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Capella 4020 Assessment 4

William Adkins — Wed, 13 Nov 2024 15:09:51 +0000

Capella 4020 Assessment 4

Capella 4020 Assessment 4 Improvement Plan Tool Kit

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan Tool Kit

The safety improvement plan for healthcare-associated infections (HAIs) in the Pearl River County Hospital (PRCH) is grounded in evidence-based practices. Thus, an improvement plan tool kit is prepared for healthcare professionals, primarily nurses, to incorporate recent and trusted evidence in their healthcare practices. This tool kit is divided into four broad themes related to HAIs, which help healthcare professionals navigate recent evidence for successful implementation of the quality improvement plan.

Annotated Bibliography

Theme 1: Risk Factors and Etiology of HAIs

Liu, X., Long, Y., Greenhalgh, C., Steeg, S., Wilkinson, J., Li, H., Verma, A., & Spencer, A. (2023). A systematic review and meta-analysis of risk factors associated with healthcare-associated infections among hospitalized patients in Chinese general hospitals from 2001 to 2022. Journal of Hospital Infection, 135, 37–49. https://doi.org/10.1016/j.jhin.2023.02.013

This review article provides valuable information on common risk factors associated with HAIs, including sociodemographic characteristics such as age (more than 60 years) and male gender. Moreover, invasive procedures, chronic diseases, comatose state, immunosuppression due to diseases and therapies, and prolonged hospital stay (more than 15 days) are other significant factors leading to hospital-acquired infections. For nurses at PRCH, this resource is beneficial as it assists in identifying risk factors within their patient population. This resource helps nurses to tailor infection prevention strategies to address the specific needs of their patient population. For instance, the incident of Mr. John reveals age, gender, invasive procedure, and chronic disease as risk factors for developed surgical site infection (SSI). Therefore, this resource is invaluable for nurses in implementing quality and safety improvements related to HAIs, ultimately contributing to enhanced patient outcomes, improved patient safety and quality of care, and reduced healthcare costs.

Murni, I. K., Duke, T., Kinney, S., Daley, A. J., Wirawan, M. T., & Soenarto, Y. (2022). Risk factors for healthcare-associated infection among children in a low-and middle-income country. BMC Infectious Diseases, 22(1), 406. https://doi.org/10.1186/s12879-022-07387-2

Capella 4020 Assessment 4

Murni et al. (2022) study investigates risk factors for HAIs among the pediatric population. The research identifies factors like age (less than one year), length of hospital stay (more than seven days), systemic sepsis, use of invasive lines (urinary and central venous catheters), and substandard antibiotic therapies as significant contributors to HAIs in children. Although this study focuses on pediatric patients, these factors also contribute to HAIs in adults and older adults. This resource provides valuable information for nurses at PRCH to tailor targeted infection prevention strategies. The resource’s value lies in enhancing nurses’ awareness of key risk factors and guiding their decision-making processes to improve patient safety and quality of care. For instance, nurses can utilize this information while implementing safety improvement plans on infection control protocols, frequent hand hygiene practices, and patient education and engagement practices. Moreover, nurses can use this information in instances such as during patient assessments, care planning, and interdisciplinary team discussions. Thus, nurses and other healthcare professionals can proactively address infection prevention measures and mitigate HAI risks.

Shrestha, S. K., Trotter, A., & Shrestha, P. K. (2022). Epidemiology and risk factors of healthcare-associated infections in critically ill patients in a tertiary care teaching hospital in Nepal: A prospective cohort study. Infectious Diseases, 15, 11786337211071120. https://doi.org/10.1177/11786337211071120

Capella 4020 Assessment 4

This study investigates 300 patients admitted to the ICUs of tertiary hospitals in Nepal. According to the study, the significant factors leading to HAIs in critical patients are the use of invasive devices (catheters, invasive lines, and mechanical ventilators) and sedative therapies. Nurses in PRCH can utilize this resource to focus on implementing infection control and prevention strategies and antibiotic stewardship, which are designed in the safety improvement plan. By emphasizing appropriate infection control practices, hygiene care, and proper handling of invasive devices, this resource reduces the incidence of HAIs, enhancing the quality of nursing care and improving patient safety in critical care settings. Nurses can use this information in various situations, such as when planning care and treatments, central line insertion, and adjusting sedation protocols. Moreover, they can disseminate this information while educating other healthcare professionals, patients, and their families. Hence, this resource provides PRCH’s nurses with actionable evidence to implement quality and safety improvements to maintain patient safety.

Theme 2: Prevention and Control Strategies for HAIs

Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F. M., Islam, S., Jahan, D., Nusrat, T., Chowdhury, T. S., Coccolini, F., Iskandar, K., Catena, F., & Charan, J. (2020). Strategies to prevent healthcare-associated infections: A narrative overview. Risk Management and Healthcare Policy, 13, 1765–1780. https://doi.org/10.2147/RMHP.S269315

A comprehensive review of literature studies presents several strategies to prevent HAIs. The narrative overview discusses hand hygiene protocols, environmental cleaning, educational initiatives, surveillance, and antimicrobial stewardship programs as effective and primarily employed strategies worldwide. However, hand hygiene, environmental cleanliness, and stewardship programs have an overwhelming impact on reducing HAIs and improving health outcomes. This resource is a guiding tool for nurses while implementing quality and safety improvements.

For instance, nurses at PRCH can use the information provided in this resource to prioritize regular hand hygiene practices, ensure thorough environmental cleaning, participate in surveillance and infection monitoring, and advocate for antimicrobial stewardship initiatives. Consequently, the targeted strategies in this resource minimize patient safety risks and improve the overall quality of care, hence declaring the resource most valuable and relevant for PRCH quality and safety issues. Nurses can utilize this resource in various instances, such as during staff education, where nurses can share insights from the article to create awareness among healthcare professionals. Additionally, nurses can incorporate information from the article into patient engagement initiatives to empower patients and families regarding infection control measures.

Capella 4020 Assessment 4

Lowe, H., Woodd, S., Lange, I. L., Janjanin, S., Barnet, J., & Graham, W. (2021). Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: A qualitative study. Conflict and Health, 15(1), 94. https://doi.org/10.1186/s13031-021-00428-8

Lowe et al. (2021) conducted a qualitative study to identify the challenges and opportunities associated with infection prevention and control (IPC) practices. While discussing the challenges of IPC implementation, this article also focuses on the importance of IPC measures for preventing HAIs, recommending it as a significant strategy to prevent infections in healthcare settings. According to the article, these measures minimize the spread of pathogens in healthcare settings, reduce morbidity and mortality, and optimize healthcare outcomes, maintaining patient safety.

IPC strategies include hand hygiene, environmental cleaning, and antimicrobial stewardship, which are integrated into our safety improvement plan for PRCH. Nurses can benefit from this resource as it offers valuable insights into the broader context of IPC challenges, providing a perspective to compare their practices and limitations within PRCH. By understanding the importance of IPC and opportunities, nurses can adapt their practices to identify innovative solutions for preserving patient safety and reducing the risk of HAIs. Additionally, this article underscores the need for resilience, adaptability, and interprofessional collaboration in overcoming barriers, thus offering a broader horizon for PRCH’s nurses to implement safety and quality improvement plans.

