NURS FPX 4020 Capella University Quality Care And Patient Safety Paper

NURS FPX 4020 Capella University Quality Care and Patient Safety Paper

For this next one, we can choose from the following options as the subject of a root-cause analysis and safety improvement plan

1. The specific safety concern identified in your previous assessment (from our last) pertaining to medication administration safety concerns.

2. The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a healthcare setting of your choice and outline a plan to address the issue.

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures.

Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

 As you prepare for this assessment? It would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan.

Activities are not graded and demonstrate course engagement.

Demonstration Of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

■ Competency 1: Analyze the elements of a successful quality improvement initiative.

■ Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;

■ Create a viable, evidence-based safety improvement plan for safe medication administration.

■ Competency 2: Analyze factors that lead to patient safety risks.

■ Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

■ Competency 3: Identify organizational interventions to promote patient safety.

■ Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.

■ Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.

■ Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Professional Context

 Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.

Scenario

For this NURS FPX 4020 Capella University Quality Care and Patient Safety Paper assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

■ The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.

■ The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

Instructions

 The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan Template [DOCX] to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the NURS DPX 4020 Capella University Quality Care and Patient Safety Paper scoring guide. Please study the scoring guide carefully so you understand ;what is needed for a distinguished score.

■ Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.

■ Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.

■ Create a feasible, evidence-based safety improvement plan for safe medication administration.

■ Identify organizational resources that could be leveraged to improve your plan for safe medication administration.

■ Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

■ Assessment 2 ;Example [PDF].

 Additional Requirements

■ Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4-6 page root cause analysis and safety improvement plan pertaining to medication administration.

■ Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

■ APA formatting: Format references and citations according to current APA style.

 Patient Safety Quality Improvement Project- Medication Errors In The Emergency Department Sample Approach

Medication errors in the emergency department (ED) are a significant health issue in contemporary medical practice. Medication errors in the ED are pretty common due to the setting and activities in the ED. Such errors lead to increased healthcare costs, poor quality care, patient dissatisfaction, and high morbidity and mortality rates. Each year,the healthcare sector incurs over $4 billion due to medication errors in the ED (Walsh et al., 2018).

Written and verbal communication is integral in the reduction of medication errors. This essay focuses on a patient safety improvement project aiming to reduce medication errors and related consequences in the emergency department. 

Project Aims

 Poor communication and missing links are significant causes of patient safety issues. The hasty nature of ED activities increases the prevalence of medication errors.

Medication errors in the ED are caused by dosage errors, failure to follow set guidelines, the emergency nature of the ED, poor communication, and increased workload (DiSimone et al., 2018). The project’s main aim is to reduce medication errors, improve medication error reporting, and decrease the healthcare costs related to medication errors by improving communication between the nurses and other healthcare providers in three months.

Another aim is to promote/ enhance effective communication during the medication administration process. Another aim is to enhance competence and efficiency during medication administration to the patient. In addition, the project aims to improve medication administration reporting in the emergency department. These aims/ objectives will inform the medication administration process and the evaluation process.

Current Practices

 Doctors or advanced practice registered nurses prescribe drugs for the patient. These drugs are generally available in the department store, and the nurses administer them as per the prescription. In some instances, nurses administer drugs directly, bypassing written prescriptions to save lives. Most prescriptions are handwritten, thus prone to poor illegible handwriting and missing files (Hassan, 2018). Transcription in the ER is hastily done also, which increases the risk for errors.

Medication errors in the ED also arise after failure to sort drugs, especially LASA drugs, due to the haste common in the emergency departments (Martyn, Palliadeli, & Perry,2019). Drugs are then administered to the patients using the prescription sheets. The nurses on duty are responsible for administering these drugs, and patient handing over occurs after every shift at the nursing desk.

Poor reporting of medication errors in the ED is attributed to stern measures taken against nurses involved in medication errors (Dirik et al., 2019 ). These current practices have many areas for improvement which require addressing.

Figure 1. Current practices in drug administration.

