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Enhancing Patient Safety Through Medication Administration: A Case Study Analysis


Task: How can healthcare organizations improve patient safety in medication administration processes by addressing root causes and implementing recommendations, using the case study of Mr. Evans' sentinel event as a guide?



Please use this template to complete assessment 2. You are required to respond to only ONE of the provided case studies. You need to indicate which case study you have chosen in the first section.

Your discussion must be cited andsupported by a wide range of relevant and credible sources for each section. You are required to include a final reference list at the end.

1. Description

Identify which case study you have chosen (1 or 2), and provide a brief description of the event and the outcome for the patient.

The factors leading to the sentinel event of Mr. Evans are delays in calling for help. Mr. Evans had dehydration due to delays in calling for help. Lorna, the nurse on duty, administered both medications (IV metoclopramide and 1g of oral paracetamol) via the IV route, which resulted in Mr. Evans' immediate symptoms of a pulmonary embolus and eventually a massive stroke. Lorna, the nurse on duty, had not worked clinically for many years and was unsure about administering the medications. She was unaware that paracetamol could be given via the IV route. Lorna consulted with an experienced ED nurse, Barry, who prepared the medications for her, but he did not supervise her while she administered the medications. Lorna did not communicate clearly with Barry about her concerns regarding medication administration. The hospital did not provide adequate training and orientation for Lorna, who was an assistant director of nursing but had not worked clinically for many years. Tragically, Mr. Evans lost his life as a result of the medication administration error that occurred in the hospital's emergency department. He had presented with a laceration to his leg and dehydration, which were treated successfully, but unfortunately, the medication error had fatal consequences (Faust, & Del Rio, 2020). Despite efforts to resuscitate him for 30 minutes, he could not be saved. It was a deeply regrettable outcome, and the incident highlights the importance of careful medication administration and communication in the healthcare system.

2. Identification of root cause and contributing factors

Identifyone (1) root cause and discuss at least three (3) contributing factors which have likely caused this sentinel event.

Identification of root cause and the contributing factors : One root cause of the sentinel event involving Mr. Evans is the breakdown in the medication administration process. Based on the information provided, one root cause of the sentinel event could be a lack of a safety culture within the hospital. A culture of safety is one in which safety is prioritized as a fundamental value and is integrated into all parts of the organization's activities. A good safety culture encourages healthcare personnel to disclose mistakes and near escapes to prevent eventualities and fosters communication, cooperation, and continuous improvement (Rodziewicz, & Hipskind, 2020).

There were three contributing factors that likely led to the breakdown in the medication administration process for Mr. Evans.

Lorna, the healthcare worker who delivered the medicine, hadn't practiced clinically in a long time and was hesitant about delivering the meds. Lorna had extensive work experience as a licensed nurse and served as the hospital's assistant director of nursing, but she lacked the clinical expertise and understanding needed to reliably dispense drugs. Furthermore, given her relocation to the crisis department, the medical facility did not offer enough instruction and orientation for her, which might have left her believing she was ill-prepared to manage the rapid and elevated situation. Secondly, Lorna's communication with Barry, the seasoned ED nurse who administered the prescription for her, was sloppy (Berliner, 2022). As a consequence, Barry was unaware of Lorna's reservations about medicine delivery. If Lorna had expressed her concerns about administering the prescription and asked Barry for an explanation or direction, he might have been able to offer the information needed to ensure that the drug was taken appropriately. Furthermore, Barry's choice of picking up the paracetamol in a syringe may have added to Lorna's misunderstanding regarding the intended method of administration, emphasizing the significance of clear interaction and collaboration among healthcare personnel in order to prevent mistakes. Lastly, the hospital lacked defined protocols and procedures for medicine delivery, especially in emergency situations. This lack of standardization and uniformity might have caused medicine administration confusion and mishaps (Akalu, Ayelign, &Molla, 2020). Clear drug administration rules and procedures may give direction as well as a framework to healthcare personnel, especially in high-pressure circumstances like emergency rooms where timing is of the essence. Healthcare practitioners may be forced to make judgments depending on their own judgment and expertise if explicit guidelines and processes are not in place, and this can lead to discrepancies and errors.

To address these contributing variables, healthcare practitioners must commit to continued education and training, good communication and collaboration among providers, and the establishment and execution of clear rules and procedures to govern clinical practice. By focusing on these areas, healthcare organizations may seek to reduce pharmaceutical mistakes and provide patients with safe and effective care. Taken together, these characteristics point to a larger problem with the facility's security environment, which may have caused the failure in the medicine administration procedure and, as a result, the sentinel incident (Fekadu, Chelkeba, &Kebede, 2019). Addressing this core cause necessitates a commitment to developing and implementing clear rules and procedures, as well as leadership support, continued learning and instruction, effective communication and cooperation, and the creation and carrying out of clear policies and processes. The hospital may endeavor to prevent such tragedies in the future by prioritizing safety as an important principle and incorporating it into all elements of its operations.

3. Links to NMBA RN Standards for Practice

Identify and discuss at least two (2) NMBA RN Standards which were not practiced or maintained by the nurses involved in this sentinel event, that may have led to the identified root causes.


Standard 1: Thinks critically and analyzes nursing practice - The nurses involved in this event did not appear to have engaged in critical thinking or analysis of the medication administration process (Cooper, Chang, Luck, & Dixon, 2022). Lorna lacked the clinical experience and knowledge required to confidently administer medications but did not seek assistance from the appropriate resources, such as a pharmacist or senior clinician. Barry prepared the medication in a way that could have led to confusion about the intended route of administration, without considering the potential consequences of this decision. By failing to engage in critical thinking and analysis of the medication administration process, the nurses may have contributed to the breakdown in communication and the ultimate outcome of the event.