Capella 4020 Assessment 4

Puro, V., Coppola, N., Frasca, A., Gentile, I., Luzzaro, F., Peghetti, A., & Sganga, G. (2022). Pillars for prevention and control of healthcare-associated infections: An Italian expert opinion statement. Antimicrobial Resistance and Infection Control, 11, 87. https://doi.org/10.1186/s13756-022-01125-8

This resource presents an expert opinion statement outlining the importance of IPC initiatives to prevent HAIs. This resource offers a practice guide for healthcare professionals and organizations to implement these initiatives successfully. The resource emphasizes essential strategies the World Health Organization (WHO) recommended, such as hand hygiene, antimicrobial stewardship, infection surveillance, and training and education. For nurses at PRCH, this resource is a valuable reference for implementing quality and safety improvement plans within the healthcare setting. This resource offers insights into best practices and evidence-based strategies that nurses can employ to implement successful infection prevention measures, strengthen hand hygiene protocols, achieve targets and objectives, and improve the quality of nursing practice and patient safety. The information within this article can be primarily used during resource allocation and policymaking within the hospital. It can be integrated into daily practice to create a safety and quality improvement culture.

Theme 3: Technology-assisted HAI Detection and Prevention

Arzilli, G., De Vita, E., Pasquale, M., Carloni, L. M., Pellegrini, M., Di Giacomo, M., Esposito, E., Porretta, A. D., & Rizzo, C. (2024). Innovative techniques for infection control and surveillance in hospital settings and long-term care facilities: A scoping review. Antibiotics, 13(1), 77. https://doi.org/10.3390/antibiotics13010077

This scoping review by Arzilli et al. (2024) explores innovative techniques for infection control and surveillance in hospital settings and long-term care facilities. The various technologies discussed in this review are machine learning, Artificial Intelligence (AI), and natural language processing. These technologies have promising results in empowering patients, reducing workload, cost-effectivity, and improved personalization. According to the article, these technologies enhanced real-time surveillance by improving communication between patients and providers. The authors combine current literature on the effectiveness of these innovations, providing insights into their practical application in healthcare settings through equitable access and improved digital knowledge. This paradigm-shifting knowledge is invaluable for nurses at PRCH to enhance their understanding of emerging HAI prevention and control technologies. Nurses can leverage this information to apply electronic/AI surveillance systems introduced in the safety improvement plan. This resource is highly relevant and valuable as nurses can learn about these innovative interventions for infection control to not only improve patient safety but also reduce the cost associated with complex treatments of HAIs. Thus contributing to minimizing patient safety risks and improving the overall quality of care.

Behnke, M., Valik, J. K., Gubbels, S., Teixeira, D., Kristensen, B., Abbas, M., van Rooden, S. M., Gastmeier, P., van Mourik, M. S. M., van Mourik, M. S. M., van Rooden, S. M., Abbas, M., Aspevall, O., Astagneau, P., Bonten, M. J. M., Carrara, E., Gomila-Grange, A., de Greeff, S. C., Gubbels, S., … Gastmeier, P. (2021). Information technology aspects of large-scale implementation of automated surveillance of healthcare-associated infections. Clinical Microbiology and Infection, 27, S29–S39. https://doi.org/10.1016/j.cmi.2021.02.027

Capella 4020 Assessment 4

This article explores the technological aspects essential for the large-scale implementation of automated surveillance systems. This resource guides along with the roadmap for healthcare professionals to implement automated surveillance within healthcare settings. These elements include data collection, electronic health records integration, data quality assurance, and feedback mechanisms. However, the article discusses several implementation challenges, including infrastructure, interoperability, and data security in automated surveillance systems. Nurses in PRCH use this information to understand the importance of automated surveillance systems, as introduced with the safety improvement plan. By incorporating these guidelines, nurses identify infection incidences within the hospital and collaborate with IT teams to implement automated surveillance systems. Additionally, nurses can utilize automated surveillance data to inform infection control protocols, educate staff, and advocate for resources to support HAI prevention efforts, preventing patient safety and improving the quality of care at PRCH.

Streefkerk, H. R. A., Verkooijen, R. P., Bramer, W. M., & Verbrugh, H. A. (2020). Electronically assisted surveillance systems of healthcare-associated infections: A systematic review. Eurosurveillance, 25(2), 1900321. https://doi.org/10.2807/1560-7917.ES.2020.25.2.1900321

Capella 4020 Assessment 4

This systematic review emphasizes the importance of electronically assisted surveillance systems in preventing HAIs. The review examines various technologies for surveillance, including computer algorithms, machine learning, and electronic health records systems. The authors assess these systems’ effectiveness, accuracy, and usability in detecting and monitoring HAIs and their impact on infection control practices, patient safety, and patient outcomes. This resource is a valuable guide for nurses to implement the safety and quality improvement proposed for PRCH. Nurses can use the findings to analyze the capabilities and limitations of electronically assisted surveillance systems. This analysis will help them compare their healthcare setting, ensuring seamless implementation of quality and safety plans. For example, nurses can integrate findings from the review into staff education sessions to raise awareness about the effectiveness and benefits of electronic surveillance systems. Through this knowledge, nurses can facilitate timely detection and intervention for infection control, ultimately enhancing patient safety and quality of care at Pearl River County Hospital.

Theme 4: Patient Engagement and Empowerment in HAI Prevention

Croke, L. (2020). Fostering patient engagement can aid in infection prevention efforts. AORN Journal, 111(5). https://doi.org/10.1002/aorn.13049

Croke (2020) discusses the importance of fostering patient engagement in infection prevention efforts within healthcare organizations. The resource explores various strategies for involving patients in infection control measures, such as education on proper hand hygiene, encouraging active participation in infection prevention protocols, and promoting open communication between patients and healthcare providers regarding infection risks and prevention strategies. Nurses can utilize this resource to implement patient and family education initiatives outlined in the safety improvement plan. During hospital stays, they can educate patients and their families about the importance of infection control measures, such as hand hygiene and environmental cleanliness. These educational initiatives will reduce HAIs, prevent patient safety, and improve the healthcare quality provided within PRCH. Additionally, nurses can involve patients in surveillance activities by encouraging them to promptly report any signs or symptoms of infection. This resource is most valuable as it relates to the safety improvement plan, assisting nurses in enhancing patient safety, improving infection control outcomes, and creating a culture of collaboration and shared responsibility for HAI prevention at PRCH.

Capella 4020 Assessment 4

This study highlights the importance of empowering patients to prevent HAIs through active participation in infection control practices using various strategies such as promoting hand hygiene, encouraging vaccination, and patient education on risks and preventive measures. The primary focus of this study is to stress the need for patient-provider to reduce the transmission of pathogens within healthcare settings, thus maintaining patient safety. Nurses can use the information provided in the article to improve their practices, engage the patient and their families, and promote infection control practices within the PRCH. For example, through active demonstrations and theoretical knowledge, nurses can involve patients and their families in preventing the risks of HAIs. Additionally, nurses can use this resource to develop patient-centered educational materials, such as pamphlets, brochures, and video presentations. Lastly, incorporating findings from this resource into discharge planning can ensure the continuity of infection prevention practices beyond the hospital setting. Thus impacting patient safety and improving the quality of healthcare.

Oliveira, M. de C., Dalcól, C., de Carvalho, R. E. F. L., & Poveda, V. de B. (2023). Patient participation in surgical site infection prevention: Perceptions of nurses, physicians and patients. Revista Da Escola de Enfermagem Da USP, 57, e20220459. https://doi.org/10.1590/1980-220X-REEUSP-2022-0459en

This study investigates the perceptions of nurses, physicians, and patients regarding patient participation in surgical site infection (SSI) prevention. Through qualitative research, the study explores the roles and perspectives of each stakeholder, highlighting the importance of patient engagement in reducing infection risks. The authors discuss various factors influencing patient participation, including communication, education, and empowerment strategies. Nurses can use the findings from the study to advocate for increased patient involvement in infection prevention activities, such as preoperative education on hygiene practices and postoperative wound care. This resource is most valuable for our patient, Mr. John, as knowledge about these practices would have prevented the incident of SSI. Additionally, nurses can incorporate patient-centered approaches into their practice, such as encouraging patients to ask questions, voice concerns, and actively participate in decision-making processes related to SSI prevention. By fostering a patient-centered care and partnership culture, nurses can empower patients to play a more active role in their healthcare, reduce SSI rates, and improve patient safety at PRCH.

References

Croke, L. (2020). Fostering patient engagement can aid in infection prevention efforts. AORN Journal, 111(5). https://doi.org/10.1002/aorn.13049

Capella 4020 Assessment 4

Donskey, C. J. (2023). Empowering patients to prevent healthcare-associated infections. American Journal of Infection Control, 51(11, Supplement), A107–A113. https://doi.org/10.1016/j.ajic.2023.03.008Haque, M., McKimm, J., Sartelli, M., Dhingra, S., Labricciosa, F. M., Islam, S., Jahan, D., Nusrat, T., Chowdhury, T. S., Coccolini, F., Iskandar, K., Catena, F., & Charan, J. (2020). Strategies to prevent healthcare-associated infections: A narrative overview. Risk Management and Healthcare Policy, 13, 1765–1780. https://doi.org/10.2147/RMHP.S269315

Capella 4020 Assessment 4

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Capella 4020 Assessment 3

William Adkins — Wed, 13 Nov 2024 14:54:42 +0000

Capella 4020 Assessment 3

Capella 4020 Assessment 3 Improvement Plan in Service Presentation

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan In-Service Presentation

Good morning, everyone. My name is ________. I am pleased to welcome you to this in-service session on the quality and patient safety of inadequate patient education. This session aims to enlighten nurses about the outcomes of inadequate patient education, describe the proposed safety improvement plan, and create buy-in to minimize the issue in Miami Valley Hospital.

Agenda and Outcomes

The intended outcomes of the presentation are as follows:

Describe the quality and safety issue of inadequate patient education and its consequences on patient safety and quality of care.
Elaborate on the need to address inadequate patient education.
Discuss the proposed safety improvement plan for the organization.
Enhance understanding of nurses’ role in addressing quality and safety issues and the importance of a successful improvement plan.
Lastly, analyze case studies in groups to improve understanding and skills related to the importance of patient education.

Inadequate Patient Education and its Poor Consequences

Patient education is an essential component of healthcare practices. It is described as a process that influences patients’ behaviors to improve their health and well-being using different teaching methods. Inadequate patient education is one of the most significant healthcare challenges related to patient safety and quality of care. A study identifies that lack of education is a systemic healthcare issue and must be addressed holistically, as patients reported that healthcare professionals lack education related to medication and treatment plans (Zhang et al., 2019). Several consequences occur due to inadequate patient education, such as inappropriate patient behaviors related to health, increased risks of disease aggravation, augmented healthcare costs, and poor patient outcomes (Johnson et al., 2023).

Safety Improvement Plan

Our proposed safety improvement plan for Miami Valley Hospital (MVH) is evidence-based and includes best practices to ensure the team integrates comprehensive patient education into their nursing practices. This two-pronged plan includes developing a patient-centered communication model and establishing Electronic Health Records (EHR)-integrated patient portals.

Patient-centered Communication Model

The patient-centered communication model impacts nurse-patient communication, eventually improving patient education. This model aims to train healthcare professionals, especially nurses, in patient-centeredness that includes respect, active listening, and cultural competence. These aspects are essential to build therapeutic communication between nurses and providers to ensure adequate information exchange related to patients’ health conditions (Kwame & Petrucka, 2021).

Secondly, dedicated protocols should be introduced into nursing practice to develop individualized patient educational materials, especially for discharge education (Banzon, 2023). This plan intends to reduce errors and prevent health complications. Providing an in-depth understanding of health conditions, their management, medication regimens, and complications to look for will empower patients to manage their health and avoid preventable harm adequately. For the implementation, we have set a timeline of six months where the plan is initially to train nursing staff and then establish discharge education materials and policy.

Integrated EHR Patient Portals

Another approach to this safety improvement plan is to establish EHR-integrated patient portals. These patient-friendly portals allow patients to access their health information, disease processes, medication regimens, diagnostic testing, and other applicable healthcare services, ensuring a holistic educational approach. Through these portals, healthcare professionals can also set appointments and medication reminders, providing ongoing support to the patients throughout their healthcare journey (Bhattad & Pacifico, 2022). For this purpose, integrating educational materials in the EHR system and healthcare providers’ training is crucial. Organizations must develop standardized educational materials to reinforce knowledge exchange and treatment compliance. Additionally, providers’ training should include the basics of EHR utilization, educational materials integration, and content modification according to patient’s needs (Hodgson et al., 2022). Simultaneously, it is essential to train providers to address potential glitches and challenges with the system.

These comprehensive EHR-integrated patient portals aim to make healthcare information accessible to individuals and communities. The timeline suggested for implementing EHR patient portals is 4-6 months. The team will gather information and formulate various educational materials in the initial phase. Then, the organization’s stakeholders will coordinate with information technology teams to develop a portal and integrate educational materials. They must ensure that patients have access to the portals and they are secure to transfer critical information.

Need for Safety Improvement Plan in the Organization

The incident of a medication error, where a patient named Mary accidentally administered an extra dose of insulin unit due to poor knowledge about the utilization of insulin pens, advocated the need to address the safety concern of inadequate patient education in MVH through a safety improvement plan. This is paramount for several reasons. Inadequate patient education directly risks patient safety as a lack of understanding about medical conditions, medication administration, and treatment plans may lead to adverse events, complications, and preventable harm (Kirimlioğlu, 2018). Secondly, the need for addressing the issue is to improve the quality of care in the organization. Effective patient education and quality of nursing care are interconnected as nurses can provide patient-centered care, enhance patient engagement in healthcare, better health outcomes, and improve patient experiences with care (Gröndahl et al., 2019). Lastly, it is essential for the organization to comply with regulatory standards established about mandatory patient education to maintain accreditation, safeguarding the organization’s position in the healthcare sector.

Nurses’ Role and Importance of a Successful Safety Improvement Plan

So, this part of the presentation is crucial for you as a registered nurse. Nurses play a significant role in making the safety improvement plan successful, aiming at addressing inadequate patient education.

Direct Patient Interaction: As frontline healthcare workers, nurses have a prime position in interacting with patients. This nurse-patient interaction aids in assessing patients’ literacy levels, identifying educational needs, and enhancing patient engagement in decision-making. This effective relationship ensures that nurses can develop personalized educational interventions and effectively communicate them through patient-centered communication, ultimately improving patient outcomes (Kwame & Petrucka, 2021).
Collaboration with Interdisciplinary Teams: Bendowska and Baum (2023) claim that patient safety is directly proportional to effective interdisciplinary collaboration. Nurses can actively coordinate with interdisciplinary teams to ensure that patients receive holistic education about their health condition and treatment and medication plans to fulfill the goals of the safety improvement plan.
Patient Advocacy: Nurses can play an essential role as patient advocates to improve patient safety and quality of care by protecting their rights and backing their educational needs (Nsiah et al., 2019). Advocating for comprehensive and tailored patient education plans helps address individualized educational needs, enhance understanding, and improve patient outcomes.

Capella 4020 Assessment 3

These nursing actions are essential for the success of our safety improvement plan. This success is vital as it results in positive patient outcomes, improved organizational reputation, cost-effectiveness, and financial stability. Additionally, regulatory compliance and accreditation are maintained, fostering a culture of continuous improvement and encouraging staff to deliver high-quality, patient-centered care.

New Process and Skills Practice

Coming to the last part of our in-service session, I hope you all understand the quality and safety issue of inadequate patient education in healthcare settings and our safety improvement plan. It’s time to make three groups and discuss some case studies of inadequate patient education. Through these case studies, you will understand the importance of patient education and integrate effective strategies into your clinical practices to improve patient education. Here are some of the case studies for each group to analyze and answer the following questions below:

Questions

What exactly happened?
What were the risk factors associated with poor patient outcomes?
What could’ve been done to minimize the patient safety risk?