 Solutions/ Change Ideas for Medication Errors

 Poor communication is a major cause of medication errors in the ED. Various evidence-based interventions help enhance the communication process. One intervention is bedside patient handing-over using the ISBAR method (Marmor & Li, 2017). This method is critical because the patients’ movement rate is relatively high compared to other departments because they are moved to other relevant departments to create space for other patients.

Thus, there is a need to pay attention to every patient’s details (Di Simone et al., 2018). Using this intervention, nurses familiarize themselves with the patients, and during each shift, they evaluate the patient’s status and the medications for possible changes and necessary adjustments. Effective communication at the bedside helps eliminate transcription errors during this step (Marmor & Li, 2017).

 The method also helps avoid confusion and forgetfulness common when nurses hand over patients at the nursing desk. The documented success rate of this intervention is high, and it is an excellent strategy to reduce medication errors.

Written communication is prone to errors such as illegibility and transcription errors. Avoiding these errors is by using electronic health records, which help in ordering,transcription, and documentation in the medication administration process (Ratwani et al., 2018). The information is also available in the systems for confirmation and reflection at any moment. These systems provide formality at the workplace and are easier and more effective than traditional methods (Patient files).

Electronic health records also increase accountability through accurate documentation, knowing the information is visible to all healthcare providers, and help trace medication errors in the ED (Alotaibi & Federico, 2017). Medication errors recorded help in hospital statistics, and follow-up is also possible to ensure errors do not occur in the future.

Another effective strategy in minimizing drug administration errors is using an assistant or medication administration companion. Medication administration errors form the most significant percentage of medication errors (Gomes et al., 2021). The errors are more prevalent in the emergency department than in other departments due to time pressure. When administering drugs alone, one can overlook errors but check with a companion; often, a qualified and experienced nurse ensures compliance to drug administration rights.

The use of companions increases the efficacy and safety of drug administration(Douglas et al., 2018). Confusions such as LASA (Look-alike sound-alike) drugs do not occur while using a companion. It also allows mitigation of other errors that might have occurred during the ordering and transcription. The intervention significantly decreases drug administration errors compared to administration by one nurse. The mentioned interventions will be integral in the change project by enhancing communication, improving accuracy and efficacy, and improving reporting of medication errors in the ED.

Evaluation of the Project

The project objective will inform its evaluation. As mentioned earlier, the project aims to reduce the incidences of medication errors in the ED. According to Parasrampuria and Henry (2019), hospital data/records analysis is the most accurate and relevant method to evaluate the effectiveness of the project.

The hospital records provide data such as the average incidences of medication errors in the ED and mortality and morbidity rates related to medication errors. An analysis of this information would directly reflect on the effect of the proposed project. Moreover, patient self-reported satisfaction report analysis will give a clear picture of the effectiveness of the change ideas.

The cost-benefit analysis will be an integral evaluation tool for this project. The cost-benefit analysis involves weighing the costs incurred during the project implementation against the project’s benefits (Mishan & Quah, 2020). The benefits must outweigh the costs for the project to be considered.

The project involves high healthcare costs such as training healthcare workers and installing healthcare information systems. The benefit of the project is reducing mortality and morbidity rates and decreasing healthcare costs associated with medication errors. Analysis of these costs and benefits provides a basis for decision-making regarding the process implementation.

Conclusion

 Nursing is a dynamic profession requiring change and interventions. Medication errors in nursing practice threaten quality care and patient safety, especially in the emergency department. They are also a significant cause of increased healthcare costs NURS FPX 4020 Capella University Quality Care and Patient Safety Paper. Nurses must identify current practices and flaws in the systems to inform the development of effective strategies to mitigate medication errors and other significant challenges in nursing practice. 

In addition, technological advances are integral in informing practice. When implementing projects, pre-and post-implementation evaluations are vital. An evaluation helps determine the applicability and benefits of a project, thus saving on costs.

