The action plan is multi-disciplinary and multimodal as it includes different actions for different stakeholders. The first step is to develop a hospital-based protocol and hierarchical response system with a medication error alert system to quickly detect the errors and provide steps taken to report the error along with the responsibilities of different stakeholders (Huckels-Baumgart et al., 2017). This plan aid in solving the first root-cause where the pharmacist sent the wrong product. The outcome of this step is it increases knowledge and competencies along with better communication between the team (Korb-Savoldelli et al., 2018).

The second step is to educate the health care professionals to predict the medication errors and fulfill the protocol through communication and discussion (Manias, 2018). This includes providing timely care, not administering the drug unless completely sure, and reporting all errors. This step solves the root-cause where the pharmacist accused the nurse of committing an error and the nurse following the pharmacist’s instruction even the system pointed out that the wrong medication was sent (Huckels-Baumgart et al., 2017). The outcome of this step is it creates a safer work culture with specific roles and responsibilities (Kellogg et al., 2016).

The third step is to implement a single system with prescription order, patient information, automated drug dispensing unit, double-check protocol (Koyama et al., 2021), bar-code-based identification, communication, and error reporting system (Thompson et al., 2018). This provides a centralized system to detect the root cause and aid in preventing delayed care and averse of sentinel events (Risør et al., 2018). This system aid in achieving the outcome of funding and solving all the root-causes as all the systems are integrated into one.

The action plan will have goals to prevent prescription errors, wrong dosage errors, dispensing and drug administration errors, blame culture, delay in care, and adverse effects. Also, it aims to increase interprofessional collaboration and the effectiveness of the system (Risør et al., 2018). However, the plan takes time as it requires organizational-level change. Developing protocols, educating health care professionals, and assigning roles can take 4 to 6 weeks. Implementing the centralized system will take 12 to 16 months.

Existing Organizational Resources

Four major existing organizational resources that aid in implementing the plan are health care professionals, IT infrastructure, finances, and leaders and managers to design a plan, implement it and evaluate the outcome (Hammoudi et al., 2017). Also, existing protocols and nurse informatics relating the medication errors help in determining the trend and effectiveness of different outcomes (Manias, 2018).