Improving Quality of Care and Patient Safety NURS-FPX4020Root-Cause Analysis and Safety Improvement

Improving Quality of Care and Patient Safety NURS-FPX4020

Root-Cause Analysis and Safety Improvement Plan

Medication administration errors (MEAs) are among the leading causes of disabilities, mortalities, lengthy hospitalization, and increased costs of compensating care services. According to Tsegaye et al. (2020), the World Health Organization (WHO) estimates the annual global cost associated with medication errors to be approximately $42 billion, accounting for about 0.7% of healthcare expenditures. Despite such ramifications, health organizations face challenges in eliminating medication mistakes because they can occur at any stage of the medication management process.

Healthcare professionals, especially nurses, must adhere to safety guidelines by observing various “rights,” including the right patient, doses, time, routes, and documentation during medication administration practices. Medical administrators must incorporate evidence-based practice and best strategies to safeguard patient safety and avert errors. Therefore, this paper describes a scenario of medication administration mistakes while elaborating root causes, evidence-based strategies, and organizational resources for preventing MEAs.

Analysis of the Root Cause

Medication administration errors are preventable acts that result in improper medication use in the treatment process, leading to multiple safety concerns such as adverse reactions, disability, and death (Tsegaye et al., 2020). In this sense, healthcare professionals responsible for administering regimens to patients fail to uphold the “medication rights” such as correct dosage, administration routes, documentation, and frequency due to the prevailing organizational, human, and technical factors. As a registered nurse operating in a skilled nursing facility (SNFs) in the cardiovascular care department, I have witnessed numerous scenarios where caregivers commit near misses or actual errors that lead to adverse medical outcomes.

In one instance, a registered nurse (RNs) tasked to administer digoxin doses to a 50-year-old male patient with arrhythmia episodes decided to delegate medication administration practices to unlicensed assistant personnel (UAP). Often, our organization allows registered nurses to delegate responsibilities to UAPs after conducting competency assessments and knowledge enhancement programs such as training and educational interventions. Although the nurse had fulfilled such guidelines, the delegate committed an error by administering incorrect dosage at the right time.

After observing the patient’s reactions, the nurse assistant detected the mistake that suggested potential digoxin toxicity, including nausea, vomiting, and irregular heart rhythms. After identifying the error, the nurse assistant did not communicate early or alert the delegator about the incident. Fortunately, one on-floor nurse saved the patient from the impending safety threats by administering an antidote. From such a scenario, l learned about the root causes of medication administration errors and possible ways to prevent mistakes.

Many scholarly studies provide evidence about the root causes of medication administration errors consistent with the case study. For instance, Vaismoradi et al. (2020) contend that various institutional factors facilitate medication mistakes. These factors include organizational patient-safety culture and environment, nurses’ workloads, the effectiveness of interprofessional collaboration and communication, the presence of education and training programs for nurses, and the availability of institutional guidelines for medication administration.

In this sense, health organizations should provide opportunities that enable healthcare professionals to adhere to and comply with patient-safety principles. In our case study, timely incident reporting and effective communication between the nurse assistant and the delegator nurse would have prevented an error that almost claimed the patient’s life.

Other primary causes of medication administration mistakes are technical and human factors. In organizations where clinicians use computerized physician order entries (CPOEs) and automated medication administration technologies, incidences of technical glitches may compromise medication administration practices leading to errors of commission and omission. Although technical factors are often accidental and unanticipated, human factors are significant causes of medication errors.

Tsegaye et al. (2020) argue that medication administration mistakes occur due to various human-related issues, including the level of knowledge and training on medication administration practices, work experience, familiarity with organizational guidelines, ability to communicate and report near misses or actual sentinel events, and competencies to adhere to safety guidelines. Since a human is to error, it is essential for healthcare organizations to invest massively in implementing evidence-based and best practices for enhancing employee competencies and knowledge of safe practices for medication administration.

Application of Evidence-Based Strategies

Health organizations must incorporate the best evidence and implement proven interventions for preventing medication administration errors. In our case study, communication breakdown and human factors facilitated an administrative error that adversely affected the patient. Manias et al. (2020) support the possibility of preventing causal factors for medication errors by implementing scientifically proven interventions, including interprofessional collaboration, prescriber education, technological advancements to incorporate computerized physician order entry (CPOE), and pharmacist-led medication reconciliation.

