Date of Conferral



Doctor of Nursing Practice (DNP)


Human Services


Catherine Garner


Five to 27% of all pediatric medication orders lead to errors and play a significant role in the morbidity and mortality of the pediatric patients admitted to hospitals. The practice problem explored the high rate of medication errors in the pediatric intensive care unit (PICU) of the project site, where the population is particularly vulnerable due to their acute illnesses. The purpose of this project was to analyze the root causes of all cases of medication error in this hospital's PICU during the last 2 years. The literature review was used to categorize secondary data extracted from the hospital's quality assurance database. An analysis of the 41 total medication errors showed that 49% of the medication errors made in the PICU were due to the nurse administering the incorrect dose of medication. Most (60%) occurred on the day shift when the unit was busy and the patient's medication orders were constantly being changed. Missed doses' €”mostly due to oversight and ineffective follow-€up by clinical staff, pharmacy, and providers €accounted for 27% of the medication errors. There were instances in which the physician and the pharmacy did not properly order and verify a medication. The summary of the root cause analysis and recommendations from the literature for improved clinical practice will be presented through the hospital's quality assurance structure. Recommendations include implementing computerized physician order entry, regular education of staff, involvement of the pharmacist in new medication orders, updated nursing protocols, and support systems for decision making. The implications of this project for positive social change include the impact of improved practices on decreasing medication errors and improving health outcomes in the PICU population.

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