Student Name

Capella University

BHA-FPX 3004

Instructor’s Name

Submission Date

Reflective Paper

Today’s healthcare setting depends on a culture of responsibility, openness, and learning that ensures patient safety and quality health care. This can be achieved by creating a ‘just culture’ in health service providers. Indeed, medication errors are the most common safety issues in health facilities and are often blamed on communication and workflow issues and the lack of safety protocols (World Health Organization, 2023).

In one instance, the medication administered to Vila Health’s patient was inappropriate since a verification process was not properly completed. While the error was not captured to cause any harm to the patient, it is a sign of a weakness in the system. As a quality manager of Vila Health, I would take advantage of this to improve our culture of patient safety, better inter-professional working among the different professions and more changes within the system to mitigate the risk of future events like this.

Culture plays a crucial role in how health employees treat errors and safety issues the organization faces in those health organizations. Culture in health organizations is the beliefs, values, and traditions that influence the way health workers do their jobs and interact with patients and co-workers. A positive safety culture has been shown to reduce adverse events and improve health outcomes in organisations (Vikan et al., 2023). There are a number of evidence-based strategies that can be used to develop a safety culture after a medication error has occurred.

A non-punitive culture begins by allowing medication errors so they can be openly discussed, analyzed, and steps can be taken to prevent a future error in the future. Another way to educate the workforce can be through training and education on safety procedures and administration of the medications, and the importance of compliance with hospital safety guidelines and protocols. The hospital administration’s participation in the safety education and training sessions is crucial since it provides the message that administration cares about safety and that the administration is committed to providing safe and high-quality service to patients.

Leadership to improve medication errors is needed and could be part of a more comprehensive effort to improve health, such as the Institute for Healthcare Improvement’s Triple Aim approach. The Triple Aim approach is aimed at improving the way patients experience the delivery of care, improving the health of the populations served, and decreasing costs (Thakur & Joshi, 2025). If a medication error has been made, communication with the patient/ family should be open and honest, and the relationship between the patient/ family and the facility should be strengthened.

To enhance the health of the populations served, leaders need to ensure the safety of the facility is standardised to minimize medication errors within the facility’s population. The third part of the Triple Aim approach is decreasing the costs, which is related to medication safety since medication errors can cause increased treatment, extended length of hospitalization, and legal costs, which can be very expensive. Thus, the facility can adopt preventive measures and use technology to ensure that medication errors do not happen and to ensure that better quality of care is provided and costs are reduced.

To address the issue of medication error and improve the safety culture in the organization, we’d implement a sound evidence-based action plan to improve patient safety. Firstly, I would perform a comprehensive Root Cause Analysis and determine the cause of the error, for example, poor communication, inadequate staffing, or poor medication verification (Thakur & Joshi, 2025). The next step in patient safety in this organisation to improve the service would be to introduce standardisation of medications by adding a number of steps within the process before giving medication to patients.

These steps could involve medicine scanning, independent double checks of high-risk medicines and/or medicine administration documentation. The third step in medication error reduction and patient safety in the organisation would be to further develop staff education and training regarding patient safety procedures for medication administration. Third, to further reduce medication errors within the organisation, the technology could be improved to increase patient safety in medication administration, for example, clinical decision tools for checking dosage and drug interaction issues. Monitoring the rate of medication errors to measure the effectiveness of the intervention to improve patient safety would be the last step in addressing medication errors in the organization.

Involving everyone in the healthcare team in safety is not only good to have, but it is also a necessity for a just safety culture. The front-line workers are usually the best placed to know the workflow problems and what the actual risks are. For instance, working cooperatively with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Pharmacy Department, and Human Resources. Therefore, involving them in the process (asking them to find problems and propose solutions) may be extremely beneficial in terms of safety.

This can be achieved through implementing unit-based safety committees for staff to raise any concerns they have about medication safety and develop solutions to the concerns. Reporting tools may also be utilized in putting staff in a setting to report any issues around near misses or hazards without the worry of repercussions or discipline (Chance et al., 2024). Daily huddles can also be utilized to identify staff issues relating to patient safety before they occur, and to communicate observations that indicate patient safety concerns. It can also be very effective if people who are passionate about patient safety are recognised and rewarded for their efforts to ensure that everyone is involved in patient safety.

A healthcare culture where everyone is treated fairly and justly is crucial to a safe patient care environment and a strong organization. Medication errors remind us that we should not focus on individual errors and instead focus on the issue in healthcare organizations. At the end of the day, a fair and just culture helps us learn from errors, creating a culture where patient care is both safe and of the highest quality while healthcare providers feel empowered to help continue safety enhancements in healthcare facilities.