NURSING STUDENT MEDICATION ERRORS: A CASE STUDY USING ROOT CAUSE ANALYSIS

Root cause analysis (RCA) has been used widely as a means to understand factors contributing to medication errors and to move beyond blame of an individual to identify system factors that contribute to these errors. Nursing schools respond to student medication errors seriously, and many choose to discipline the student without taking into consideration both personal and system factors. The purpose of this article is to present a case study that highlights an undergraduate nursing student medication error and the application of an RCA. The use of this method was a direct result of our nursing program implementation of the Quality and Safety Education for Nurses competencies. The RCA included a critical evaluation of the incident and a review of the literature. Factors identified were environmental, personal, unit communication and culture, and education. The process of using the RCA provided an opportunity to identify improvement strategies to prevent future errors. The use of the RCA promotes a fair and just culture in nursing education and helps nursing students and faculty identify problems and solutions both in their performance and the systems in which they work. (Index words: Root cause analysis; Student medication errors; Quality and safety; Fair and just culture) J Prof Nurs 29:102-108, 2013. (C) 2013 Elsevier Inc. All rights reserved.