NURS FPX 4020 Assessment 1 Attempt 3 Enhancing Quality and Safety

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Enhancing Quality and Safety

NURS FPX 4020 Assessment 1 Attempt 3 Enhancing Quality and Safety

Medication errors are defined as errors that might occur due to the wrong administration of a drug or dose or prescribing the wrong medication. Medication administration is one of the most common types of medication error. It means to administer the wrong medication either orally or intravenously. Hence, the healthcare community emphasizes providing quality care without medical errors. According to the statistics provided by Patient Network System in 2018, the rate of medication administration error ranges from 8-25% (Schroers et al., 2021). Hence, the healthcare community needs to address the issue related to medication administration errors. The wrong drug administration, dose, duration, and frequency are included in prescribing and dispensing errors. 

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Scenario Chosen for Medication Administration

In 2014, a medication administration error occurred at Vibra Hospital of Sacramento, California. This administration error took the life of the patient. The California Department of Public Health (CDPH) took legal action against the facility and penalized them for about $75,000. The issue was that Levophed (a drug used when a patient is in hypotension) was administered by the nurse 3000-8000 times more than the prescribed dosage intravenously (IV). The medication error was due to certain factors like lack of experience of the nurse, lack of safeguards for any high-alert medication, and the senior nurse did not sign off on dispensing the medication. She did not check the doctor’s prescription that stated Levophed was to be administered only when the blood pressure was below 65. In the report by the CDPH regarding the facility, it was mentioned that the facility has failed to highlight the importance of Standard Operating Procedure (SOP)’s and did not implement the policies properly (Hamzaoui & Shi, 2020). 

Elements of Quality Improvement Initiative

Improving the quality of the healthcare facility is linked to improving the care of the patients. Quality improvement means standardizing structures for reducing variation, achieving results that were once hypothetical, and improving outcomes for patients and organizations. Healthcare facilities can improve the quality of care by setting goals, analyzing data provided and not repeating the same mistakes, and communicating with the interprofessional team (Afaya et al., 2021). The Electronic Health Record (EHR) can record a patient’s medical history digitally; it includes progress notes, problems, medications, and critical administrative and clinical data. For improving medication administration errors, barcodes can be used. It will ensure that the right drug is administered every time. A quality improvement plan has four major components.

  • Problem- It is essential to have in-depth knowledge about the problem before finding a solution for it.
  • Goal- Setting a goal is challenging for a lot of healthcare facilities. They have to form a plan for promoting cost-effective health quality. 
  • Aim- The aim is to implement the plan by setting milestones fully.
  • Measure- Baselines should be set to evaluate the success of implementing the plan.

For the success of the quality improvement plan, it is essential to have leadership qualities, knowledge and devotion to make a change. The research shows that medication administration errors (MAEs) have an error rate of 60%, usually due to the administration of the drug at the wrong time, wrong rate or wrong dose (Härkänen et al., 2019). In another study, it has been reported that one in every three adverse drug events occurs due to nurses administering the wrong medication. Medical errors can be reduced by (1) Computerized Physician Order Entry (CPOE) which reduces medical errors by 3.15%. It further reduced medical errors by up to 20% by minimizing the use of wrong acronyms. (2) 2.10% of medical errors are reduced by using Electronic Medication Administration Record (EMAR). It reduces medical errors by 80% when using barcode readers (Härkänen et al., 2019). 

NURS FPX 4020 Assessment 1 Attempt 3 Enhancing Quality and Safety

Factors that lead to Patient Safety Risk

Many factors are concerned with patient safety in a healthcare setting. If there is poor communication between doctors, doctors and nurses, the healthcare organization will not be successful. They will face various problems, medical errors and financial loss. The drugs that sound alike and medications that look alike may confuse nurses who are not experienced. When the doctors may use medical abbreviations that the rest of the organization is unaware of, it can lead to medical errors as there will be a communication gap between the members of the organization (Keers et al., 2018). The nurses and doctors need to realize their responsibilities and ensure that the patient is safe in the hospital. Experienced personnel should tackle intricate procedures; otherwise, medical errors may occur. If the organization is understaffed, the staff does not get sufficient sleep; they are not aware of the hospital’s policies, which can also lead to medical errors.

