Medication Error Assignment

Beyond Blame: A Root Cause Analysis of a Medication Administration Error

Medication errors are a leading cause of patient harm. The Institute of Medicine’s landmark report, *To Err Is Human*, established that most errors result from faulty systems, not incompetent people. To improve safety, nursing practice must shift from a punitive culture to a Just Culture that encourages reporting and systemic analysis. This paper will analyze a specific medication error—the administration of an incorrect insulin dose—using Root Cause Analysis (RCA) to identify system failures and propose evidence-based solutions.

Description of the Medication Error

The incident occurred on a busy medical-surgical unit at 0730 during shift change. A registered nurse (RN) administered 10 units of Humalog insulin to a patient, Mr. J, instead of the prescribed 4 units. Mr. J subsequently developed hypoglycemia (blood glucose 45 mg/dL), requiring IV dextrose. The immediate outcome was patient harm (hypoglycemia) and increased length of stay. The nurse realized the error immediately after administration and reported it.

Root Cause Analysis (RCA)

Using the “5 Whys” method reveals the systemic roots of this error.
1. Why did the nurse give the wrong dose? She misread the sliding scale order on the MAR.
2. Why did she misread the MAR? She was rushing and distracted.
3. Why was she rushing? She had 6 patients, two were calling for help, and the night shift nurse was waiting to give report.
4. Why was she distracted? The medication room is a high-traffic area with constant interruptions.
5. Why was the order confusing? The font size on the printed MAR was small, and the sliding scale columns were poorly aligned.
The root causes are: environmental distractions, inadequate staffing ratios, and poor interface design of the MAR. It was not merely “carelessness.”

Just Culture Analysis

In a Just Culture framework, this error falls under Human Error (unintentional slip) or possibly At-Risk Behavior (rushing/drift). It was not Reckless. The nurse did not intend harm and was working within a flawed system. Therefore, the appropriate response is to console the nurse and coach her on managing interruptions, rather than punishment. Punishing her would discourage future reporting and leave the systemic traps (staffing, MAR design) in place for the next nurse.

Evidence-Based Solutions

To prevent recurrence, system-level changes are required.
1. Barcode Medication Administration (BCMA): Implementing mandatory scanning would have alerted the nurse to the dose discrepancy before administration.
2. “No Interruption Zones”: Establishing a policy where nurses wearing a sash cannot be interrupted during medication pass reduces cognitive load and errors.
3. Independent Double-Checks: For high-alert medications like insulin, requiring a second nurse to verify the dose is a proven safety redundancy (ISMP, 2023).

Conclusion

The insulin error was a symptom of system failures—distraction, staffing, and design—not individual failure. By applying RCA and Just Culture, the organization can move from blaming the nurse to fixing the process. Implementing BCMA and interruption-free zones will create a safer environment for both patients and staff.

References

Agency for Healthcare Research and Quality. (2019, September 7). *Medication errors and adverse drug events*. PSNet. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

Institute for Safe Medication Practices. (2023). *ISMP list of high-alert medications in acute care settings*. https://www.ismp.org/recommendations/high-alert-medications-acute-list

Reason, J. (2000). Human error: Models and management. *BMJ*, *320*(7237), 768–770. https://doi.org/10.1136/bmj.320.7237.768