Quality Improvement Project on Medication Errors


According to the Center for Drug Evaluation and Research (2019), medication errors are preventable events that result in inappropriate use of medications which could subsequently harm the patients. FDA further highlights some of the potential outcomes of medication errors as death, hospitalization, disability, and birth defects. Center for Drug Evaluation and Research (2019) further highlights that at least 100,000 cases of medication errors are reported annually in the country. There are many stages at which the errors may occur, including prescription, entering wrong drug information in the database, dispensing wrong drugs, or taking the wrong drug or inappropriate dosage. Therefore, emphasis on the causes of the medication errors can help to address the problem which is adversely affecting the healthcare system.

CDC highlights the current situation, which points to the growing risk of medication errors within the healthcare facilities and at home. According to CDC (2019), the adverse drug events that are associated with medication errors include allergic reactions, the side effects of the drugs, adverse drug interactions, and overmedication in some instances. CDC further points out that about 82% of the adult population in the US use at least one prescription drug, with 29% of the population using at least five prescription drugs. Moreover, the federal agency notes that 1.3 million emergency department visits and 350,000 cases of hospitalization are linked to medication errors each year. The errors are also linked to a greater economic burden on the already strained healthcare system. CDC notes that $3.5 billion is the cost of treating the adverse drug events annually, with at least 40% of the costs linked to ambulatory ADEs being preventable. The projected estimates by CDC suggest a potential increase in the number of cases of adverse drug events attributed to the development of new medicines, the discovery of new uses of old medicines, the aging American population, increased reliance on prescription drugs, and the expansion of insurance coverage to include prescription drugs. Putting in place adequate measures to address the problem can thus help to prevent and reduce the number of cases of medication errors. This will also be a cost-saving measure that will free more financial resources to support other urgent healthcare needs within the American society.

Rodziewicz et al. (2021) highlight two major categories of medication errors that are common in contemporary healthcare, including errors of omission and commission. The interventions put in place to address the errors depend on the type of error. However, one of the best practices is the adoption of information technology to facilitate data management and tracking of treatments administered to the patients (Gorgich et al., 2016). According to the researchers, electronic health records can help to minimize clerical errors but could introduce some challenges. According to some clinicians, the computers form barriers between them and the patients, while other healthcare professionals note that the EHRs are designed in additive fashions, which make it difficult to identify and correct previous errors (Rodziewicz et al., 2021). This could result in the propagation of incorrect information, further putting the life of the patient at risk. The other measure recommended to tackle the problem is proper stakeholder education. Escrivá Gracia et al. (2019) established that addressing the drug knowledge gaps could minimize the risk of wrong drugs being administered to patients. Also, adequate drug knowledge would help to identify potential cases of adverse drug interactions, which can be promptly addressed without jeopardizing the health and wellbeing of the patient.


Health care departments have a bigger role to play in ensuring quality improvement in care delivered to patients. Quality improvement is a systematic analysis of the practices developed in a health care setup to better the services rendered to patients. Medication errors are a common phenomenon experienced in many hospitals, which has devastating effects on patients’ lives. There is a need to reduce these errors to help save the lives of innocent people. This paper will address the SWOT analysis for medication errors common in health care organizations and the foundation of an action plan for quality improvement.

SWOT Analysis

Good communication strategies instituted for effective shift hand-off. This would help eliminate errors associated with miscommunication.

Highly trained registered nurses with vast knowledge in medical prescription help in prescribing correct medication for patients

Healthcare structure and policies that do not allow unqualified personnel to handle patients in the hospital. Such structures ensure that the health of patients is their priority.

Nurses’ burnout as a result of staff shortage creates loopholes for medication errors. Burnout also leads to poor communication between nurses during shift hand-off, which contributes highly to medication errors.

Limited training offered to nurse leaders creates room for errors in medication prescription.

Lack of record-keeping for patients’ treatment overtime leads to medication errors as doctors do not fully record how the patient was previously treated.

Technological advancement helps hospitals maintain patient health care records, which facilitates easy sharing with other medical practitioners.

