NURS FPX 4020 Assessment 4 Attempt 1 Improvement Plan Tool Kit

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Improvement Plan Tool Kit

NURS FPX 4020 Assessment 4 Attempt 1 Improvement Plan Tool Kit

This paper will be proposing an improvement plan tool kit to enhance the quality and safety of the care being provided to the patients. This is crucial to the nurses as they play a vital role in working closely with the patients. Adhering to this plan would mitigate the medication errors that pose harm to the patients and distress to the nurses. Consisting of 12 credible resources this plan will support the analysis of the elements of a successful improvement initiative and factors that lead to safety risks. It would then go on to determine organizational interventions and nurses’ role in enhancing patient safety. This plan is focusing on the incident of a young cancer patient Sam who was given the wrong rate of infusion pumps; thus, this plan will be talking about the initiative to mitigate the medication errors specific to wrong drugs or doses being given to the patient. 

Elements of Successful Quality Improvement Initiative

Taylor, M., & Jones, R. (2019). Risk of medication errors with infusion pumps. Patient Safety, 61–69.

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This article emphasizes the significance of medication errors that result from infusion pumps. There has been a reporting of 1,004 medication error cases with infusion pumps in the state of Pennsylvania in 2018. These cases occurred in 132 different hospitals. Such errors in hospitals cause high-alert as they demonstrate the poor quality of care being provided to the patients, making them lose trust. This article describes that most of the errors with infusion pumps result from malfunctioning devices, poor maintenance of devices, incorrect order or transcription of medication, insufficient information among the nurses, and patient behavior. This article is excellent for all roles of nurses to go through to recognize the nature of this device. For example, in a case where a nurse was unaware that the device they have been using could be malfunctioning, several cases of errors would occur without the nurse even realizing, the awareness of such cases through these papers would allow the nurses to recognize the problems and allow them to maintain such devices more carefully. 

NURS FPX 4020 Assessment 4 Attempt 1 Improvement Plan Tool Kit

Reiner, G., Pierce, S. L., & Flynn, J. (2020). Wrong drug and wrong dose dispensing errors are identified in pharmacist professional liability claims. Journal of the American Pharmacists Association, 60(5), e50–e56. https://doi.org/10.1016/j.japh.2020.02.027

This study gathered the data for the claims of the wrong dose of dispensing errors and wrong drug dispensing errors. The study showed that with automation and technology the claims of wrong drug dispensing error decreased from 43.8% in 2013 to 36.8% in 2018, whereas, the wrong dose claims in 2013 were 31.5% and it decreased to 15.3%. The study concluded that even with smarter systems the wrong dose and drug dispensing errors continue to occur due to system or human factors. This supports the implementation of an improvement initiative. This resource is helpful for the nurses in a managerial position to realize that human factors contribute the most to dispensing errors and with the right training for the staff, these factors could be improved and minimized. In a case where implementation of technology was considered to avoid errors without recognizing the human factors, then technology would not prove to be as helpful as even the smarter technological systems require great human skills. 

Hoffman, L., & Bacon, O. (2020). Making healthcare safer iii: A critical analysis of existing and emerging patient safety practices [Internet]. [E-book]. Agency for Health Care Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK555506/

This book talks about how 72.9% of the hospitals in the US are using smarter infusion pumps and many organizations have identified them to be safer as they have safety features like an alarm system. The Institute of Medicine has suggested the adoption of smarter infusion pumps as an effective intervention to reduce medication errors. But along with this, this book emphasizes the education of nurses, protocols, and workflows to be an important part of the system to make sure that the implementation of such technologies is successful. Standardization and streamlining of the workflow are important facilitators. All of these reviews were supported by credible studies. This is again helpful for the administration and managerial nurses to recognize the importance of providing protocols, guidelines, and education so the nurses have steps to follow through when working with technology. For example, in a case where nurses are unaware of the workflows with technology, the technology implementation would fail and it would instead become time-consuming because the nurses would spend time figuring out the system.

Implementing Quality & Safety Improvements in Medication Administrations

Hanson, A., & Haddad, L. (2021). Nursing rights of medication administration [E-book]. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK560654/

This book identifies the nurse’s responsibility when administering medications to patients. It claims nurses have a standard guideline of instructions to minimize patients’ risks. It bases the instructions on the implementation of five “rights” which includes the sequence of:

  • Right Patient
  • Right Drug
  • Right Route
  • Right Time
  • Right dose

This makes sure that a correct recipient is identified before prescribing a medication, the right drug is being administered to the patient by making sure the name of the patient and the drug, nurses should be educated about the safe delivery of drugs, drugs should be administered at the right time, and the correct concentration should be given. This resource is helpful for registered nurses, emergency room nurses, and students of nursing as it provides a guideline for the nurses to follow through. Emergency room nurses can highly benefit from this as they would have a checklist of these five rights to quickly double-check when a patient suddenly arrives in the ER needing quick treatment making the chances of error happening to rise. For example, in a case where nurses do not have such protocols to make sure safe medication administration, the nurses might be unsure or feel lost as to if they followed the right track. 