On the other hand, Reeves et al. (2017) suggest effective communication and reporting systems as ideal approaches for reducing medication mistakes. Implementing these recommendations requires institutions to embrace contingency plans and consolidate resources for enacting quality improvement initiatives.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Undoubtedly, health organizations must implement quality improvement initiatives and evidence-based strategies to prevent medication administration errors. In this sense, these steps include educating and training prescribers about safe medication administration practices, enhancing reporting and communication systems, installing advanced technologies to replace the traditional documentation steps, and encouraging interprofessional collaboration by transforming workplace cultures.

According to Yousef & Yousef (2017), an ideal plan for preventing medication errors must contain educational workshops for physicians, process automation and technological advancement, setting standardized general guidelines, creating suitable workplace environments to eliminate blame, and punishment for error perpetrators, and empowerment programs. Institutions should consistently implement these recommendations because eliminating medication errors requires continuous quality improvement initiatives.

Existing Organizational Resources

Health organizations and quality improvement implementation teams should leverage the existing institutional resources to guarantee plan sustainability and realize strategic goals. In this sense, it is possible to utilize employees’ competencies, experience, and skills when implementing training and educational programs for newly registered nurses and prescribers. Reputable physicians, IT experts, and informaticists can input these initiatives by sharing information, educating novice nurses about safety guidelines, and ensuring smooth operations of technological infrastructures.

Also, organizations should utilize the existing health record systems and information frameworks to promote interprofessional collaboration and effective communication. In this sense, the presence of electronic health records (EHRs), automated alert systems, and other technologies provide ideal opportunities for healthcare organizations to prevent medication errors. When leveraging the existing organizational resources, it is essential to conduct need assessments to identify resource strengths, opportunities, weaknesses, and threats.

Conclusion

Medication administration errors (MAEs) are among sentinel events that result in multiple patient safety concerns, including adverse reactions to medications, disabilities, mortalities, lengthy hospitalization, and increased economic burden of compensating care. From the case study, it is valid to contend that human, technical, and organizational factors combine to determine the likelihood of error occurrence.

In this sense, issues like ineffective communication and timely reporting systems, time pressure, prescriber experience, familiarity with guidelines, and technological advances significantly determine organizational susceptibility to medication administration errors. While many scholarly studies propose training and educational programs for prescribers, among other strategies, it is essential to embrace the evidence-based practice and implement the best interventions that are consistent with the need to prevent medication errors. Also, it is vital to align and leverage the existing resources when implementing these prevention approaches.

Improving Quality of Care and Patient Safety NURS-FPX4020 References

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 204209862096830. https://doi.org/10.1177/2042098620968309

Reeves, S., Clark, E., Lawton, S., Ream, M., & Ross, F. (2017). Examining the nature of interprofessional interventions designed to promote patient safety: A narrative review. International Journal for Quality in Health Care, 29(2), 144–150. https://doi.org/10.1093/intqhc/mzx008

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, Volume 13, 1621–1632. https://doi.org/10.2147/ijgm.s289452

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 2028. https://doi.org/10.3390/ijerph17062028

Yousef, N., & Yousef, F. (2017). Using a total quality management approach to improve patient safety by preventing medication error incidences. BMC Health Services Research, 17(1), 1-16. https://doi.org/10.1186/s12913-017-2531-6

NURS-FPX4020 Assessment 1 Instructions: Enhancing Quality and Safety

• For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses.

Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.

You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

Demonstration of Proficiency for Improving Quality of Care and Patient Safety NURS-FPX4020

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.

• • • Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.

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

• • • Explain factors leading to a specific patient-safety risk focusing on medication administration.

• • Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.

• • • Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.

• • • Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.

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

• • • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.

• • • Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

References

Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

Scenario

Consider a previous experience or hypothetical situation pertaining to medication errors, and consider how the error could have been prevented or alleviated with the use of evidence-based guidelines.

Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care.   

For this assessment:

• • Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.

Improving Quality of Care and Patient Safety NURS-FPX4020 Instructions

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.

Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.

• • Explain factors leading to a specific patient-safety risk focusing on medication administration.
  • Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
  • Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
  • Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
  • Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Additional Requirements

• • Length of submission: 3–5 pages, plus title and reference pages.
  • Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
  • APA formatting: References and citations are formatted according to current APA style.

Collaboration and Leadership

• 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 recommendation 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].

• • 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.

• Boomah, 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.

• • 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.

Quality and Safety Education

• 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 is 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 patients 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, may help you identify useful strategies for your assessment.

Quality and Safety Case Studies

Consider reviewing the following case studies as you complete your assessment:

• Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
• Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx

NURS-FPX4020 Assessment 2: Root-Cause Analysis and Safety Improvement Plan

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

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

Solution: