their involvement can reveal technical shortcomings. Finally, the hospital’s quality improvement and risk management teams are essential for analyzing incidents systematically and developing safety protocols. Engaging these stakeholders ensures that the root causes are identified from multiple perspectives and that solutions address systemic vulnerabilities rather than placing blame on individuals (Institute for Safe Medication Practices, 2022). **Comparing the Five Whys of Medication Administration** The Five Whys technique involves asking successive questions to drill down to the root cause of an issue. For example: 1. Why was the wrong medication given? Because the nurse misread the order. 2. Why was the order misread? Because the handwriting was illegible and medications had similar names. 3. Why was there no double-check? Because the barcode system was down and manual verification was not performed. 4. Why was the barcode system not functioning? Due to lack of regular maintenance and contingency planning. 5. Why was there no backup process? Because staff lacked training in manual verification procedures. Addressing these questions helps uncover systemic weaknesses such as communication breakdowns, technological failures, and inadequate staff training. This process shifts focus from individual blame to understanding how organizational systems contribute to errors, enabling targeted interventions to prevent recurrence (Serrat, 2017). **Preventing Future Medication Errors** To reduce medication errors, hospitals should implement several strategies. Transitioning to electronic prescribing minimizes errors from illegible handwriting. Ensuring regular maintenance and testing of barcode scanning systems maintains technological safeguards. Establishing mandatory manual verification protocols when technology fails adds an extra layer of safety. Continuous staff education on medication safety and error reporting fosters a culture of transparency and learning. Additionally, standardizing medication labeling and differentiating look-alike/sound-alike medications can significantly reduce confusion. Combining technological solutions with process improvements and staff training creates a robust defense against medication errors. **Conclusion** The root cause analysis highlights that medication errors often result from multiple interconnected system failures. Engaging key stakeholders and applying the Five Whys technique reveal systemic vulnerabilities that, once addressed, can greatly enhance patient safety. Implementing comprehensive preventive measures, including technological safeguards, staff training, and clear protocols, is essential to minimizing future medication errors. **References** Institute for Healthcare Improvement. (n.d.). *Root Cause Analysis*. http://www.ihi.org/resources/Pages/Tools/RootCauseAnalysis.aspx Institute for Safe Medication Practices. (2022). *Strategies to reduce medication errors*. https://www.ismp.org/ Serrat, O. (2017). The Five Whys Technique. In *Knowledge Solutions* (pp. 307-310). Springer.