Formulation of a committee that will provide insights into medication errors that occur in the hospital to help staff members level up their medical prescriptions

Increase training of nurse leaders in medical prescription and record keeping.

Low salaries discourage nurses from working.

High turnover rates in the healthcare sector jeopardize healthcare service delivery to patients.

Weak record management systems in health care organizations jeopardize the safety of records leading to medication errors.

SWOT Data Analysis

A good communication plan in a healthcare setup helps doctors share patient’s records before their shift ends to keep the incoming doctors up to speed. The CDC (2019) argued that this would help reduce errors associated with poor communication between nurses, hence reducing medication errors. According to the center for disease control, the training of nurse leaders plays a vital role in reducing medication errors. Escrivá Gracia et al. (2019), there is a 20% surge in nurse turnover, which has increased mortality rates associated with medication errors. Lack of record keeping in health care organizations is a rampant problem that has led to poor service delivery resulting in medication errors that have claimed the wellbeing of many people. Adopting information technology to facilitate data management and tracking of treatments administered to patients is the most viable option for reducing medication errors. As postulated by Rodziewicz et al. (2021), technological advancement in information systems would help the healthcare management share patient’s data with other hospitals, which would reduce medication errors likely to be experienced.

Indeed, quality of care improvement in hospitals is critical in creating a medication error-free society. The SWOT analysis gives some insight into the challenges and the solutions introduced to address this problem. For an effective action plan to be developed, the healthcare management should look at the SWOT analysis data to devise an action plan that would reduce medication errors in a health care facility.

Clinical Issue Assessment

Clinical errors have become a widespread tendency over the last ten years. While technology prosperity is at its highest historical levels, the human factor still plays a significant role in clinical issues increase. Thus, nearly 100,000 cases are recorded annually, which indicates a stable but not growing tendency (Center for Drug Evaluation and Research, 2019). Even though the scale of the medical errors is sufficiently large for more than 350,000,000 people, the crucial cases that lead to deaths are still rare. As a result, the assessment should be concentrated on the most critical part of the medical errors, which is the drug prescription mistake (Center for Drug Evaluation and Research, 2019). Correct drug usage is crucial for Americans since any misalignment might result in devastating health conditions or allergy development, which is enough widespread practice (CDC, 2019). While the technological advance is consistently increasing its influence on the medical industry, the rising number of drug types and nomenclatures will result in a positive correlation with the clinical issues

Clinical Issue Assessment Action Plan: Affected Audience, Costs of Executing, and Time Line

In fact, the action plan consists of three aspects: providing a higher level of medical education, increasing the efficiency of technologies in the drug prescribing sphere, and assessing the risk of human error. First and foremost, when identifying the medical stakeholders who will be affected by the possible improvements in the industry, it is critical to distinguish different levels and understand the specific hierarchy principles correctly (Jin, 2016). First and foremost, these educators will be influenced to change their teaching methods and approaches by providing the new techniques described in the action plan. Secondly, medical professionals, such as nurses, surgeons, medical assistants, will have a different knowledge base so that they will be informed about their practice “pitfalls.” Last but not least, the patients will be mainly affected by the implications of the new policies and practices. Moreover, they indicate the plan’s progress since the significant decrease in medical errors will demonstrate the efficiency of specific measures and vice versa. From the general perspective, the government authorities whose liability is to maintain and increase the level of medical service would be influenced to change their “improvement” tactics from enforcing the observational resources to directing their workforce to create the valuable strategy of decreasing the number of medical errors.

Secondly, the costs of plan execution should be specifically defined and applied to the appropriate timeline. Moreover, one of the methods of increasing the efficiency of costs calculation is to define the resources of funds for each aspect of the plan theoretically. To be more specific, the investments in the development of necessary IT solutions for automatic drug prescription systems will be majorly made by private entities. As a result, they would use from 10 to 15 % of the research and development expenses, which is the average percentage in the industry (Kahriman, 2016). Since it is impossible to accurately assess the market capitalization of growing companies that provide technological solutions for clinics and other entities, the average percentage of research and development expenses would help visualize and compare the expenses.