Standard 5: Provides safe, appropriate, and responsive nursing practice - The nurses involved in this event did not provide safe, appropriate, or responsive nursing practice (Pennington, Clark, & Knight, 2020). Lorna administered the medications without confirming the intended route of administration, despite being unsure about their use. Barry prepared the medication in a way that could have led to confusion about the intended route of administration. Kate provided incorrect information about the administration of paracetamol, without checking the medication chart or consulting with a senior clinician (Federation, 2022). By failing to provide safe, appropriate, and responsive nursing practice, the nurses may have contributed to the patient's adverse outcome.

4. Links to National Safety and Quality Health Service (NSQHS) Standards

Identify and discuss at least two (2) NSQHS Standards which were breached (or not met)by this health organisation, that may have led to the identified root causes.


Certainly, based on the information provided, two NSQHS Standards that were breached (or not met) by this health organization, which may have led to the identified root causes, are:

Clinical Governance Standard 4: Medication Safety - The health organization may have breached this standard by failing to ensure that there were effective systems and processes in place to support safe medication use. The absence of successful guidelines and processes, which include a clear process for preparing drugs and administration, as well as a lack of adequate training and education for staff members like Lorna, might have led to a breakdown in communication and confusion about the intended method of administration (Crevacore, Coventry, Duffield, & Jacob, 2022). Furthermore, there might have been insufficient control and monitoring of medicine use, as indicated by Lorna's ability to give the prescription without necessary checks and balances.


Partnering with Consumers Standard 2: Partnering in Healthcare - The health organization may have breached this standard by failing to ensure that patients and their families were involved in the decision-making process around their care. The absence of Mr. Evans from the medicine delivery procedure, as well as Lorna's failure to check the proposed route for administration with him, demonstrates that the medical facility did not prioritize patient engagement in the treatment process (Hains, (2021). Because the patient's wants and concerns were not properly understood or addressed, this lack of patient engagement might have led to a collapse in communication.

5. Recommendations

Outline a minimum of three (3) recommendations to address the root causes identified from the chosen case study. These recommendations need to include practical examples and identify who is responsible for actioning these recommendations.

(NOTE: you can add more rows if required – right click on the last row of the table, “insert”, “insert row below”)

Recommendations to address root cause Practical example(s) to achieve recommendations Position responsible/ accountable


1. To address the fundamental issues found in the case study, here are three recommendations:

Develop standardized prescription preparation as well as administration protocols: To address the core cause of drug administration misunderstandings and miscommunications, the hospital should develop standardized prescription preparation and administration procedures (Ostaszkiewicz, Thompson, & Watt, 2019).

Enhance training and education for nursing staff:

Develop an education program on medication administration and safety that covers the latest evidence-based practices and guidelines for medication administration, including the appropriate use of intravenous paracetamol and metoclopramide (Hamlin, &DNurs ). Nurse Unit Manager (NUM)


To address the core cause of insufficient patient engagement in the delivery of care, medical facilities should take initiatives to increase the involvement of patients in their care choices.

Improve communication and collaboration among healthcare professionals:

Implement a formal process for handover and transfer of care, including medication orders and administration details, to ensure clear and concise communication between nurses and other healthcare professionals.

Clinical Governance Manager


Establish a safety culture: To address the core cause of the hospital's lack of a safety culture, the medical center should take efforts to establish a safety culture that prioritizes transparency, continuous learning, and responsibility.

Strengthen the governance framework and reporting system:

Develop and implement a medication incident reporting system that encourages reporting of medication errors and near misses to promote a culture of transparency and continuous improvement.

CEO or General Manager

Reference List (APA 7th edition format)

1. References

Faust, J. S., & Del Rio, C. (2020). Assessment of deaths from COVID-19 and from seasonal influenza. JAMA internal medicine, 180(8), 1045-1046. Retrieved from

Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from

Berliner, H. S. (2022). Scientific medicine since Flexner. In Alternative medicines (pp. 30-56). Routledge. Retrieved from

Akalu, Y., Ayelign, B., & Molla, M. D. (2020). Knowledge, attitude and practice towards COVID-19 among chronic disease patients at Addis Zemen Hospital, Northwest Ethiopia. Infection and drug resistance, 1949-1960. Retrieved from

Fekadu, G., Chelkeba, L., & Kebede, A. (2019). Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study. BMC neurology, 19(1), 1-11.

Retrieved from

Cooper, K. L., Chang, E., Luck, L., & Dixon, K. (2022). Spirituality and Standards for Practice: A Critical Discourse Analysis. Journal of Holistic Nursing, 40(1), 16-24. Retrieved from

Pennington, K. R., Clark, K. D., & Knight, S. (2020). A bitter pill to swallow: registered nurses and medicines regulation in remote Australia. Rural and Remote Health, 20(4). Retrieved from

Crevacore, C., Coventry, L., Duffield, C., & Jacob, E. (2022). Factors impacting delegation decision making by registered nurses to assistants in nursing in the acute care setting: A mixed method study. International Journal of Nursing Studies, 136, 104366. Retrieved from

Hains, T. (2021). The role of the non-medical surgical assistant in Australia: legitimacy, effectiveness, and equity. Retrieved from

Ostaszkiewicz, J., Thompson, J., & Watt, E. (2019). A national project to develop and validate practice standards for Australian nurse continence specialists. Australian and New Zealand Continence Journal, The, 25(1), 16-21. Retrieved from

Federation, M. (2022). Department of Health and Aged Care Consultation-Review of the Aged Care Quality Standards. Retrieved from

Hamlin, L., &DNurs, R. N. Identifying research priorities for improving patient care in the perioperative environment: A descriptive cross-sectional study. Retrieved from


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