Root-cause assessment or analysis is an essential design for unfolding the causes behind medication mistakes and adopting measures for the future prevention (Singh et al., 2021). 

These mistakes have lethal results which affect patient’s well-being and healthcare. This assessment aims at evaluating the root causes of medication mistakes and devising evidence-based practices to avoid adverse incidents. Moreover, it determines the available institutional resources to support the execution of the approaches.

Root Causes of Medication Errors in Healthcare Delivery

Medication mistakes during drug management can have immense patient safety problems. These are emergency situations which need prompt interrogation and handling. Some root causes associated with this are weak communication, human errors, design issues and structured problems (Tariq & Scherbak, 2023).

The root cause evaluation of medication mistakes incident of a 50-year-old patient shows some significant contributing factors. First factor is weak communication among healthcare workers for reading patient’s allergies, medical and medication history. 

Nurse responsible for medication administration did not review the patient’s medical history properly which had important information about medication history and allergy.  Next factor is lack of standard procedure for medication management which also results in medication mistakes as healthcare workers do not comply with the standard guidelines or protocols. 

NURS FPX 4020 Assessment 2

Culture of a healthcare organization may also contribute to the medication error because patient’s safety and quality enhancement is not focused in some healthcare cultures. The interrogation of medication error revealed that insufficient training and education of nurses about patient’s safety and medication management is also a significant factor.

To avoid such events in future, the root cause evaluation suggests the need of executing standard medication management procedures, strengthened communication among healthcare workers, highlighting the importance of patient’s safety in healthcare organization’s particular culture and educate the healthcare staff on medication administration.

Factors Contributing to Safety Issues

There are many factors in a hospital’s setting which result in a patient’s safety problems. These factors are human errors such as lack of focus, exhaustion, and system errors i.e., failed equipment or insufficient guidelines.

• Factors related to human errors are inappropriate staffing, inadequate training, exhaustion, stress, depression and lack of focus which can cause medication mistakes (Kim et al., 2022). For example, nurses who are facing extreme workloads due to increased patient flux may become exhausted and fatigued which leads to wrong medication administration.

• Weak communication is also a significant factor which leads to medication mistakes (Tiwary et al., 2019). Confusing medication guidelines from doctors or mishandling during the prescription delivery among healthcare workers can cause medication errors or dosage mistakes. 

• Design issues i.e., inappropriate naming or wrong storage can lead to medication mistakes (Mutair et al., 2021). For example, if the labelling on medicine is incorrect the nurse can give wrong medicines to a patient.

• Process problems in a healthcare institute i.e., insufficient accessibility of the electronic health records (EHR) or medication databases can cause medication mistakes. For instance, if there is insufficient information available about the latest medication, they can administer the wrong medicine and dose to the patient.

Execution of Evidence-Based Strategies

For handling the medication mistakes which occurred in this given plot, following are the evidence-based practices and best approaches which can be executed:

• Medication Reconciliation: In this approach, discrepancies such as drug reactions or allergies are identified by comparing the patient’s medication sequence with their current medication list. It can help to decrease the medication mistakes occurring during hospitalization, shifting and discharge (Elbeddini et al., 2021).  Nurses dealing with medication administration should have the patient’s medication data and thoroughly investigate before giving any medicine.
• Scanning and Barcoding Technology: It can decrease the probability of medication mistakes by digitally validating the patient’s individual barcode and medicine tag with medication sequence (Chou et al., 2019). This advanced technology can a