University of Twente Student Theses


Root Causes of Medication Errors in Nursing Homes

Koster, M.J.J. (2014) Root Causes of Medication Errors in Nursing Homes.

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Abstract:The ageing of the population is growing and unfortunately, medication-related problems are the fifth leading cause of death in the United States. Many causes of incidents are known, but not the relations among the (known) causes and so not the root causes, which are needed to know to solve a problem efficiently. In this study, the root causes are determined by the PRISMA method. This research is performed in an health organization. Two medication errors with the highest frequency are chosen to investigate: ‘medication not given’ and ‘client does not take the medication’. The selected incidents are randomly chosen and the information is obtained through interviews with nurses. The research shows that the most frequent factors of ‘medication not given’ are the organizational factor and the human behavior factor. The causes are the management priorities, an unclear coordination between teams or the nurses making many slips, and are the external organizational aspects. The most frequent factor of ‘client does not take the medication’ is the patient related factor. A solution for the slips can be a second medication list or an automatic system which controls the medication lists and the coordination problems can be solved by clear responsibility lists.
Item Type:Essay (Bachelor)
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:44 medicine, 85 business administration, organizational science
Programme:International Business Administration BSc (50952)
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