Medication Errors: Patient Safety Concern in Nursing


Medication errors are a widespread patient safety issue: in fact, it is the most common medical error, which illustrates its significance for nursing practice (Gorgich, Barfroshan, Ghoreishi, & Yaghoobi, 2015; Vito, Borycki, Kushniruk, & Schneider, 2017). The adverse outcomes of medication errors range from distrust towards the healthcare institution to disability and even death (Gorgich et al., 2015). The causes of medication errors are multiple, but a major one is illegible or damaged orders, which increases the risk of nurses administering wrong drugs (Gorgich et al., 2015; Hayes, Jackson, Davidson, & Power, 2015; Shahverdi & Javadzadeh, 2016). The problem is an ongoing one at my workplace, which is a correctional institution.

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The apparent solution consists of the improvement of the order system, and computerization has been shown to reduce medication errors by eliminating illegible and unreliable prescriptions (Khalil, Bell, Chambers, Sheikh, & Avery, 2017). In particular, Computerized Provider Order Entries (CPOE) result in long-term reduction of medication errors (Liao et al., 2017). A systematic review by Prgomet, Li, Niazkhani, Georgiou, and Westbrook (2016) indicates that this outcome is consistent and can achieve an 85% reduction. Thus, the present paper considers the adoption of CPOE at my workplace (correctional institution) to reduce the medication errors that are attributable to damaged or illegible orders and improve the safety of patients.

Description of Selected Systems Change for Quality Improvement Proposal

The proposed change is not going to be limited to the nurses; instead, it will involve all the providers engaged in the medication process (Vito et al., 2017). As a result, more stakeholders will need to be involved, which emphasizes the importance of leading the change effectively. Due to the focus of the present paper on leadership, Lippitt’s model is going to be used in it. The primary feature of this model is its focus on the change agent (leader), and this role can be fulfilled by a Doctor of Nursing Practice (D.

The model includes seven steps, which use the three-element Lewin’s theory of change and expand it to describe the process in greater detail (Spear, 2016). The first step consists of a problem diagnosis, which has been carried out to an extent in this paper. However, the organizational needs assessment and the collection of additional evidence are required to ensure a successful change and enable its customization (Hanrahan et al., 2015). The data collected during this stage will be employed for future planning, for example, in determining the specific CPOE to be purchased.

The second stage reviews the capacity of the organization (for example, its financial resources) and the motivation of the stakeholders. The latter element is particularly important for stakeholder engagement; for example, it is not uncommon for people to exhibit various levels of resistance to change (Laker et al., 2014). The resistance needs to be appropriately managed, for instance, with specific change management models like that by Rogers (Hanrahan et al., 2015). The third step is devoted to assessing the resources of the change agent: their ability to lead the project, which makes this stage a part of recruitment procedures.

The fourth stage is concerned with planning. The information that is gathered during the previous steps needs to be organized and analyzed to propose the objectives of the change, a well-aligned plan, and specific strategies for its elements. The examples of the latter can include a stakeholder engagement strategy, information dissemination strategies, and so on (Spear, 2016). The use of other models and theories to govern the specific elements of the plan may be appropriate. For instance, Kotter’s change model is useful for the communication of the change and its mission and vision to the stakeholders (Small et al., 2016).

The fifth stage involves the introduction of the participants and the change agent; the former need to understand the role of the latter to ensure the transparency of their interactions. This step is followed by the implementation and maintenance of the change. The latter element is extensive and includes several features. First, the stakeholder engagement needs to be continuous and multifaceted as indicated by the model: the sixth stage has to promote “communication, feedback, and group coordination” (Spear, 2016, p. 59). The specific methods of achieving these outcomes vary; examples can include conferences and meetings, as well as newsletters and e-mails and direct feedback solicitation in the form of questionnaires or reports (Hanrahan et al., 2015).

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Other significant features include barrier management (for example, resistance to change or financial constraints). Also, training is essential for the majority of change activities (Ryan et al., 2015), especially those related to the implementation of new technology (Liao et al., 2017; Vito et al., 2017).

As a result, all the stakeholders who are involved in the medication process will receive appropriate training. The sixth stage may include iterations, especially if the feedback provides information on issues and challenges. For example, Vito et al. (2017) point out the fact that the nurses’ feedback is often ignored and demonstrates that they might experience issues with logistics (for instance, computer access). The problems reported by the stakeholders need to be addressed to ensure the success and sustainability of the change.

The final element of the model is the termination of the helping relationship between the change agent and the organization; it establishes the new status quo (Spear, 2016). However, this outcome is only possible after the evaluation of the change, which is why Mitchell (2013) suggests introducing evaluation activities into this step. The model does not provide details on the process, but additional models can supplement it. For example, by employing the evaluation framework developed by the Centers for Disease Control and Prevention and Program Performance and Evaluation Office (2017), the agent will be able to create a customized evaluation model for the change. When the evaluation determines that the objectives of the change have been achieved, the project will be terminated.

Presentation of Selected Systems Change for Quality Improvement Analysis

As follows from the model, the specifics of the evaluation plan need to be established by the change agent together with other stakeholders. However, certain preliminary outcomes can be suggested. The change will involve certain objectives related to the organizational aspects of the project. First, CPOE software will be installed, and the participants of the medication process will be provided with access to appropriate devices to avoid the logistics issues mentioned above. Then, the training of the stakeholders will be completed and evaluated; this factor is a direct requirement for CPOE-based quality improvement (Gorgich et al., 2015; Liao et al., 2017).

