Date of Award

December 2020

Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Kim Litwack

Committee Members

Hyunkyoung Oh, Cheryl Baldwin, Sarah Morgan


administration, education, errors, medication, near-miss, nursing


The report, To Err is Human, by the Institutes of Medicine (IOM, 2000) brought attention to medication safety in the United States healthcare system. While advances have been made in patient safety, including electronic medication dispensing systems, electronic medication administration records, and scanning systems, it is estimated that 7,000 to 9,000 people die each year due to medication errors (Tariq et al., 2019). The medication administration process involves steps from prescribing to administration. However, nurses administering the medications are the final check point. James Reasons’ Swiss Cheese Model of Accident Causation illustrates the role that systems play in medical errors. The purpose of this dissertation is to determine the factors that contribute to undergraduate, prelicensure student nurse medication errors and near misses as identified by clinical instructors and the interventions that may help to mitigate these factors. The top 5 most common contributing factors of medication errors and near misses were ‘students having limited knowledge about medications,’ ‘the names of many medications are similar.’ ‘all medications for one team of patients cannot be passed within an accepted time frame,’ ‘the packaging of many medications is similar,’ and ‘students do not receive enough instruction on medications.’ The results have implications in nursing education and the potential to impact patient safety.