Khalil, H., & Lee, S. (2018). The implementation of a successful medication safety program in primary care. Journal of Evaluation in Clinical Practice, 24(2), 403–407. https://doi.org/10.1111/jep.12870

NURS FPX 4020 Assessment 4 Attempt 1 Improvement Plan Tool Kit

Improving patient safety should be the priority of an organization and for that nurse training has been recognized to be a crucial step to minimizing error. This study was set up to analyze the success of the implementation of the medication safety program in rural Australia. This safety program consists of the implementation of the newly developed medication safety guidelines, delivery of safety training to clinicians, and collection of baseline medication incidents in an organization. The results of this study showed improved knowledge of the clinicians’ and the behavior, confidence, and attitude of the clinicians’ increased significantly. This study consisted of stages that were to communicate, collaborate, and connect. This shows the importance of such training programs that emphasize the culture of patient safety, identifying the issue and types of medication errors, understanding the medication incident reports, and applying of an evidence-based approach in daily practices. If the clinicians and managing nurses go through this resource, they can highly benefit from this awareness of how training is highly important. Following this, there could be changes in policies to set up workshops to improve the behavior and attitude of the clinicians so there is effective communication and collaboration. In a case where. there was no attention paid to the behavior of the clinicians which resulted in poor communication and commitment, the errors would never be avoided. There will always be a chance of adverse events due to miscommunication or misunderstandings as there would be a lack of transparency.

Melton, K. R., Timmons, K., Walsh, K. E., Meinzen-Derr, J. K., & Kirkendall, E. (2019). Smart pumps improve medication safety but increase the alert burden in neonatal care. BMC Medical Informatics and Decision Making, 19(1). https://doi.org/10.1186/s12911-019-0945-2

The implementation of smart pumps has been said to be successful in increasing the quality of care and patient satisfaction. They prevent manual programming and other indirect tasks that distract the nurses leading to medication errors. They provide alerts of wrong infusion conditions avoiding cases like the one with Sam. This study concluded that when compliance with dose error-reducing software is high, medication safety is improved. This is an important resource for all roles of nurses to recognize the newer technology and help the administration to implement such in the organization for better quality care and patient satisfaction. Failure in cases of recognizing the right technology would lead to wastage of potential and resources to be implemented in the right place which would lead to the same manual systems being used causing burnout in the nurses and causing them to lose focus resulting in medication errors. 

Value of Resources to Reduce Patient Safety Risks

Philips, J., Malliaris, A., & Bakerjian, D. (2021). Nursing and Patient Safety. Nursing and Patient Safety. https://psnet.ahrq.gov/primer/nursing-and-patient-safety#:~:text=From%20a%20patient%20safety%20perspective,countless%20other%20tasks%20to%20ensure

This journal published by the University of California highlights the important role of nurses who spend most of their time with the patient. It focuses on the nurses’ vigilance to ensure the safety of the patient. The journal talks about studies that associate the staffing of the nurse with patient safety. Increased patient safety events have been linked with more nurse staffing and also increased mortality. But it is important to recognize that even nurse staffing is a complex process that changes based on the shifts, as nurse work overload impacts patient safety. Nurse staffing requires the availability of skills, settings of care, and coordination between management and nursing. Longer shifts and interruptions have been linked to increased errors. The nursing environment has to be as conducive as possible. This is the most valuable resource for reducing patient safety risk as it is helpful for different roles in the health care organization including the administration, educators, registered nurses, and managerial nurses. The staffing of the nurses would lead to more skills in the workplace which would reduce burnout in nurses causing fewer errors. This resource is important as it would aware these stakeholders that hiring more staff is not just it, they have to be skillful and talented too. There could be a workshop by the administration to train the current nurses too. For example, in a case where there was a lot of untrained staff, the responsibilities would be divided but the failures of such staff would lead to more errors that would then lead to more money being spent by the organization. And the treatment of the patient who suffered from harm because of these errors would be prolonged, causing more distress to the staff. 

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235

This study focuses on the primary act of the nurses which is administering drugs safely. Medication errors lead to unpleasant results so an analysis was conducted on 1 physician and 16 nurses and the two themes that were extracted to avoid medication errors are presenting technical strategies and acting professional. If nurses act professionally most of the medication errors can be mitigated.

Vaismoradi, M., Tella, S., Logan, P., Khakurel, J., & Vizacaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6). https://doi.org/10.3390/ijerph17062028

This review highlights that the prevention of errors and quality care improvement relies on nurses adhering to patient safety principles. The patient outcomes depend on the compliance of nurses to the guidelines which is impacted by factors like time pressure, patient-safety climate, level of ward performance, provision of education to improve skills, communication between healthcare staff and patients, institutional protocols and procedures, and encouragement by leaders. All these factors enhance the adherence of nurses to patient-safety principles minimizing errors. 

