It has to be said that medication errors remain one of the most significant factors threatening patient safety. NURS FPX 8030 Assessment 5 Adverse drug events are estimated to cause between 7,000 and 9,000 hospital deaths annually in the US, costing the healthcare system more than $40 billion over (Tariq et al. , 2020). Despite efforts that have been made towards avoiding drug mistakes for more than three decades, over 5% of admitted patients end up having a drug mistake (Al-Worafi, 2020). This is due to the challenges that are associated with ordering, giving, administration, and tracking systems. A recent Cochrane, PubMed, and CINAHL databases search presented in a dozen of high-quality systematic reviews, meta-analyses, and multi-site studies indicates that CUSP initiatives could significantly and sustainably decrease medication-related patient harm. They do this through enhancing safety culture, identifying mistakes, as well as determining high-reliability organizational practices (McGinty et al., 2021).
These are unacceptably high numbers of drug errors that harm patients during their hospital stay, and this puts pressure on healthcare organizations to respond promptly and vigorously through systematic, research-based safety initiatives. According to Santos and Jones (2023), it is crucial to establish an official CUSP Medication Safety policy that would ensure all the patient care groups adhere to the same measures when it comes to error prevention; they should have a higher level of safety attitude and should have active tracking systems in place. Of course, it will be difficult to accomplish these changes and improvements in patient safety gradually and sustainably if there are no policy frameworks and drug risk mitigation strategies are employed sporadically or not at all.
NURS FPX 8030 Assessment 5 Population Affected by the Policy
The CUSP Medication Safety Program policy implemented in all the organization’s hospitals and outpatient surgery centers extends over all the intensive care units for patients, and procedure rooms where medicines are prescribed, delivered, or administered. This refers to operation theatres and medical wards, casualty departments, operating theatres and other treatment rooms. The program is targeted to nurses and pharmacists as these two professions are directly linked to medication management. However, the safety management and the efforts to set up best practices will target all the professionals who are involved in the management of medication, including doctors, pharmacists, and the members of the quality/safety departments. As the pharmacy fills over 15,000 drug orders monthly, and the estimated error rate ranges from 3% to 5% based on previous safety reports, this intervention could potentially impact more than 500 patients every month, who may be exposed to prescription errors under the current care delivery models. Ottosen and Bucknall (2023).
Policy Statement
The policy will also include another CUSP that will be implemented in all intensive care units within the next year to address drug safety. The intended outcome is to reduce drug error rates and the resulting harm by 20%. The goals for this program in the group are to foster a culture of high reliability for medication safety, implement proven error prevention approaches, and monitor the performance of the system in terms of the medication safety outcomes. NURS FPX 8030 Assessment 5 quality improvement effort to make real improvements in patient safety, the following changes will be made: enhance staff education, implement clinical decision support tools, enhance drug reconciliation processes and standardization, and enhance reporting and analysis processes.
Procedure
Create an interdisciplinary CUSP team: Every unit shall have a CUSP team with a nurse manager, a chemist, a doctor, and a quality/safety leader to implement the plan (Merriman & Freeth, 2022). The Johns Hopkins CUSP Training Program should be complete by the team members within 30 days of the policy implementation. Particularly, the following medication safety measures should be implemented:The pharmacist will be the chair of the Medication Safety Workgroup which will review and revise the standards of high-risk medications, compare the CPOE order sets, and enhance the decision support alerts and notifications (Gurwitz et al. , 2021). Nurses will incorporate barcode affirmation with the aim of achieving 95% compliance on how medications are administered. A standard EHR script will be used by prescribers to perform DR at all places of care transfer (Rungvivatjarus et al. , 2020).
NURS FPX 8030 Assessment 5 Teach Medication Safety:
It will ensure that all the unit staff members are given a 4-hour course on medication safety which will involve lessons from different fields by the CUSP team. The drugstore will provide its employees with high-risk drugs, safety tools, the potential to avoid mistakes, and training every three months (Dineen-Griffin et al., 2020). Set up an auditing and error reporting system: The CUSP team will identify system deficiencies during regular monthly drug process checks, using a facility audit plan. During the next day, staff will report to EHR Safety Reporting System if they have seen any drug errors or near misses (McCarty, 2021). To monitor medication-related adverse events, length of stay, and deaths, the CUSP team will track the data at the beginning of the implementation and then every 3 months afterward (Narayanan et al., 2020). Cohort reports from the CUSP team will be reviewed by senior management regarding how well drug safety is being managed and training will be offered to units that are performing poorly. NURS FPX 8030 Assessment 5 process incorporates the best practices from AHRQ, ISMP, and recent studies regarding awareness, attitude change, technology integration, and constant oversight to improve medication safety. Discipline defines specific standards on what is expected of a person with an aim of promoting responsibility and accountability.
