In today's demanding and fast-paced healthcare environment, medication administration has become a complex and time-consuming task. About a third of nurses' time is spent administering medications. There is a great risk of error due to the complexity of the medication administration process. Since nurses are the last to administer the medication to the patient, therefore they become responsible for medication administration errors (MAEs). The reasons for MAE may include individual factors, organizational factors, or systemic factors. This article will discuss the root cause analysis of MAE and strategies to prevent them. Root Causes – Fishbone DiagramCommunicationWieman TJ and Wieman EA (2004) demonstrate the communication factors that lead to MAE. They say that nurses' failure to question unclear orders or address concerns due to intimidation from the prescriber (doctor or pharmacist) contributes to these errors. Illegible handwritten orders and ambiguous orders written in MARs or patient profiles also contribute to these medical errors. Additionally, other factors that also contribute are incomplete medication orders such as missing dose or route, misunderstood abbreviations (Appendix B) (Davis NM, 2005), and misheard oral orders. According to Cohen MR (2007), nurses assisting with MAE fail to identify the patient (verified ID band, allergy band, MAR sheet), unable to share correct information during shift report and communication ineffective. In the methadone case scenario above, the nurse was not able to communicate adequately with the doctor and colleagues. She did not ask the doctor about the transcription error (dosage error). She did not apply the "Five Me...... middle of paper....../AssessERR.pdfParker, ME (2006)" criterion. Nursing theories and nursing practice (2nd ed.). Philadelphia: FA Davis Company. Rogers, AE, Hwang, WT, Scott, LD, Aiken, LH, & Dinges, DF (2004). Work schedules of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212. Tang, FI, Sheu, SJ, Yu, S., Wei, IL, and Chen, CH (2007). Nurses relate contributing factors involved in medication errors. Journal of Clinical Nursing, 16(3), 447-457. Taken from EBSCOhost. Wakefield, BJ, Holman, TU and Wakefield, DS (2005). Development and validation of the Medication Administration Error Reporting Survey. Agency for Healthcare Research and Quality. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK20599/#N0x1a52fc0N0x5b8ac78Wieman TJ, Wieman EA. A systems approach to error prevention in medicine. J Surg Oncol. 2004; 88 (3): 115-21.