Author: Robyn B. Caldwell, DNP, FNP-BC, CNE
Title: Assistant Professor
Institution: Auburn University Montgomery
Quality Improvement, Safety
New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN
Classroom, Clinical Setting
1. Examines the human aspect of nursing practice which influences the delivery of safe patient care.
2. Identifies individual components within a health system and its impact on quality patient outcomes.
1. Demonstrates the use of root cause analysis in identifying human influences in medication errors.
2. Differentiates best practice and local practice in examining nursing medication errors.
1. Values individual responsibility for safety and quality when providing patient care.
Healthcare organizations strive to provide safe, quality care in every patient setting. The complexities of the healthcare environment however, allows prospective errors. Medication related errors are the most common type of error and also account for a sizable increase in healthcare costs (IOM, 2000). Medication errors account for lost wages, disability, and productivity, and are responsible for over 7000 deaths annually (IOM, 2000). The Joint Commission mandates healthcare systems demonstrate strong leadership which creates a fair and just culture of safety. This approach holds both the organization and individual accountable for safe, quality patient care (Joint Commission, 2017). This accrediting body recognizes that individuals human and capable of mistakes in an often flawed system. This case study examines the human factor in a fatal medication error using a root cause analysis.
This case study was developed in an effort to stimulate discussion about the influence of human errors in healthcare systems. Intended uses include root cause analysis, group discussion, and independent study. The evaluation may be tailored to meet the needs of the audience.