Usage of Resource Tool Kit for Nursing

Oldland, E., Botti, M., Hutchinson, A., & Redley, B. (2020). A framework of nurses’ responsibilities for quality healthcare — Exploration of content validity.  Collegian, 27(2), 150-163. https://doi.org/10.1016/j.colegn.2019.07.007

NURS FPX 4020 Assessment 4 Attempt 1 Improvement Plan Tool Kit

Health care quality can be reduced if nurses fail to understand their responsibilities. The findings of this journal were about the framework for the nurses which consists of 7 domains that are evidence-based practice, positive interpersonal behaviors, management of the environment, person-centered care, clinical leadership and governance, and promotion of safety. These domains summarized the responsibilities of the nurses. 

Witczak, I., Rypicz, U., Karniej, P., Młynarska, A., Kubielas, G., & Uchmanowicz, I. (2021). Rationing of Nursing Care and Patient Safety. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.676970

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This study carefully analyzed the relationship of nurses with the patient’s safety as the nursing role affects the quality of care being provided to the patient. This study consisted of 245 nurses and the results showed that there were a lot of workloads that impacted patient satisfaction causing it to decrease. With the report of adverse events, there was a lack of transparency and lack of cooperation. All these factors reduce patient safety causing the margin of error to be higher. 

Kitson, & Alison, L. (2018). The fundamentals of care framework as a point-of-care nursing theory. Nursing Research. 67 (2), 99-107. https://doi.org/10.1097/NNR.0000000000000271

This journal looks into the nursing theories that help nurses carry on their daily practices or shape them to achieve the best quality of patient care. The theoretical framework analyzed in these focuses on patient-centered fundamental care which requires the nurses and the patients to work together and have active management of the processes. This framework should be incorporated into the patient care plan for it to be useful.

Conclusion

For nurses to provide quality care to patients, there should be collaboration, effective communication, and total transparency. Training and education should be provided so they are not a barrier when intervening with smart infusion pumps in the facility to reduce medication errors. The nurses should strictly adhere to the protocols and guidelines to enhance the patient’s safety.

References

Hanson, A., & Haddad, L. (2021). Nursing rights of medication administration [E-book]. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK560654/

Hoffman, L., & Bacon, O. (2020). Making healthcare safer iii: A critical analysis of existing and emerging patient safety practices [Internet]. [e-book]. Agency for Health Care Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK555506/

Khalil, H., & Lee, S. (2018). The implementation of a successful medication safety program in primary care. Journal of Evaluation in Clinical Practice, 24(2), 403–407. https://doi.org/10.1111/jep.12870

Kitson, & Alison, L. (2018). The fundamentals of care framework as a point-of-care nursing theory. Nursing Research. 67 (2), 99-107. https://doi.org/10.1097/NNR.0000000000000271

Melton, K. R., Timmons, K., Walsh, K. E., Meinzen-Derr, J. K., & Kirkendall, E. (2019). Smart pumps improve medication safety but increase the alert burden in neonatal care. BMC Medical Informatics and Decision Making, 19(1). https://doi.org/10.1186/s12911-019-0945-2

Oldland, E., Botti, M., Hutchinson, A., & Redley, B. (2020). A framework of nurses’ responsibilities for quality healthcare — Exploration of content validity.  Collegian, 27(2), 150-163. https://doi.org/10.1016/j.colegn.2019.07.007

NURS FPX 4020 Assessment 4 Attempt 1 Improvement Plan Tool Kit

Philips, J., Malliaris, A., & Bakerjian, D. (2021). Nursing and patient safety. Nursing and Patient Safety. https://psnet.ahrq.gov/primer/nursing-and-patient-safety#:~:text=From%20a%20patient%20safety%20perspective,countless%20other%20tasks%20to%20ensure

Reiner, G., Pierce, S. L., & Flynn, J. (2020). Wrong drug and wrong dose dispensing errors are identified in pharmacist professional liability claims. Journal of the American Pharmacists Association, 60(5), e50–e56. https://doi.org/10.1016/j.japh.2020.02.027

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235

Taylor, M., & Jones, R. (2019). Risk of medication errors with infusion pumps. Patient Safety, 61–69. https://doi.org/10.33940/biomed/2019.12.7

Vaismoradi, M., Tella, S., Logan, P., Khakurel, J., & Vizacaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6). https://doi.org/10.3390/ijerph17062028

Witczak, I., Rypicz, U., Karniej, P., Młynarska, A., Kubielas, G., & Uchmanowicz, I. (2021). Rationing of nursing care and patient safety. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.676970