References

● Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi Medical Journal, 38(12), 1173–1180. DOI:

https://doi.org/10.15537/smj.2017.12.20631

 ● Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5-6), 931-938. https://doi.org/10.1111/jocn.14716

● Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M.(2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 22(5), 346. Doi: 10.4103/ijccm.IJCCM_63_18

● Douglass, A. M., Elder, J., Watson, R., Kallay, T., Kirsh, D., Robb, W. G., Kaji, A. H., & Coil, C. J. (2018). A randomized controlled trial on the effect of a double check on the detection of medication errors. Annals of emergency medicine, 71(1), 74-82. https://doi.org/10.1016/j.annemergmed.2017.03.022

● Gomes, A. N. H., da Silva, R. S., Alves, E. B., da Silva Moura, G., & de Oliveira, H. M. (2021). Safety in the administration of injectable medications: Scoping review.

Research, Society and Development, 10(6), e1510615381-e1510615381. https://doi.org/10.33448/rsd-v10i6.15381

● Hassan, I. (2018). Avoiding medication errors through effective communication in a healthcare environment. Movement, Health & Exercise, 7(1), 113-126.

http://dx.doi.org/10.2139/ssrn.3573437

 ● Marmor, G. O., & Li, M. Y. (2017). Improving emergency department medical clinical handover: Barriers at the bedside. Emergency Medicine Australasia, 29(3), 297-302. https://doi.org/10.1111/1742-6723.12768

● Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviors beyond the five rights. Nurse Education in Practice, 37, 109-114. https://doi.org/10.1016/j.nepr.2019.05.006

● Mishan, E. J., & Quah, E. (2020). Cost-benefit analysis. (6th Ed.). Routledge.

 ● Parasrampuria, S., & Henry, J. (2019). Hospitals’ Use of Electronic Health Records Data, 2015-2017. ONC Data Brief, 46, 1-13.

● Ratwani, R. M., Savage, E., Will, A., Arnold, R., Khairat, S., Miller, K., Fairbanks, R. J.,

 Hodgkins, M., & Hettinger, A. Z. (2018). A usability and safety analysis of electronic health records: a multi-center study. Journal of the American Medical Informatics Association, 25(9), 1197-1201.https://doi.org/10.1093/jamia/ocy088 

● Walsh, E. K., Hansen, C. R., Sahm, L. J., Kearney, P. M., Doherty, E., & Bradley, C. P. (2017). Economic impact of medication error: a systematic review.

Pharmacoepidemiology and Drug Safety, 26(5), 481-497. https://doi.org/10.1002/pds.4188

Collaboration And Leadership Resources

■ Cho, S. M., & Choi, J. (2018). Patient safety culture associated with patient safety competencies among registered nurses. Journal of Nursing Scholarship, 50(5),

549–557. https://doi-org.library.capella.edu/10.1111/jnu.12413

■ This article discusses the importance of creating a unit-specific patient safety culture that is tailored to the competencies of the unit’s RNs in patient safety practice.

 ■ SonÄŸur, C., Özer, O., Gün, C., & Top, M. (2018). Patient safety culture, evidence-based practice and performance in nursing. Systemic Practice and Action Research, 31(4), 359–374.

■ Evidence-based practice is a problem-solving approach in which the best available and useful evidence is used by integrating research evidence, clinical expertise, and patient values and preferences to improve health outcomes, service quality, patient safety and clinical effectiveness, and employee performance.

■ Stalter, A. M., & Mota, A. (2017). Recommendations for promoting quality and safety in health care systems. The Journal of Continuing Education in Nursing, 48(7), 295–297.

■ This article provides recommendations to promote quality and safety education with a focus on systems thinking awareness among direct care nurses. A key point is error prevention, which requires a shared effort among all nurses.

■ Manno, M. S. (2016). The role transition characteristics of new registered nurses: A study of work environment influences and individual traits. (Publication No.

10037467) [Doctoral dissertation, Capella University].

http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdis sertations-theses%2 Role-transition-characteristics-new-registered%2f Docview% 2F1775393522%2Fse-2%3 Accountid%3D27965

This research study may be helpful in identifying traits and qualities of new registered nurses that are helpful in coordinating and leading quality and safety measures related to this assessment.

■ Boombah, S. A. (2018). Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction. Journal of Advanced Nursing. 75(5), 1000–1009. https://doi-org.library.capella.edu/10.1111/jan.13895

■ This research analyzes attributes and best practices of leadership and nursing staff that help aid in patient care quality and job satisfaction.

■ Greenstein, T. (2020). Leading innovation is completely different from leading change. WWD.com.

■ This article examines competencies that may help nurses collaborate more effectively to improve patient outcomes.

■ Poder, T. G., & Mattais, S. (2018). Systemic analysis of medication administration omission errors in a tertiary-care hospital in Quebec. Health Information

Management Journal, 49(2-3), 99–107.

■ This examination of underlying systemic causes of medication errors may be useful as you consider QI vest practices and ways to coordinate care to increase safety and quality.

■ Antevy, P. (2017). How care collaboration is improving patient outcomes. EMS World, 46(4), 26–33.

■ This article examines competencies that may help health care professionals collaborate more effectively to improve patient outcomes.

■ Keers, R. N., Plácido, M., Bennet, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018, October 26). What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLOS One.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206233

■ This examination of underlying systemic causes of medication errors may be useful as you consider QI best practices and ways to coordinate care to increase safety and quality.

Resources

■ Lyle-Edrosolo, G., & Waxman, K. (2016). Aligning healthcare safety and quality competencies: Quality and safety education for nurses (QSEN), the Joint

Commission, and American Nurses Credentialing Center (ANCC) Magnet® standards crosswalk. Nurse Leader, 14(1), 70–75.

■ This article attempts to align the language used in three quality and safety standards and reduce confusion for health care professionals.

■ Altmiller, G., & Hopkins-Pepe, L. (2019). Why quality and safety education for nurses (QSEN) matters in practice. The Journal of Continuing Education in Nursing, 50(5), 199–200.

■ This article discusses the needs for quality and safety education in nursing and how the Journal of Continuing Education in Nursing supports QSEN competency implementation in practice.

■ Johnson, L., McNally, S., Meller, N., & Dempsey, J. (2019). The experience of undergraduate nursing students in patient safety education: A qualitative study. Australian Nursing and Midwifery Journal, 26(8), 55.

■ This article discusses educating nursing students about patient safety early within their learning journey and how it has shown to have a compelling positive impact on each individual’s knowledge, skills, and behavior growth surrounding the concept of patient safety.

■ Wieke Noviyanti, L., Handiyani, H., & Gayatri, D. (2018). Improving the implementation of patient safety by nursing students using nursing instructors trained in the use of quality circles. BMC Nursing, 17(2).

■ Abstract: It is recognized worldwide that the skills of nursing students concerning patient safety are still not optimal. The role of clinical instructors is to instill in students the importance of patient safety.

Therefore, it is important to have competent clinical instructors. Their experience can be enhanced through the application of quality circles.

This study identifies the effect of quality circles on improving the safety of nursing students. Patient safety is inseparable from the quality of nursing education. Existing research shows that patient safety should be emphasized at all levels of the healthcare education system. In hospitals, the ratio between nursing students and clinical instructors is disproportionately low. In Indonesia, incident data relating to patient safety involving students is not well documented, and the incidents often occur in the absence of a clinical instructor (Wieke Noviyanti, Handiyani, & Gayatri, 2018).

■ Havaei, F., MacPhee, M., & Dahinten, V. S. (2019). The effect of nursing care delivery models on quality and safety outcomes of care: A cross‐sectional survey study of medical‐surgical nurses. Journal of Advanced Nursing, 75(10),

2144–2155.

■ This study examines components of nursing care delivery and the mode of nursing care delivery. This may be helpful in seeing safety and quality education and best practices.

■ Health and medicine – quality of care; new findings from Karolinska Institute in the area of quality of care reported (shared responsibility: school nurses’

experience of collaborating in school-based interprofessional teams). (2017, July 21). Health and Medicine Week.

■ This wire feed examines evidence-based and best-practice strategies for improving the care offered by school nurses, and may help you identify useful strategies for your assessment.