Case Study # 1: Cardiovascular Medication Mismanagement

Mrs. Johnson, a 65-year-old woman with hypertension, is prescribed a new antihypertensive medication. She has a history of limited health literacy and is a language barrier patient who relies on her daughter for translation. Although her daughter was unavailable during the discharge, the assigned nurse explained Mrs. Johnson’s prescribed medication routine for home, claiming that she had other patients to look after and couldn’t wait for her daughter to join. Mrs. Johnson, misunderstanding the medication instructions, takes the new medication irregularly. This leads to uncontrolled blood pressure, resulting in a hypertensive crisis and subsequent hospitalization. These poor complications increased healthcare costs and compromised Mrs. Johnson’s overall well-being.

Case Study # 2: Diabetes Self-Management Challenges

Mr. Rodriguez is a 55-year-old man recently diagnosed with diabetes. He works long hours and struggles with finances to manage his disease. He has poor educational background and lives in a community with a lack of healthcare access. During his recent visit to the hospital, doctors have asked him to switch from oral medicines to insulin administration. The patient is not instructed on how to administer insulin. Mr. Rodriguez, due to long working hours and a busy schedule, faces difficulties managing his diet and insulin administration, experiencing dynamic blood sugar levels. This has resulted in recurrent emergency visits due to hypoglycemia and hyperglycemia and has increased treatment costs.

Case Study # 3: Post-Surgical Complications

John, a 40-year-old man undergoing elective knee surgery, has a history of anxiety. He receives minimal pre-operative education due to a high nurse-to-patient ratio and is not provided with written instructions. After discharge, John experienced serious complications at home due to improper wound care and a lack of rehabilitation exercises. This results in a surgical site infection and delayed recovery, contributing to increased length of hospital stay, augmented healthcare costs, and diminished patient satisfaction.

Conclusion

To conclude my presentation, I want to reinforce that inadequate patient education is a significant healthcare challenge and must be addressed comprehensively. For this purpose, we have developed a safety improvement plan to integrate EHR patient portals and a patient-centered communication model. As registered nurses, audiences play a crucial role in understanding patients’ educational needs, tailoring educational interventions according to those needs, advocating for patient education, and collaborating with interdisciplinary teams to provide effective and adequate education to patients, ensuring the sustainability and success of safety improvement plans.

References

Banzon, C. (2023). Discharge education protocol to improve patient satisfaction. South Dakota State University. https://openprairie.sdstate.edu/cgi/viewcontent.cgi?article=1185&context=con_dnp

Bendowska, A., & Baum, E. (2023). The significance of cooperation in interdisciplinary health care teams as perceived by Polish medical students. International Journal of Environmental Research and Public Health, 20(2), 954. https://doi.org/10.3390/ijerph20020954

Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7), e27336. https://doi.org/10.7759/cureus.27336

Gröndahl, W., Muurinen, H., Katajisto, J., Suhonen, R., & Leino-Kilpi, H. (2019). Perceived quality of nursing care and patient education: A cross-sectional study of hospitalised surgical patients in Finland. BMJ Open, 9(4), e023108. https://doi.org/10.1136/bmjopen-2018-023108

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Hodgson, J., Welch, M., Tucker, E., Forbes, T., & Pye, J. (2022). Utilization of EHR to improve support person engagement in health care for patients with chronic conditions. Journal of Patient Experience, 9, 237437352210775. https://doi.org/10.1177/23743735221077528

Johnson, A. M., Brimhall, A. S., Johnson, E. T., Hodgson, J., Didericksen, K., Pye, J., Harmon, G. J. C., & Sewell, K. B. (2023). A systematic review of the effectiveness of patient education through patient portals. JAMIA Open, 6(1), ooac085. https://doi.org/10.1093/jamiaopen/ooac085

Kirimlioğlu, N. (2018). Patient education and its importance in terms of patient safety. International Journal of Research -GRANTHAALAYAH, 6(12), 109–120. https://doi.org/10.29121/granthaalayah.v6.i12.2018.1090

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158. https://doi.org/10.1186/s12912-021-00684-2

Capella 4020 Assessment 3

Nsiah, C., Siakwa, M., & Ninnoni, J. P. K. (2019). Registered Nurses’ description of patient advocacy in the clinical setting. Nursing Open, 6(3), 1124–1132. https://doi.org/10.1002/nop2.307

Zhang, L., Luan, W., Geng, S., Ye, S., Wang, X., Qian, L., Ding, Y., Li, T., & Jiang, A. (2019). Lack of patient education is risk factor of disease flare in patients with systemic lupus erythematosus in China. BMC Health Services Research, 19(1), 378. https://doi.org/10.1186/s12913-019-4206-y

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Capella 4020 Assessment 2

William Adkins — Wed, 13 Nov 2024 14:43:11 +0000

Capella 4020 Assessment 2

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

Inadequate patient education is a common quality and safety concern in the healthcare sector. This Root-Cause Analysis (RCA) is performed to analyze a clinical scenario where a lack of patient education led to harmful consequences for a patient at Miami Valley Hospital. This assessment analyzes the root causes of the situation, applies evidence-based best practices to address the concern, develops a safety improvement plan for the particular organization, and identifies the existing organizational resources to address the concern using the proposed safety improvement plan successfully.

Analysis of the Root Cause

The case scenario for this assessment is from the Miami Valley Hospital. On November 15, 2023, Olivia, a registered nurse, discharged her patient, Mary, who was recently diagnosed with diabetes. To control her hyperglycemia, Mary was prescribed insulin as take-home medication. Her discharge prescription stated to administer She was ten units of insulin Lantus at night. Since Olivia had a hectic shift managing five chronic patients, she could not adequately instruct Mary on using insulin pens. A few days later, the patient was received in the emergency room for fluctuating blood glucose levels. Upon investigation, the emergency team identified that the patient had inadvertently taken incorrect doses of insulin while failing to recognize hypoglycemia symptoms. The problem significantly impacted patient safety by risking her for complications related to hyperglycemia and hypoglycemia.

While analyzing the situation, we can infer that adequate patient education is necessary to avoid several medical errors, ultimately preventing patient health complications related to medication action and utilization. A study states inadequate medication education is a significant patient safety and quality concern (T et al., 2022). Some root causes of the situation are inadequate patient education, staff workload, and ineffective nurse-patient communication. Lack of patient education is a systemic issue persisting in all healthcare settings. Adequate patient education is essential to improve patient outcomes, enhance patient experiences, and reduce healthcare costs by encouraging patient engagement (Johnson et al., 2023). Conversely, a lack of patient education may lead to poor health behaviors, eventually making room for health complications. Secondly, nurses’ workload is contemplated as an essential root cause for both inadequate patient education and medication errors.

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Banda et al. (2022) presented a study showing that nurses’ workload directly impacts patient safety. These effects include poor care quality, lack of patient engagement, and medical errors. It also leads to insufficient nurse-patient communication, another root cause for inadequate patient education, stemming from the nurse’s busy schedule managing multiple chronic patients. Effective communication between nurses and patients increases patient engagement in healthcare, ultimately improving patients’ adherence to medication and treatment plans (Kwame & Petrucka, 2021). Communication is essential to ensure healthcare providers and patients work on shared goals to lessen uncertain circumstances and enhance patient safety.

Evidenced-Based and Best Practice Strategies

Several evidence-based best practices are suggested by literature to address the quality and safety concerns of inadequate patient education and the root causes identified in RCA. These include establishing a patient-centered communication model, task delegation, and integrating patient education portals in the Electronic Health Records (EHR) system.

