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QI Presentation:

Medication Error
Kanchana Allan, Alia Hajou,
Jessica Johnson & Saranya Sampath

• An infant was born with sluggish respirations. The mother was

given meperidine for pain during labor. The physician started
resuscitation and ordered naloxone. The physician administered
the medication, but the infant’s condition worsened.
• Prompted by the infant’s declining health, the physician decided to
check the medication package, and realized the syringe was filled
with digoxin (Lanoxin), not naloxone. The package of both
medications were made by the same manufacturer and were
almost identical.
• The ECG revealed directional ventricular tachycardia, which is
indicative of digoxin toxicity.
• One hour later, the infant died. Post-mortem analysis confirmed a
digoxin level of 17 ng/mL, exceeding the upper limit of the
therapeutic range of 2 ng/mL.
Fishbone Diagram
Manpower Methods

Doctor administered incorrect antidote Failed to use six rights of med

Nurse did not use
barcode scanner Pharmacy stocked wrong
medication in compartment Lack of communication process
between nursing staff and physician
Nurse failed to use six rights No time out in place
of med administration
Nurse selected incorrect Lack of inclusion of indication with med order
Nurse did not notice Pyxis med from cabinet
Infant died due to
medication error
Lack of package differentiation in
color and/or labeling
Proper Pyxis safeguards not in
Barcode scanner not place or did not function
used or malfunctioned Pyxis dispensed wrong med
Location and access to both meds drawer
within Pyxis too close

Materials Machines
Root Cause Analysis Continued
A lack of safety checks preceded the
administration of the incorrect medication,
leading to the death of an infant
Actions to Prevent Future Occurrence
● Hospital will purchase products from different manufacturers
○ to eliminate look-alike errors
● Review how look-alike, sound-alike drugs should be stored
○ highlight and separate drugs that could potentially be confused
○ pharmacy should ensure that the pyxis is functioning appropriately
● Improve systems of communication between nurses and prescribers
○ all orders should include the indication for the drug
● Organization should provide safety training for staff
○ the six rights of medication administration should always be done to
eliminate medication errors
○ in an emergency situation they must be done out loud with another
staff member
Outcome Measures
Numerator: Number of medication errors

Denominator: Total number of all given medication

doses on a unit

Threshold: Medication errors will be reduced from 10%

to 0%

Date/Time frame: Data will be collected for 6 months

Adverse Event Outcome Measure
Demonstrate that the actions taken have reduced or prevented the
adverse event from happening again

• One month after implementing a new storage system for look-alike/ sound-
alike drugs, the number of medical errors on the unit will be reduced by
100 percent.
Root Cause Outcome Measure
Measures the impact the action will have on the root cause

• After improving systems for communication between nursing staff and

prescribers, medication errors will not occur because of
Stakeholder Analysis
Internal Stakeholders External Stakeholders
• Patients • Unions
• Patient’s families • Patient advocacy groups
• Physicians • Insurance companies
• Nurses • Professional organizations
• Pharmacists • Lawyers
• Board of Directors • Joint Commission
Force Field Analysis
Goal: Reduce or Eliminate Medication Errors
Driving Forces Restraining Forces
• A culture that embraces change • Disgruntled staff unwilling to
to improve patient safety adopt additional safety measures
• Pharmacy staff willing to • Staff fatigue resulting in errors
implement additional safety • Financial constraints of the
checks to prevent error hospital limiting resources to
• Manufacturing company implement necessary changes
changing packaging
• Hospital staff willingness to
adhere to safety protocols and
double checks/time outs
VA National Center for Patient Safety RCA Tools (2015). Root Cause Analysis Tools: VA national center for patient

safety. Retrieved from: