Degree Name

Doctor of Nursing Practice (DNP)

Document Type

Project Paper


Zvart Onanian School of Nursing



Date of Original Version

May 2022


Background: Medication errors are one of the most common errors in healthcare that have the potential to cause patient harm. Despite achieving the goal of 95% compliance with medication safety process metrics, medication errors persisted at the organization where the study was completed. Purpose: This project was launched as an organizational assessment to determine what the causes and contributing factors to medication errors are from the perspective of the bedside nurse. Nurses’ opinions regarding potential solutions to errors were also sought for future process improvement planning. Methods: The Lifespan and Rhode Island College Internal Review Board approved this research which consisted of a mixed-methods survey and focus group that completed a failure modes and effects analysis. Results: Major barriers to medication safety practices identified in the data were distractions, lack of time, availability of staff to perform safety checks, and scarcity of updated, working computers, and scanners. Factors contributing to errors were confusing or incorrect orders and inadequate communication between healthcare disciplines and the family. Potential solutions to errors proposed by the respondents were pharmacy preparation of exact medication doses, additional working computers, and more staff to verify doses and infusions when needed. Conclusion: Information gained from the failure modes effects analysis (FMEA) performed by the focus group substantiated the survey data and revealed educating the patient and family about medication being given is an important intervention for staff working with the pediatric population at this setting. Nurses participating in this study had adequate knowledge about safety practices and were able to identify barriers to the established medication administration process, factors associated with errors, and potential solutions to systems issues. Safety practices are not always followed by these nurses due to distractions, lack of time, staffing, and improperly functioning computers.