Task Delegation

Delegating nurses’ tasks allows them to distribute the workload effectively, which assists them in focusing on essential tasks that require nursing competencies (Crevacore et al., 2023). According to the literature, nurses’ workload significantly impacts patient education as it doesn’t allow nurses to efficiently engage patients in their healthcare (Akhtar et al., 2019). Therefore, delegating tasks allows nurses to allocate more time to patient care and education. Moreover, task division enables nurses to focus on their expertise, leading to more effective and tailored patient education. This way, it will address the patient safety issue of inadequate education.

EHR Patient Education Portals

Another evidence-based best practice to improve patient education is integrating patient portals into the EHR system. These portals provide holistic access to patients’ records, medication regimens, appointments, telehealth visits, and educational materials, allowing patients to receive comprehensive knowledge and make informed decisions about their healthcare (Johnson et al., 2023). A study mentioning the effectiveness of educational materials emphasized the need for EHR-integrated patient portals as they provide continuous education to the patients and support their decision-making for healthcare needs (Bhattad & Pacifico, 2022). Thus, these portals are essential to improve patient education in healthcare settings.

Patient-Centered Communication Model

The patient-centered communication model focuses on improving nurse-patient communication. This model leads healthcare providers to interact with patients and identify their educational needs, preferences, and barriers to effective comprehension. The educational materials can be individualized to avoid medical jargon and remove irrelevant information to improve patient engagement and participation in their healthcare (Ricci et al., 2022). These open and accessible communication lines, centered on individual patients, will enhance nurse-patient communication, eventually augmenting patient health literacy levels, informing health behaviors, minimizing errors, and maintaining patient safety.

Safety Improvement Plan

The evidence-based safety improvement plan proposed for Miami Valley Hospital is a two-pronged approach allowing interdisciplinary teams to address the safety issue of inadequate patient education. The plan includes establishing a patient-centered communication model and integrating the patient portal into the EHR system.

Patient-Centered Communication Model

To address communication issues as a root cause for inadequate patient education, the essential required action is training healthcare professionals, especially nurses, about patient-centered communication principles. These include empathetic (respect and active listening) and culturally sensitive interactions (Kwame & Petrucka, 2021). Another process is integrating structured communication protocols into nursing workflows to ensure dedicated time for patient education. The organization should have a policy and protocols to improve discharge education by providing individualized educational materials to ensure patients acquire knowledge in home settings, preventing adverse outcomes (Banzon, 2023). The goal is to reduce medication and treatment errors and associated complications by improving patient education and promoting a trusting and collaborative provider-patient relationship. The timeline required for establishing a patient-centered communication model is six months; initially, in the first three months, the organization will develop and implement training programs for nursing staff on patient-centered communication, and in the next three months, stakeholders must establish a discharge education policy and start pilot implementation.

Integrated EHR Patient Portals

The organization should train healthcare providers on using EHR-integrated patient portals for educational purposes. This training should include primary EHR navigation, integrating educational materials, modifying the content according to patient’s needs, and addressing barriers patients may encounter while using these tools (Hodgson et al., 2022). Organizational changes include developing standardized educational materials within the EHR system to reinforce consistent knowledge and encourage treatment compliance and implementing a policy to document patient education reports in EHR, guaranteeing the coverage of comprehensive topics. The goal is to optimize the use of EHR-integrated patient portals and enhance the availability of healthcare information, enabling them to review it continuously. EHR patient portal will require 4-6 months for successful implementation. Initially, stakeholders will collaborate with IT teams to integrate educational materials into the existing EHR system and ensure patients have adequate access to the EHR portal. This action also requires monitoring privacy and security issues related to patient health information.

Organizational Resources

Existing organizational personnel, such as clinical educators, are essential for the safety improvement plan. The best way to leverage them is by utilizing their competencies to design high-quality content for healthcare providers, ensuring they receive training according to the standards set for patient-centered care (Kaarlela et al., 2022). They will also assist in developing educational materials for EHR portals. Another team from the IT department will help streamline the integration process of EHR and patient portals and address technical and security issues that may arise during execution. Leveraging the existing quality assurance team will aid in identifying loopholes to make continuous improvements.

On the other hand, the resources that would be leveraged are computers at nursing stations and the organization’s existing EHR system. According to the priority, resources that need to be obtained include a user-friendly EHR interface. This is prioritized as the organization needs a seamless system to support patient portals and ensure strict security channels. The second priority is some educational materials to ensure standardized protocols and professional information to add to the content. Lastly, the organizations must collaborate with external experts for specialized training, which will enhance the plan’s impact, ultimately harnessing organizational resources to maximize the success of the safety improvement plan.

Conclusion

In conclusion, inadequate patient education is an alarming concern for healthcare organizations requiring immediate interventions. The issue encountered by Miami Valley Hospital is an explicit example of harmful complications of lack of patient education. Thus, we described some evidence-based best practices and developed a safety improvement plan entailing a patient-centered communication model and EHR-integrated patient portals to enhance patient engagement, make information accessible to the patients, and improve patient education to reduce the risk of errors and improve patients’ well-being.

References

Akhtar, N., Hussain, M., Afzal, M., & Gilani, S. (2019). Factors influencing practice of patient education among nurses. Saudi Journal of Nursing and Health Care, 2(4), 116-128. https://doi.org/10.21276/sjnhc.2019.2.4.1

Banda, Z., Simbota, M., & Mula, C. (2022). Nurses’ perceptions on the effects of high nursing workload on patient care in an intensive care unit of a referral hospital in Malawi: A qualitative study. BMC Nursing, 21, 136. https://doi.org/10.1186/s12912-022-00918-x

Banzon, C. (2023). Discharge education protocol to improve patient satisfaction. South Dakota State University. https://openprairie.sdstate.edu/cgi/viewcontent.cgi?article=1185&context=con_dnp

Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7), e27336. https://doi.org/10.7759/cureus.27336

Capella 4020 Assessment 2

Crevacore, C., Jacob, E., Coventry, L. L., & Duffield, C. (2023). Integrative review: Factors impacting effective delegation practices by registered nurses to assistants in nursing. Journal of Advanced Nursing, 79(3), 885–895. https://doi.org/10.1111/jan.15430

Hodgson, J., Welch, M., Tucker, E., Forbes, T., & Pye, J. (2022). Utilization of ehr to improve support person engagement in health care for patients with chronic conditions. Journal of Patient Experience, 9, 237437352210775. https://doi.org/10.1177/23743735221077528

Kaarlela, V., Mikkonen, K., Pohjamies, N., Ruuskanen, S., Kääriäinen, M., Kuivila, H.-M., & Haapa, T. (2022). Competence of clinical nurse educators in university hospitals: A cross-sectional study. Nordic Journal of Nursing Research, 42(4), 195–202. https://doi.org/10.1177/20571585211066018

Capella 4020 Assessment 2

Ricci, L., Villegente, J., Loyal, D., Ayav, C., Kivits, J., & Rat, A. (2022). Tailored patient therapeutic educational interventions: A patient‐centred communication model. Health Expectations : An International Journal of Public Participation in Health Care and Health Policy, 25(1), 276–289. https://doi.org/10.1111/hex.13377

T, R., I U, H., M Y, M., & P, G. (2022). Patients’ knowledge about medicines improves when provided with written compared to verbal information in their native language. PloS One, 17(10), e0274901. https://doi.org/10.1371/journal.pone.0274901

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Capella 4020 Assessment 1

William Adkins — Wed, 13 Nov 2024 14:35:37 +0000

Capella 4020 Assessment 1

Capella 4020 Assessment 1 Enhancing Quality and Safety

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Enhancing Quality and Safety

Inadequate patient education is one of the quality and safety issues in healthcare settings that may lead to misunderstandings related to disease processes, patient-related medication errors, and suboptimal compliance with treatment plans. This assessment will analyze a similar case scenario where inadequate patient education led to serious patient safety risks. Further, this paper presents the evidence-based best practices to address the concern and nurses’ role in effective care coordination.