Organizational Interventions to Promote Patient Safety

Safety improvement plans help with reducing medical errors. It has been reported by the Institute of Medicine (IOM) that about one million individuals in the United States are harmed every year due to medical errors (Rodziewicz et al., 2022). The organization can improve the quality of care by forming an interprofessional team that keeps a check and balance for all the events in the healthcare facility. The organization can hire new nurses, arrange workshops, guide them by hiring experienced mentors, and grab new stakeholders’ attention. It will increase the amount of funds and resources, which will ultimately help the organization in providing better care to the patient (Jember et al., 2018). Due to excessive workload, nurses get burnt out and do not perform well. Hence, it is necessary to hire a nurse manager who can schedule nurses’ shifts so they can rest and have a positive aura the next time they come to the hospital.

NURS FPX 4020 Assessment 1 Attempt 3 Enhancing Quality and Safety

Furthermore, the organization can form protocols for discharging patients, medication reconciliation, and electronic tools. The organization can hire a risk manager who could assess the positives and negatives of the hospital by analyzing the data provided to find solutions for minimizing medication administration errors. The organization can label drawers and bottles with SOPs for their usage. It will significantly reduce the risk of administration errors (Rodziewicz et al., 2022).

Role of Stakeholders

In a healthcare setting, stakeholders help ensure that patients get premium care. They are not harmed by nurses, doctors, educators, researchers, and administrators. The stakeholders include professionals, policymakers, managers, clinicians, clinical assistants, patients, and payors (the one who provides funds to the organization). Stakeholders include pharmaceutical, biotechnology companies and research communities at the industry level. Stakeholders are essential as they ensure the successful adoption of resources, skills, and knowledge by the organization for implementing the plan related to minimizing medical administration errors (Shawahna, 2020). Stakeholders have the power to influence the opinions of the public as well. They ensure that the best outcomes are produced. According to World Health Organization (WHO), a lack of training and evidence-based knowledge affects nurses’ decisions and can enhance the rate of medical errors. The stakeholders in such a situation address the issue and try to find solutions for it. If the Quality Improvement (QI) measures proposed by stakeholders are fully implemented, it can lead to a better quality of care for patients (Clapper, 2018).

Conclusion

It is essential to address medical errors. They are a cause of multiple deaths around the world each year. This assessment aims to minimize medical errors due to the wrong administration of drugs or doses. Stakeholders are crucial for improving the quality of care for the patients. Medication administration errors can be minimized by better communication between doctors and nurses and proper mentoring or training inexperienced nurses. 

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References

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research21(1), 1-10. https://doi.org/10.1186/s12913-021-07187-5

Clapper, T. C. (2018). TeamSTEPPS® is an effective tool to level the hierarchy in healthcare communication by empowering all stakeholders. Journal of Communication in Healthcare11(4), 241-244. https://doi.org/10.1080/17538068.2018.1561806

Hamzaoui, O., & Shi, R. (2020). Early norepinephrine use in septic shock. Journal of Thoracic Disease12(Suppl 1), S72. https://doi.org/10.21037/jtd.2019.12.50

Härkänen, M., Vehviläinen-Julkunen, K., Murrells, T., Rafferty, A. M., & Franklin, B. D. (2019). Medication administration errors and mortality: incidents reported in England and Wales between 2007 ̶ 2016. Research in Social and Administrative Pharmacy15(7), 858-863.https://doi.org/10.1016/j.sapharm.2018.11.010

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and associated factors among nurses: a cross-sectional study. BMC Nursing17(1), 1-8. https://doi.org/10.1186/s12912-018-0280-4

NURS FPX 4020 Assessment 1 Attempt 3 Enhancing Quality and Safety

Keers, R. N., Plácido, M., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PloS One13(10), e0206233. https://doi.org/10.1371/journal.pone.0206233

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and prevention. StatPearls [Internet].https://www.ncbi.nlm.nih.gov/books/NBK499956/ 

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: a qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety47(1), 38-53. https://doi.org/10.1016/j.jcjq.2020.09.010

Shawahna, R. (2020). Quality indicators of Pharmaceutical Care in Palestinian Integrative Healthcare Facilities: findings of a qualitative study among stakeholders. Evidence-Based Complementary and Alternative Medicine2020.http://dx.doi.org/10.1136/bmjqs-2018-009082