References
Agency for Healthcare Research and Quality. (2021). Implementing near-miss reporting and improvement tracking in primary care practices: Lessons learned | Agency for Healthcare Research and Quality. Www.ahrq.gov. https://www.ahrq.gov/patient-safety/reports/liability/crane.html
Al-Worafi, Y. M. (2020, January 1). Chapter 6 – Medication errors (Y. Al-Worafi, Ed.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/pii/B9780128198377000066
Dieplinger, B., Egger, M., Jezek, C., Heinisch-Finke, C., Altendorfer, C., Pernerstorfer, T., Hefler, L., Pateisky, N., & Mueller, T. (2020). Implementation of a comprehensive unit-based safety program to reduce surgical site infections in cesarean delivery. American Journal of Infection Control, 0(0). https://doi.org/10.1016/j.ajic.2020.01.016
Dineen-Griffin, S., Benrimoj, S. I., & Garcia-Cardenas, V. (2020). Primary health care policy and vision for community pharmacy and pharmacists in Australia. Pharmacy Practice, 18(2). https://doi.org/10.18549/PharmPract.2020.2.1967
Earl, T. R., Katapodis, N. D., Schneiderman, S. R., & Shoemaker-Hunt, S. J. (2020). Using deprescribing practices and the screening tool of older persons’ potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults. Journal of Patient Safety, 16(3), S23–S35. https://doi.org/10.1097/pts.0000000000000747
Gurwitz, J. H., Kapoor, A., Garber, L., Mazor, K. M., Wagner, J., Cutrona, S. L., Singh, S., Kanaan, A. O., Donovan, J. L., Crawford, S., Anzuoni, K., Konola, T. J., Zhou, Y., & Field, T. S. (2021). Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications. JAMA Internal Medicine, 181(5), 610. https://doi.org/10.1001/jamainternmed.2020.9285
McCarty, C. (2021). Improving multidisciplinary adherence to a daily goals checklist in the ICU: A quality improvement initiative. UKnowledge. https://uknowledge.uky.edu/dnp_etds/339/
McGinty, E. E., Thompson, D., Murphy, K. A., Stuart, E. A., Wang, N.-Y., Dalcin, A., Mace, E., Gennusa, J. V., & Daumit, G. L. (2021). Adapting the Comprehensive Unit Safety Program (CUSP) implementation strategy to increase delivery of evidence-based cardiovascular risk factor care in community mental health organizations: Protocol for a pilot study. Implementation Science Communications, 2(1). https://doi.org/10.1186/s43058-021-00129-6
Merriman, C., & Freeth, D. (2022). Conducting a good ward round: How do leaders do it? Journal of Evaluation in Clinical Practice, 28(3). https://doi.org/10.1111/jep.13670
Mulac, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. Bio Med Journal Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223
Narayanan, S., Kaivalya Mannam, R Sunitha, & P. Venkat Rangan. (2020). Evaluation of transfer learning for Adverse Drug Event (ADE) and medication entity extraction. https://doi.org/10.18653/v1/2020.clinicalnlp-1.6
Ottosen, K., & Bucknall, T. (2023). Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit. Australian Critical Care. https://doi.org/10.1016/j.aucc.2023.04.004
Rungvivatjarus, T., Kuelbs, C. L., Miller, L., Perham, J., Sanderson, K., Billman, G., Rhee, K. E., & Fisher, E. S. (2020). Medication reconciliation improvement utilizing process redesign and clinical decision support. The Joint Commission Journal on Quality and Patient Safety, 46(1), 27–36. https://doi.org/10.1016/j.jcjq.2019.09.001
Santos, G., & Jones, M. W. (2023). Prevention of surgical errors. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK592394/
Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2020). Medication dispensing errors and prevention. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30085607/