Factors Leading to the Safety Problem

Olivia, a registered nurse at Miami Valley Hospital, discharged her patient, Mary, on November 15, 2023. Mary has been recently diagnosed with diabetes and needs insulin for her hyperglycemia management. Upon discharge, she received a prescription for administering ten units of Lantus at night. However, while managing five chronic patients, Olivia couldn’t provide sufficient education on using insulin pens. Unaware of proper injection skills and the importance of regular monitoring, the patient unintentionally administered incorrect doses and failed to recognize signs of hypoglycemia. As a consequence, Mary experienced severe blood glucose instabilities, leading to an emergency hospitalization.

As mentioned above, the root cause of the scenario is patient education. A study presented statistics that estimated medication errors related to prescription, administration, and dispensing in the United States account for 1.5 million avoidable adverse events. Further in the study, it is mentioned that the World Health Organization considers this a greatest patient safety challenge and advocates the importance of patient education and knowledge on medication to address the challenge and improve patient safety (T et al., 2022). Another study examining the lack of patient education as a safety risk factor identified that most patients reported healthcare professionals’ underperformance in providing medication action and usage education, indicating that inadequate patient education is a system-level issue and must be comprehensively addressed (Zhang et al., 2019). Increased workload is a significant risk factor for insufficient education provision, as identified in the case mentioned above study.

Literature found a connection between nurses’ workload and patient safety risk by concluding that nursing workload can have severe negative outcomes on patient care, such as compromised quality, poor documentation, inadequate patient education, and medical errors (Banda et al., 2022). This evidence and the case scenario illustrate the importance of patient education to improve patient outcomes and treatment adherence, prevent medication errors, reduce recurrent admissions, improve cost-effectiveness, and enhance patient satisfaction. Other factors that may lead to inadequate patient education are time constraints, language barriers, limited patient engagement, lack of training for healthcare providers, and healthcare system complexities.

Evidenced-based and Best-practice Interventions

Since inadequate patient education is becoming a healthcare challenge, it is vital to implement some evidence-based best practices to ensure that patients receive adequate knowledge about their conditions and treatment regimens. One of the best practices is to establish a patient-centered communication model. This model involves an interdisciplinary team to tailor educational interventions to individual patient needs and preferences, improving comprehension and adherence to the healthcare plan. Through this method, the content is personalized to remove unnecessary information, and only relevant and applicable information is added to gauge patients’ attention and participation in their healthcare (Ricci et al., 2022).

Another effective evidence-based best practice is to establish a multidisciplinary education team. The team comprises healthcare professionals and health educators. It is identified through the study that the collaborative efforts of interdisciplinary teams result in enhanced prevention and improved health education, ultimately promoting healthy behaviors among patients. A multidisciplinary team accommodates several aspects of healthcare needs, so multidisciplinary collaborations precisely address individual needs, improving adherence to the plans and reducing errors (Schor et al., 2019).

Capella 4020 Assessment 1

Lastly, empowering patients by promoting patient education using educational materials is essential. A study showed the effectiveness of educational materials such as personalized, informative handouts and patient portals integrated into Electronic Health Records (EHR), showing that these materials help patients on an ongoing basis to ensure they are physically and psychologically supported throughout the healthcare journey (Bhattad & Pacifico, 2022). Thus, these evidence-based best practices are essential to address the challenge of inadequate patient education in healthcare settings. Improving patient education is vital to increasing treatment adherence among the patient population and reducing hospital readmissions. Reducing hospital readmission rates decreases the need for further healthcare interventions, eventually making healthcare cost-effective for individuals. Furthermore, it engages patients in healthcare, resulting in informed and autonomous decisions.

Nurses Role in Care Coordination

Nurses are pivotal in care coordination, particularly in addressing inadequate patient education, improving patient safety, and reducing costs. Developing a personalized educational program is one of the nursing actions where nurses can coordinate with patients to understand their individual needs, health literacy levels, and self-management abilities. This assessment helps nurses tailor educational interventions for the patient by collaborating with other healthcare professionals. A study on the effectiveness of nurse-led personalized programs for diabetic patients concluded that improved treatment adherence enhanced patient participation and health outcomes (Cengiz & Korkmaz, 2023). Such individualized plans help prevent adverse events stemming from lack of education, reducing the likelihood of hospital readmissions and costs associated with health complications.

Moreover, nurses can advocate within the organization to implement health information technology tools for patient education. Collaborating with other stakeholders in the organization, they can bring digital education and assist patients in utilizing those tools, such as patient portals and mobile applications. Many nurses believe these platforms can simplify patient education, foster better self-management, reduce the need for additional healthcare interventions, and minimize associated costs (Kahouei et al., 2021). Hence, nurses can meaningfully enhance patient safety and improve cost-effectiveness by taking an active role in coordinating care, with a specific focus on addressing inadequate patient education.

Nurses’ Coordination with Stakeholders

To successfully address the quality and safety issue, nurses must collaborate with several stakeholders, including patients and their families, other healthcare professionals, IT professionals, health educators, and quality assurance teams. Patients and their families are central stakeholders, so collaborating with them is crucial to understanding individual needs, preferences, and potential barriers (Cengiz & Korkmaz, 2023). This collaboration fosters a shared decision-making environment, involving patients in their healthcare to improve treatment adherence and reduce errors. Simultaneously, coordination with physicians, pharmacists, and other healthcare providers is essential. Interdisciplinary communication promotes a comprehensive understanding of the patient’s healthcare plan, reducing the risk of miscommunication and errors.

In establishing patient portals, nurses must coordinate with IT professionals to integrate technology into the education process. These tools can expand information accessibility, patient engagement, and the overall efficiency of educational interventions (Kahouei et al., 2021). Similarly, nurses must collaborate with health educators to develop educational material according to professional standards and policies. These educators contribute their knowledge in designing instructional material tailored to individual needs for easy comprehension. Lastly, the quality assurance team is essential to perform ongoing assessments of the patient education process, collect patient feedback, and improve the quality of services, ultimately enhancing patient safety and quality of healthcare.

Conclusion

In conclusion, inadequate patient education is a significant quality and safety healthcare concern, as evident in the case study where lack of patient education led to medication error, severe complications, and hospital readmission for a diabetic patient. Evidence-based best practices provide several solutions to address this challenge, including a patient-centered communication model, establishing a multidisciplinary team, and availability of personalized educational material through electronic portals. Nurses play a vital role in achieving these outcomes through care coordination with several stakeholders by developing individualized educational programs and advocating for technology integration within the organization. These approaches and coordinated care are essential to improve patient education within the organization, enhance patients’ adherence to care plans, minimize medication errors, and reduce healthcare costs, eventually improving patient safety and well-being.

References

Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7), e27336. https://doi.org/10.7759/cureus.27336

Cengiz, D., & Korkmaz, F. (2023). Effectiveness of a nurse‐led personalized patient engagement program to promote type 2 diabetes self‐management: A randomized controlled trial. Nursing & Health Sciences, nhs.13048. https://doi.org/10.1111/nhs.13048

Kahouei, M., Soleimani, M., Mirmohammadkhani, M., Doghozlou, S. N., & Valizadeh, Z. (2021). Nurses’ attitudes of a web patient portal prior to its implementation in home health care nursing. Health Policy and Technology, 10(3), 100524. https://doi.org/10.1016/j.hlpt.2021.100524

Capella 4020 Assessment 1

Schor, A., Bergovoy-Yellin, L., Landsberger, D., Kolobov, T., & Baron-Epel, O. (2019). Multidisciplinary work promotes preventive medicine and health education in primary care: A cross-sectional survey. Israel Journal of Health Policy Research, 8(1), 50. https://doi.org/10.1186/s13584-019-0318-4

Capella 4020 Assessment 1

Zhang, L., Luan, W., Geng, S., Ye, S., Wang, X., Qian, L., Ding, Y., Li, T., & Jiang, A. (2019). Lack of patient education is a risk factor of disease flare in patients with systemic lupus erythematosus in China. BMC Health Services Research, 19(1), 378. https://doi.org/10.1186/s12913-019-4206-y

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NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

William Adkins — Tue, 08 Oct 2024 13:19:27 +0000

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan Tool Kit

In patient safety, one of the critical challenges we face is the occurrence of medication errors within healthcare settings. Today, we will explore the essential aspect of ensuring patient safety and recovery by addressing this pressing issue. Medication errors demand evidence-based solutions like the global challenges. This assessment introduces a toolkit tailored for healthcare workers to alleviate the risks associated with medication errors and ultimately enhance patient safety. Leveraging reputable sources like PubMed, Google Scholar, CINAHL, and the Capella Online Library, this toolkit is built upon trustworthy data. The primary goal is to create an educational resource consisting of twelve annotated bibliographies tailored to the challenges of medication errors.