Finally, a properly adjusted timeline plays a pivotal role in planning success since the concrete dates allow the executives and observers to measure the efficiency of the process. To correctly implement the time perspective to the overall strategy, it is critical to understand the possible resources and their maximum or, in some cases, minimum potential. In fact, while technological solutions are a growing industry, some significant improvements in developing the automatic drug prescription system will occur in the next five years (Jin, 2016). However, concerning the educational facet, the structural changes would take more time since medicine is a “traditional” field of study. Nevertheless, the possible time line for sufficient increase of educational quality will take from five to ten years, which is retrieved from economic theory since this is the average number of years that significant changes occur in any type of industry.

Potential Strategies for Implementation and Evaluation

Nowadays people are beginning to discover new significant aspects in the medical community considering better and more useful ways of implementing innovative strategies of preventing aforementioned medical errors. It is stated that nurses and other people who are connected with the job of taking care of people’s health are much more likely to be unsatisfied with their work-life balance (Trockel et al., 2018). Therefore, specialists are trying to come up with effective ways to implement positive changes into their overall work experience for the well-being of medical workers and, consequently, of patients. Thus, innovative survey tools that are being invented to measure physicians’ health and analyze their job performance, special psychiatry training programs are the best methods in medical sphere to this day (Trockel et al., 2018). Existing intervention strategies on medical workers’ burnout or fulfillment meet some of the criteria of reliability and validity, however, there is always room for improvement. That is why possible implementation methods are essential in medical workspace development and inevitable errors prevention.

Social studies present that emotional exhaustion and burnout are rather popular among health workers due to social and psychological specifics of their job. These mental health issues, subsequently, affect medical proficiency and the quality of job performance in the workplace. Hence, medical errors that exist due to psychologically overwhelming medical experience have to be dealt with under well-managed evaluation and analysis by psychiatrists and social workers in the medical field (Trockel et al., 2018). Speaking of evaluation, medical studies show that assessment and analysis of main issues connected with general mistakes while treating patients help to better understand the nature of those errors. Indeed, modern sociological analysis allows people to be aware of the repercussions of complicated job conditions of physicians and complex drug prescriptions. Hence, new advanced methods of implementation are required to achieve prevention of systemic and systematic medical errors.

Looking at the approach of medical errors, people can see the statistics of the mistakes made by workers that have unfortunately negatively affected their patients. In the article by Korhan et al (2017), the authors mention another significant struggle that analysts face – the lack or absence of helpful and tolerant management support system which causes non clear definition of medical error and real numbers of mistakes that are damaging to patients. This distorted perception of medical error influences the entire issue of implementation and evaluation because there are various factors that could be described as harmful medical behavior. Such factors are, for example, giving the wrong medication, misleading information, or general cruelty from the physicians. However, new implementations in the medical field have improved greatly for the past twenty years (Korhan et al., 2017). Therefore, the medical perception of what a general error is has become quite consistent, so scientists view the situation as positively changing.

To sum up what has been mentioned before, there are multiple issues medical scientists face while trying to find effective ways of evaluating harmful errors to prevent them in the future and protect their patients. Further, implementation of preventative measures has been a crucial topic of discussion because people are trying to stop medical errors from happening by using best possible strategies. Moreover, such strategies as well-managed psychiatric evaluation, innovative survey tools and analysis of burnout and exhaustion in the workplace have already proved its effectiveness in preventing the continuation of damaging medical errors.


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Jin, H., Munechika, M., Sano, M., Kajihara, C., Chen, H., & Guo, F. (2016). A Study on the Methodology to Analyse and Prevent Medical Errors Due to Non-observance. Advances in Intelligent Systems and Computing, 355–364. Web.

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Trockel, M., Bohman, B., Lesure, E., Hamidi, M. S., Welle, D., Roberts, L., & Shanafelt, T. (2018). A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians. Academic Psychiatry, 42(1), 11-24.

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1. NursingBird. "Quality Improvement Project on Medication Errors." September 22, 2022. https://nursingbird.com/quality-improvement-project-on-medication-errors/.


NursingBird. "Quality Improvement Project on Medication Errors." September 22, 2022. https://nursingbird.com/quality-improvement-project-on-medication-errors/.