Lolita Rodriguez
IHP-430-X6701 Healthcare Quality Management
1-2 Short paper: The wrong Medication
Southern New Hampshire University
7/6/22
Medication Errors
The local hospital had an incident involving the wrong medication administered to a patient. You
have been asked to perform a root cause analysis. First, you need to discover: The event that
happened, how it happened, and why it happened.
For this case study involving a patient receiving the wrong medication I would recommend key
stakeholders to investigate the case to determine if a change is needed and whether it leads to an
improvement. Medication administration errors are thought of as a failure in one of the five
“rights” of medication administration (right patient, medication, time, dose, and route). The five
rights were implicated to ensure safe medication administration. Some system-related causes of
medication administration errors include inadequate training, distractors, convoluted processes,
and system misconfiguration. I believe stake holders should be involved because they are
affected by the results, to provide support for long-term sustainability, help make decisions and
encourage the employees. Errors can even occur when trying to figure out which dosage of
medication to use on a patient based on a patient’s weight, height or age. Medical professionals
make mistakes also when prescribing medications by writing it for the wrong person, duration,
time, and abbreviation. These types of mistakes cause the whole team to fail the medication
administration processes. This type of errors is critical even fatal to the patient. Many factors can
lead to this type of failure, and it is important to address medication errors to avoid undesirable
patient results. Some other reason medication errors can occur are not giving them at all, not
knowing the patient’s medical history. Giving expired medications and even preparing
medications incorrectly.
In RCA, there are three main components that help individuals move from problem identification
to action: data collection, data analysis, and corrective or preventive action (Johnson and Sollecit
o, 2021). Addressing the five whys of medication administration could help identify he root
IHP-430-X6701 Healthcare Quality Management
1-2 Short paper: The wrong Medication
Southern New Hampshire University
7/6/22
Medication Errors
The local hospital had an incident involving the wrong medication administered to a patient. You
have been asked to perform a root cause analysis. First, you need to discover: The event that
happened, how it happened, and why it happened.
For this case study involving a patient receiving the wrong medication I would recommend key
stakeholders to investigate the case to determine if a change is needed and whether it leads to an
improvement. Medication administration errors are thought of as a failure in one of the five
“rights” of medication administration (right patient, medication, time, dose, and route). The five
rights were implicated to ensure safe medication administration. Some system-related causes of
medication administration errors include inadequate training, distractors, convoluted processes,
and system misconfiguration. I believe stake holders should be involved because they are
affected by the results, to provide support for long-term sustainability, help make decisions and
encourage the employees. Errors can even occur when trying to figure out which dosage of
medication to use on a patient based on a patient’s weight, height or age. Medical professionals
make mistakes also when prescribing medications by writing it for the wrong person, duration,
time, and abbreviation. These types of mistakes cause the whole team to fail the medication
administration processes. This type of errors is critical even fatal to the patient. Many factors can
lead to this type of failure, and it is important to address medication errors to avoid undesirable
patient results. Some other reason medication errors can occur are not giving them at all, not
knowing the patient’s medical history. Giving expired medications and even preparing
medications incorrectly.
In RCA, there are three main components that help individuals move from problem identification
to action: data collection, data analysis, and corrective or preventive action (Johnson and Sollecit
o, 2021). Addressing the five whys of medication administration could help identify he root
