The Errors in Medication Administration: Case Study


Modern medicine and pharmacology are more closely connected than ever. As a result, there is an increase in the requirements for medical institutions for personnel in knowledge in both areas. As a rule, the consequence of negligent attitude to such a thing is dangerous and sometimes fatal mistakes, the victims of which are patients. In the case described below, just such a situation occurred in which his condition worsened and complicated further treatment due to the nurse’s mistake. The nurse, poorly familiar with the patient’s medical history and prescription, provided the patient with neurosis with hydroxyzine. Although this drug is applicable in this case, the patient had an increased sensitivity to cetirizine, which is part of the hydroxyzine. This was the deterioration of the patient’s condition and increased anxiety, and a further emotional reaction expressed in aggression towards the medical staff. After this description of the case, the essay will contain the following points of the situation analysis: a description of what happened, the person who discovered the problem, which led to the problem, and its impact on the described persons. After describing the details of the root cause analysis, the application of evidence-based strategies, improvement plan with evidence-based and best-practice strategies, and existing organizational resources will also be described.

Analysis of the Root Cause

In the chosen event, the patient was admitted for treatment; in addition to his primary diagnosis, he had neurosis, resulting in which he hurt himself. In an attempt to stabilize the patient’s blood pressure, he has prescribed hydralazine, but due to the nurse’s carelessness, he was given hydroxyzine. Not noticing a typo in the prescription, the nurse felt that they wanted to calm the patient with a mild tranquilizer, which is hydroxyzine. However, she also inattentively and negligently reviewed the patient’s medical history without noticing or ignoring the fact that he was hypersensitive to cetirizine. This component is part of hydroxyzine, as a result of which the drug is contraindicated in patients with hypersensitivity to it. The problem was identified by another nurse, who noticed the deterioration of the patient’s condition, which arose due to the mistake of her colleague. The patient’s physical condition deteriorated, exacerbating symptoms and increased nervousness, leading to further panic on his part. In order to avoid such a problem, steps such as detailed analysis of the data provided and the formulation of the drugs associated with the patient were not taken. Such external factors could influence this as nurses’ fatigue due to the stressful specifics of work, overwork, and the resulting fatigue. The resource factor was the provision of an incorrectly executed prescription provided by the attending physician.

The reasons for the problem associated with the human factor can be called inattention when reading the treatment documentation and the prescription by the nurse, associated with the desire to quickly and efficiently do their job. However, the situation with the patient’s neurosis and its aggravation as a result of the provision of the wrong drugs became communication factors, namely the inability of the nurse to convey the situation to the patient correctly and calmly. These factors led to the emergence and escalation of the problem, which could have been avoided with a more careful approach to documentation and other factors.

Looking at all of the above, the situation was influenced by the human factor both on the part of the nurse and the attending physician, overwork and fatigue due to a stressful environment, and other features inherent in the work of nurses. Specific causes of the problem include inattentive analysis of customer-related documentation and prescription and negligent filling of the prescription by the doctor. Due to inattentive reading or neglect of the medical history by the sister, the patient experiencing hypersensitivity to the active ingredient of the hydroxyzine drug received it instead of the hydralazine he was entitled to. The consequence of this was only a worsening of the patient’s condition and the emergence of new problems in treatment.

Application of Evidence-Based Strategies

As it was established in the earlier paragraphs, the event was caused by several issues with the safety of medication administration. Namely, these were medication administration errors in drugs prescription and communication. The literature on the issues is enormously rich since errors in medication administration occur the most frequently in the sphere of caregiving (Doyle, n.d.). As such, several authors in their studies mention different factors contributing to the errors. First of all, there is a possibility of insufficient training among the nurses (Wondmieh et al., 2020). Such neglect eventually leads to situations where a nurse cannot discern between the titles of medications or provide a proper diagnostic procedure, as in the event described previously. Moreover, communication problems often arise from the lack of specialized discipline that would cover the most efficient strategies for informing patients. The similar factors that lead to the same undesirable consequences are the lack of a program for medication administration and work background (Wondmieh et al., 2020). Thus, some of the medication administration errors are after the nurses’ insufficient knowledge and experience.

Next, other safety concerns can cause unpleasant or even sentinel events leading to the patient’s lethal outcome. Precisely, the wrong interpretation of the prescriptions due to the looking and alike sounding drugs are the consequences of several factors. One of the reasons why a nurse can confuse some titles is interruption coming from the environment during the medication administration (Wondmieh et al., 2020). As such, noisy rooms or people present during medication administration disrupt the nurses’ workflow. Next, night shifts are the popular cause of misunderstandings and errors in the treatments that involve medications (Wondmieh et al., 2020). Working at night might result in a lack of concentration, dissatisfaction with the working conditions, and further neglect of one’s responsibilities. Although the consequences of distracted behavior can be fatal, nurses tend to commit these actions since they are primarily people who make mistakes when they are tired. Thus, distracting conditions and uncomfortable shifts produce a high probability of mistakes among the nurses.

The literature also describes what strategies are preferable for preventing the issues mentioned above. For instance, PSNet’s authors (2019) describe some efficient ways that might help avoid undesirable situations claiming that these are low-tech solutions. First, standardized communication is evoked to help the medical workers discern similar medications by placing labels that warn the workers about the possible confusion (PSNet, 2019). Next, an effective and low-cost solution can be to educate patients (especially ones with chronic diseases) about the basics of pharmacology and medication administration practices (PSNet, 2019). In this way, they would be prepared to be careful when accepting prescriptions from doctors and nurses. Finally, it is possible to minimize the risks of the errors by reducing the disturbing conditions and interruptions as well as introducing an independent double-check procedure (PSNet, 2019). Hence, the strategies are aimed at preventing the cause of the errors and the subsequent events.

Improvement Plan with Evidence-Based and Best-Practice Strategies

After discussing the professionals’ opinions and solutions to the problem, an improvement plan can be developed and implemented in the facility. The most important action that should be undertaken to prevent future staff mistakes is providing training and guidance in medication administration and communication with the clients since the lack of training negatively influences the nurses’ practice (Wondmieh et al., 2020). Such action aims to ensure that all the workers should become equally competent to provide high-quality care for the patients. The training will be complete within six months if all the nurses and interns of the facility participate. Further, a system of minimizing interruptions would be guaranteed through the new arrangement of the workplaces and a new schedule for the nurses (PSNet, 2019). This practice aims to eliminate the possibility of spontaneous errors in eight months. Finally, in eight months, a new policy of the patients with chronic diseases’ education will be acquired to protect them from erroneous care.

Existing Organizational Resources

The facility can obtain certain resources for further enhancement of the improvement plan. As such, the healthcare organization needs to hire professional trainers in communication both for the nurses and other personnel and for the customers. Additionally, there is a need to renovate the existing conditions of the working places and supply them with more personal space for nurses. Fortunately, the facility can use the doctors and highly-experienced nurses to organize the education of the nurses in the medication administration and leverage the plan.


To conclude, the event that occurred in the facility is in the highest way unacceptable and due to safety concerns. The errors in medication administration are frequent phenomena in the nurse practice and the cause of the described event; yet, they could be prevented by the rational choice of the strategies for increasing safety in healthcare. Therefore, the possible negative consequences might be eliminated through the use of the proposed improvement plan.


Doyle, G. R. (n.d.). 6.2 safe medication administration – clinical procedures for safer patient care. Pressbooks. Web.

PSNet. (2019). Medication administration errors. Web.

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1). Web.

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