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Medication safety Case Analysis

Intent:
Medication errors can impact patient outcomes, therefore safe and appropriate
administration of medicines is an important part of patient safety. The intent of this
assessment is to prepare students for clinical practice by developing their understanding of
the types of medication errors and the reasons these occur, and to develop strategies for
students’ own clinical practice to prevent medication errors.

Task:
You are required to view one of the case study videos provided, then analyse and discuss
the factors within the video that lead to the medication error.

1. https://youtu.be/CspIrlJ2bd4
2. https://youtu.be/MGT8yoAIun4
Watch all of them and then choose only one (1) to analyse for your Medication Safety Case Analysis.

1. Discuss your understanding of James Reason’s Model of System Failure ‘Swiss Cheese
Model’ (2000) in relation to patient safety.
2. List all the factors in the video that lead to the medication error occurring.
3. Select and analyse three main factors that lead to the medication error occurring.
4. Discuss how the nurses’ involved could have prevented the medication error with
reference to the factors identified in point 3.

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