Finally, the major outcome is the reduction in the rates of medication errors, which might amount to 85% (Prgomet et al., 2016). It may be helpful to include the objectives for short-term and long-term effects (the former may be rather low due to the confusion of change) and take into account the specifics of the errors documented (they may change after CPOE implementation) (Liao et al., 2017). This outcome should result in patient safety improvements.

Although it is possible for them to be a regular contributing participant, the intended role of a DNP-prepared nurse in the proposed change is that of the change agent (or one of them). The DNP-prepared nurse will have the opportunity to employ their research skills during the first three stages, leadership skills during the fourth, fifth, and sixth stages, and the knowledge and experience of change evaluation during the final stage (Udlis & Mancuso, 2015).

From this perspective, the chosen model is helpful because it emphasizes the role of the agent and provides them with a framework for their actions. For example, it highlights the fact that the agent needs to be prepared for the change and capable of managing it, which is a major consideration. Also, it emphasizes the interactions between the agent and the stakeholders. As it has been established in nursing practice and research, the engagement of stakeholders may be critical for promoting the change (Hanrahan et al., 2015; Mitchell, 2013; Spear, 2016). In general, the model should provide a viable framework for a DNP nurse who chooses the role of a change agent to promote and sustain the change.

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However, the chosen model is not very detailed from other perspectives. For example, the implementation phase is contained in one stage, but the preparation consists of the first five steps. As a result, the model barely addresses the implementation process, predominantly focusing on the interactions of participants. Since the model aims to make Lewin’s theory more detailed (Spear, 2016), this feature might be viewed as a drawback.

However, this drawback is caused by the specifics of the model. It aims to describe the role of the agent in the process of change, which is why the remaining aspects are not reviewed thoroughly. To detail other aspects of change, it is possible to merge this model with other ones or employ several models at once (Mitchell, 2013). Eventually, all the major elements of the innovation are mentioned explicitly or implicitly in the stages, which suggests that the model is usable.


Medication errors are a major issue, which can be prompted by illegible prescriptions. CPOE is an appropriate evidence-based solution. The proposed change consists of the adoption of CPOE by a correctional institution with the help of Lippitt’s model, which emphasizes the role of the change agent (DNP). A DNP will be able to employ their research and leadership skills to ensure the sustainability of the change by carefully planning it, engaging stakeholders, and establishing communication and feedback. Also, the change agent can lead the effort of the program evaluation. The model is helpful as a framework for a leader, but it lacks details pertinent to the implementation and evaluation of change.

These elements can be found in additional models if required. As for the benefits of the proposed innovation, they are connected to its key outcome, which is the reduction of medication errors. Also, the change can produce some information on organizational needs and challenges, as well as lessons learned regarding the use of technology by the institution and change management. The latter can be employed for future projects and programs, ensuring continuous quality improvement and increasing patient safety.


Centers for Disease Control and Prevention, & Program Performance and Evaluation Office. (2017). A framework for program evaluation. Web.

Gorgich, E., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2015). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 220. Web.

Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C., Greiner, J.,… Williamson, A. (2015). Sacred cow went to pasture: A systematic evaluation and integration of evidence-based practice. Worldviews on Evidence-Based Nursing, 12(1), 3-11. Web.

Hayes, C., Jackson, D., Davidson, P., & Power, T. (2015). Medication errors in hospitals: A literature review of disruptions to nursing practice during medication administration. Journal of Clinical Nursing, 24(21-22), 3063-3076. Web.

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Khalil, H., Bell, B., Chambers, H., Sheikh, A., & Avery, A. (2017). Professional, structural and organizational interventions in primary care for reducing medication errors. Cochrane Database of Systematic Reviews, 10, 1-147. Web.

Laker, C., Callard, F., Flach, C., Williams, P., Sayer, J., & Wykes, T. (2014). The challenge of change in acute mental health services: Measuring staff perceptions of barriers to change and their relationship to job status and satisfaction using a new measure (VOCALISE). Implementation Science, 9(1), 1-11. Web.

Liao, T. V., Rabinovich, M., Abraham, P., Perez, S., DiPlotti, C., Han, J. E.,… Honig, E. (2017). Evaluation of medication errors with implementation of electronic health record technology in the medical intensive care unit. Open Access Journal of Clinical Trials, Volume 9, 31-40. Web.

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Prgomet, M., Li, L., Niazkhani, Z., Georgiou, A., & Westbrook, J. (2016). Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. Journal of the American Medical Informatics Association, 24(2), 413–422. Web.

Ryan, R., Harris, K., Mattox, L., Singh, O., Camp, M., & Shirey, M. (2015). Nursing leader collaboration to drive quality improvement and implementation science. Nursing Administration Quarterly, 39(3), 229-238. Web.

Shahverdi, E., & Javadzadeh, H. (2016). The Role of a computerized system of medical order registration on the reduction of medical errors. Jundishapur Journal of Chronic Disease Care, 5(2), 1-4. Web.

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Vito, R., Borycki, E. M., Kushniruk, A. W., & Schneider, T. (2017). The Impact of computerized provider order entry on nursing practice. In F. Lau, ‎J.A. Bartle-Clar, & ‎G. Bliss (Eds.), Building capacity for health informatics in the future (pp. 364-369). Amsterdam, Netherlands: IOS Press.

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