CSU Dominguez Hills Quality R


For your final Portfolio Project, you will write a paper based on the following case study scenario: Interim Bulletin: Wrong Route Administration of an Oral Drug into a Vein

Your goal is to address the areas of risk and quality improvement related to healthcare/medical errors, as well as to safeguard future patients from having their safety compromised like what occurred in this case study.


Your quality and risk management plan must include:

  • A root-cause analysis;
  • At least two recommendations for improvement;
  • Identification of all employees’ roles in your analysis;
  • An assessment of what the facility can do going forward to create a culture of quality and safety;
  • Quality, risk, and performance improvement diagrams and charts (e.g., a fishbone or other visual forms of root cause analysis, Pareto chart, tables, etc.) to support your analysis; and
  • A commentary that relates the case broadly to what has been covered throughout the course and describes the roles played by quality and regulation to prevent occurrences such as the case described.

Brief Summary-

A nine year old pediatric patient was administered an oral liquid sedative medication (Midaolam) by vein before an elective surgery of a renal biopsy. The medication was prescribed as intravenous by the doctor. The nurse prepared the medication in the treatment room, but she assumed it was for oral administration and prepared the drug with the specific oral syringe with a purple top. Both the nurse and the doctor checked the medication and did not recognize the mistake. The nurse left the room and a different doctor entered the side room (where the operation was to be preformed) and administered the oral drug intravenously. The oral syringe would not connect correctly to the cannula and the contents were decanted to the clear syringe which was designed to connect to the cannula. The doctor noted that the syringe was difficult to push. Medicine then leaked on the doctor’s hand who then realized that there was a serious problem and ceased the procedure. The child was monitored for 24 hours and then underwent the procedure with general anesthesia the next day. 

Root-Cause Analyst


“Root-cause analyism is an analytical process and calls for rigourous thinking about interlated cause and effect relationships within a system that has failed” (Okes, 2008). 

In regards to this case study, the problem is defined as an oral medication being dispensed intervenously, thus putting the patient’s health in jeapordy. Mistakes regarding intravenous medication are the most common medication mistake (Guiliano, 2018). The causes of this case study can be debated, but it there seems to be a lack of communication between the prescribing doctor, the nurse who chose the oral medication, and then the doctor who administered the drug. A key word in the case study is that the nurse “assumed” that the medication was for oral administration. However, both the nurse and the prescribing doctor admitted to double checking the medication prior to administering. Increased communication and a stronger system in place to monitor medication administration could have made a big difference in this case.

The supporting data shows that there are many steps to medical administration where the problem can begin — from prescribing, transcribing, dispensing, administering, and even though in this case study the administration was ceased after realizing the error, monitoring the drug. 

Root-cause analyst infograph


(Okes, 2008)

Recommendations for Improvement




This case study is not a one-time accident. Medical Administration Errors are the most common type of medication error (Wondmieneh et al., 2020). Therefore, I would find it prudent for our hospital to utilize another layer of protection over our patients. It is common in risk management to set up preventative emergency measures to ensure the safety of the staff and patients (Labelle & Rouleau, 2017). This extra layer of protection can be in the form of added software to our EHR that will filter algorithims to monitor for Medical Administration Errors. There is a way to monitor in real-time for medication errors by using a four step system through an EMR update that will allow for automated medication error detection This has been proven to be more effective than reporting and trigger tools that are also used to prevent errors (Ni et al., 2018). 

This chart used data from the EHR update and non-automated error detection processes to show that doctors who are utilizing the automated error dection are able to catch the problem much quicker, usually in time to prevent the incorrect administration (Ni et al. 2018). The algorithims within our EHR can tell us things about our patients and their medications, and possibly even save their lives.

Automated Error Detection

(Ni et al., 2018)




Communication and Leadership

There were multiple steps to this case study, from the prescribing doctor, the nurse who filled the prescription, and finally, the administering doctor. In these high risk situations, our staff needs to be able to effectively communicate as a team in order to ensure better patient safety and quality of care. In fact, clear communication between the doctor and the nurse is listed as one of the main factors in positive healthcare results (Lari et al., 2019.) Also, strong leader should have been present during this young patient’s procedure. Had there been an overseeing physcian or a medical administrator monitoring the procedure, the medication administration error may have been avoided. A strong leader is transparent about decisions (Greengard, 2019), therefore, there would have been no room for the nurse to make “assumptions” about the oral medicatoin because the order would have been very clear if it was from an appointed leader. Total Quality Management in healthcare values the patient’s safety above all (Dlugacz, 2017), and in this situation, due to comminucating errors and lack of a leader, the quality of patient care suffered.


Going Forward

In the future, in order to preserve risk managment: 

  • A clear leader needs to be assigned to patient rounds. 
  • Prescribed medication needs to be clearly communicated to all concerning parties. 
  • Automated Detection for Medical Errors Software needs to be implemented 
  • Communication seminars and even utilizing checklists between medical staff, which help ensure accuracy and communication in high stress situations (Alzoubi, 2019). 


Employee Roles


  • Prescribing Doctor: This was the doctor who prescribed the medication to the pediatric patient. The patient was to be put under concious sedation for a renal biopsy. The doctor prescribed the sedative for intravenous administration. 
  • Nurse: The nurse who prepared the medication and chose the oral prescription AND oral syringe.
  • Administering Doctor: This doctor administered the drug intravenously as prescribed but noted that the plunger of the syringe was difficult to press and medicine even leaked out. It was upon the leakage that the doctor realized that the medication was inccorect. 



Quality and Risk Management Board Take-Aways

As a whole, we (Quality and Risk Managment Board of Operations) can all learn from this case study to improve quality care and prevent errors in medication administration. 

  • Risk Managment: Our hospital’s risk management team needs to curate policies to handle worst-case scenarios such as the case study — or worse, if the patient were to die due to wrongful administration.
  • Quality Management: Implementation of a clear leader during procedures and patient care and communication improvement seminars.
  • Together: Together we need to all consider the new software for the EHR to prevent medication administration errors and collaborate quantitative and qualitative data on the results of these decisions. 

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