Nurses engaging with this toolkit will gain crucial insights into evidence-based strategies, fostering a safer healthcare environment and significantly contributing to improved patient well-being. The improvement plan toolkit offers a comprehensive approach based on four thematic areas to address medication errors and improve patient safety in healthcare settings. It focuses on best practices for mitigating risks in medication error, educational resources and guidelines to reduce medication errors, interprofessional collaboration and communication to reduce medication errors, and leveraging technology to enhance patient safety to reduce medication errors.

Best Practices for Mitigating Risks in Medication Error

Wianti, A., & Koswara, R. (2021). Description of the implementation of SBAR communication. Asian Community Health Nursing Research, 9. https://doi.org/10.29253/achnr.2021.3951

The study underscores the pivotal role of SBAR communication in mitigating medication errors during patient handovers at Community Health Centers (CHCs) with inpatient care. While identifying deficiencies in SBAR implementation, it acknowledges the framework’s significant potential to enhance patient safety through improved communication practices. SBAR communication offers a structured and standardized approach to information exchange, facilitating clear and concise communication between healthcare professionals during handovers. By adhering to the SBAR format—Situation, Background, Assessment, and Recommendation—nurses can systematically convey vital patient information, including medical history, current condition, and treatment plans. Moreover, the study recognizes SBAR communication as a valuable tool for promoting interdisciplinary collaboration and teamwork among healthcare teams.

By providing a common language and framework for communication, SBAR fosters effective collaboration between nurses, doctors, and other healthcare professionals, thereby reducing the likelihood of misunderstandings and communication errors. Furthermore, SBAR communication promotes thorough documentation practices, ensuring that essential patient data is accurately conveyed during handovers. This comprehensive approach to information exchange minimizes the risk of medication errors resulting from incomplete or inaccurate information.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Killin, L., Hezam, A., Anderson, K. K., & Welk, B. (2021). Advanced medication reconciliation: A systematic review of the impact on medication errors and adverse drug events associated with transitions of care. The Joint Commission Journal on Quality and Patient Safety, 47(7), 438–451. https://doi.org/10.1016/j.jcjq.2021.03.011

The article underscores several aspects regarding medication reconciliation interventions to reduce medication errors. Firstly, it highlights the potential of electronic medication reconciliation to positively impact medication errors and discrepancies, mainly when implemented with a low risk of bias. Studies with robust methodologies consistently demonstrated significant positive impacts, suggesting that electronic systems have the potential to enhance medication safety. Additionally, identifying successful patterns in intervention approaches provides valuable insights for optimizing medication reconciliation practices. Studies emphasizing provider-pharmacist collaboration showed promising results, indicating that effective teamwork can improve medication management and reduce errors.

Moreover, interventions that utilized gold standards for comparison tended to report positive outcomes, emphasizing the importance of robust evaluation methodologies in assessing intervention effectiveness. Furthermore, the article underscores the significance of standardizing outcome measures and intervention components to facilitate meaningful study comparisons. The article provides a foundation for advancing medication reconciliation interventions to mitigate risks associated with medication errors. By building on these positive points and addressing methodological challenges, healthcare professionals can work towards implementing evidence-based strategies to improve medication safety and patient outcomes.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Chiewchantanakit, D., Meakchai, A., Pituchaturont, N., Dilokthornsakul, P., & Dhippayom, T. (2020). The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis. Research in Social and Administrative Pharmacy, 16(7). https://doi.org/10.1016/j.sapharm.2019.10.004

The systematic review and meta-analysis aimed to evaluate the effect of medication reconciliation (MR) interventions on medication errors in Thailand. Medication errors, prevalent during care transitions, can lead to patient harm. MR, comparing a patient’s current medication list with records, aims to prevent errors like omission, duplication, and interactions. Patient safety organizations endorse MR to enhance medication safety. MR interventions significantly reduce medication errors. Meta-analysis showed a 75% reduction in errors among patients receiving MR compared to usual care, with substantial heterogeneity. Subgroup analyses by care transition revealed significant decreases, particularly in secondary care hospitals and ambulatory care settings.

The findings underscore MR’s importance in mitigating medication errors in Thai healthcare settings. Strategies to promote MR, especially in secondary care hospitals and for ambulatory patients, could significantly improve medication safety. Further research is needed to address study design limitations and explore MR’s impact on clinical outcomes. MR emerges as a crucial best practice for mitigating medication error risks, with implications for enhancing patient safety.

Educational Resources and Guidelines to Reduce Medication Error

Jaam, M., Naseralallah, L. M., Hussain, T. A., & Pawluk, S. A. (2021). Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis. PLOS ONE, 16(6), e0253588. https://doi.org/10.1371/journal.pone.0253588

The systematic review and meta-analysis examined pharmacist-led educational interventions designed to mitigate risks associated with medication errors among healthcare providers. The analysis encompassed 12 studies with varying intervention components, including didactic lectures, practical teaching sessions, posters, and individualized feedback mechanisms. These interventions targeted nurses and resident physicians, focusing on medication preparation, administration, and prescribing errors. The review highlighted the effectiveness of pharmacist-led educational interventions in reducing medication errors, with most studies reporting significant decreases in error rates post-intervention. Key findings indicated that interventions supplemented with printed handouts summarizing session content, posters addressing medication administration errors, and individualized reports to healthcare providers were particularly effective.

Furthermore, frequent educational sessions were observed to yield better outcomes compared to one-time sessions. Notably, the study identified areas for improvement in reporting quality, particularly in ethics considerations and sampling methodologies. Recommendations were made for future research to explore the impact of pharmacist-led educational interventions on other types of medication errors, such as transcribing and dispensing errors, as well as their effects on morbidity, mortality, and economic outcomes. Overall, the systematic review underscored the importance of pharmacist-led educational initiatives in enhancing medication safety practices among healthcare providers. Pharmacists can be crucial in reducing medication errors and improving patient outcomes by providing targeted education supplemented with practical tools and individualized feedback.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025

The article provides comprehensive insights into best practices for mitigating risks associated with medication errors, mainly through educational resources and guidelines. It stresses the importance of adhering to established protocols and policies, such as the “five rights” of medication administration, to ensure patient safety. Furthermore, it emphasizes the need for proper medication reconciliation procedures during patient transfers and read-back techniques to verify medication orders accurately. Moreover, the article highlights the significance of ongoing education and training for healthcare providers, especially nurses, who play a pivotal role in medication administration. It underscores the importance of nurses being familiar with institutional policies and guidelines and equipped with the knowledge and skills necessary to prevent medication errors.

Additionally, it advocates for creating structured protocols and standardized procedures to facilitate error reporting and improve patient safety. Overall, the article underscores the critical role of educational resources and guidelines in promoting best practices for medication error prevention. It calls for a collaborative effort among healthcare providers, institutions, and regulatory bodies to implement effective strategies and ensure patient safety in medication management.

