DefinePK

Abstract

This case study explores a medication error committed by a nursing student during hospital clinical practice, analyzed using a Root Cause Analysis (RCA) framework. A structured exploration of contributing factors educational, environmental, communication, and systemic reveals complex interrelations that extend beyond individual negligence. Findings highlight gaps in pharmacological education, supervision weaknesses, workflow pressures, and cultural barriers. Recommendations include reinforcing curricula with simulation and pharmacology integration, strengthening preceptor support, fostering a just culture, and implementing technological safeguards. This analysis underlines the importance of system-level interventions to enhance safety and learning.