Paccagnella, D., Isaac, R., Patel, B., & Vallabhaneni, P. (2022). Reducing medication errors through multi-disciplinary collaboration: A quality improvement initiative. Journal of Patient Safety & Quality Improvement, 10(3), 97–99. https://doi.org/10.22038/psj.2022.67108.1368

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

The article discusses a quality improvement initiative focused on reducing medication errors in pediatric care through a structured educational program and inter-professional collaboration. It highlights the prevalence of medication errors in pediatric settings and emphasizes the importance of addressing this issue due to its potential harm to patients. The study aimed to reduce medication errors by at least 10% through collaboration among nursing, medical, and pharmacology teams. This alliance facilitated the development and implementation of a structured educational program.

The program included mandatory online modules for medical trainees, competency packages for nursing staff, and daily multidisciplinary meetings led by the Pediatric Lead Pharmacist. These meetings provided opportunities for learning from errors in a supportive environment and emphasized safe prescribing and medication administration practices. The results showed a significant reduction in medication errors following the implementation of the educational program. The percentage of mistakes decreased from 89.3% to 12.1% after the first cycle and further reduced to 53.8% after the second cycle.

The findings suggest that inter-professional collaboration and structured education are crucial in mitigating medication errors in pediatric care settings. The discussion section acknowledges the educational program’s success in reducing medication errors and identifies areas for improvement. It recognizes the complexity of factors influencing medication errors, including individual prescriber/administrator characteristics and environmental variables. They emphasize the feasibility and cost-effectiveness of implementing similar targeted educational programs in a broader scale to enhance patient safety and quality improvement in pediatric care.

Interprofessional Collaboration and Communication to Reduce Medication Error

Alhur, A., Alhur, A. A., Rowais, D. A., Asiri, S., Muslim, H., Alotaibi, D., Rowais, B. A., Alotaibi, F., Hussayein, S. A., Alamri, A., Faya, B., Rashoud, W., Alshahrani, R., Alsumait, N., Alqhtani, H., Alhur, A., Alhur, A. A., Rowais, D. A., Sr, S. A. A., & Muslim, H. (2024). Enhancing patient safety through effective interprofessional communication: A focus on medication error prevention. Cureus, 16(4). https://doi.org/10.7759/cureus.57991

The article delves into the critical nexus between interprofessional collaboration, communication, and reducing medication errors within healthcare settings, focusing on Saudi Arabia. A noteworthy aspect of the study is its emphasis on the prevalence of medication errors and the pivotal role of effective communication in mitigating such errors. Prescription and dispensing errors are identified as everyday occurrences, underscoring the urgent need for improved communication channels, particularly between physicians and pharmacists. Technology-based solutions, such as advanced Electronic Health Records (EHR) systems, could streamline communication and reduce the likelihood of errors. However, caution is advised regarding over-dependence on technology.

Recommendations proposed in the article advocate for a multifaceted approach to enhance interprofessional communication and reduce medication errors. Comprehensive communication training programs, structured forums for collaboration, and the integration of communication tools within healthcare systems are among the proposed strategies. Additionally, fostering a culture of mutual respect and understanding and prioritizing effective communication at organizational and policy levels are essential for improving patient safety.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Wei, H., Corbett, R. W., Ray, J., & Wei, T. L. (2020). A culture of caring: the essence of healthcare interprofessional collaboration. Journal of Interprofessional Care, 34(3), 1–8. https://doi.org/10.1080/13561820.2019.1641476

The article extensively explores the critical role of interprofessional collaboration and communication in reducing medication errors within healthcare settings. It begins by highlighting the implementation of Team STEPPS training, which aims to enhance communication skills among healthcare professionals to improve patient safety and minimize medication errors. Effective communication and constructive feedback emerge as fundamental elements for delivering high-quality patient care, particularly in acute care settings like intensive care units, where medication errors can have severe consequences. Moreover, the article underscores the importance of a strengths-based practice in mitigating medication errors. By fostering an environment where team members feel valued and appreciated for their contributions, healthcare teams can ensure well-rounded patient care and minimize the occurrence of medication errors.

This mindset necessitates that all healthcare professionals take responsibility and are held accountable for preventing errors and promoting patient safety, especially in medication management. It underscores the collective responsibility of the entire team to safeguard patient well-being and reduce the likelihood of medication errors through vigilant monitoring and adherence to established protocols. A caring culture within healthcare teams is central to the discussion and a powerful mechanism for reducing medication errors. Building loving relationships, fostering an ownership mentality, providing constructive feedback, and embracing a strengths-based approach are vital in promoting such a culture. This caring culture is posited as a foundational element that facilitates effective interprofessional collaboration, thereby improving patient outcomes and reducing the incidence of medication errors.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Hapsari, M. K., Rivai, F., Thamrin, Y., Pasinringi, S. A., Irwandy, I., & Hamzah, H. A. (2022). Analysis of the implementation of effective communication on interprofessional collaboration in the inpatient installation of Hasanuddin university hospital. Journal of Asian Multicultural Research for Medical and Health Science Study, 3(1), 23–35. https://doi.org/10.47616/jamrmhss.v3i1.234

The article delves into the implementation of Interprofessional Collaboration (IPC) and its impact on communication, specifically focusing on reducing medication errors. It underscores the crucial role of effective communication among healthcare professionals in swiftly identifying, addressing, and mitigating medication-related issues within the hospital setting. Communication within the hospital is described as frequent and consistent, facilitated by routine procedures and communication tools such as CPPT (Clinical Pathway Patient Treatment). Professionals from various departments interact regularly, particularly concerning patient care needs and medication management. The article emphasizes the pivotal role of IPC in fostering collaborative relationships among healthcare professionals, ultimately leading to improved patient outcomes and reduced medication errors.

It highlights the importance of situational awareness in guiding effective communication and decision-making within interdisciplinary teams. Additionally, it underscores the significance of mutual respect, shared decision-making, and partnership in cultivating a collaborative work environment that reduces medication errors. Furthermore, the study discusses the critical role of leadership in driving the successful implementation of IPC, particularly in promoting a culture of collaboration and ensuring that all professionals receive adequate training and support. Effective leadership is essential for aligning organizational goals with IPC objectives and fostering a collaborative approach to patient care, aiming to reduce medication errors and enhance overall healthcare outcomes.

Leveraging Technology to Enhance Patient Safety to Reduce Medication Error

Abraham, J., Kitsiou, S., Meng, A., Burton, S., Vatani, H., & Kannampallil, T. (2020). Effects of CPOE-based medication ordering on outcomes: An overview of systematic reviews. BMJ Quality & Safety, 29(10), 1–2. https://doi.org/10.1136/bmjqs-2019-010436

The systematic review on integrating Computerized Provider Order Entry (CPOE) with Clinical Decision Support (CDS) systems to enhance patient safety and reduce medication errors provides a comprehensive analysis of the existing evidence. The findings suggest a consistent positive impact of CPOE systems on medication safety outcomes, particularly in reducing medication errors and adverse drug events (ADEs).

Analysis revealed a significant decrease in medication ordering errors with CPOE use, ranging from 54% to 92%. These findings underscore the critical role of CPOE systems in enhancing medication safety and reducing adverse events associated with medication use. Integrating CPOE with CDS promises to improve patient safety and reduce medication errors. However, further research is warranted to address existing limitations and build upon the current evidence base. Standardizing methodologies, conducting multi-center studies, and evaluating the effectiveness of CPOE systems in diverse healthcare settings are crucial steps toward optimizing medication safety and improving patient outcomes.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Ho, J., & Burger, D. (2020). Improving medication safety practice at a community hospital: A focus on bar code medication administration scanning and pain reassessment. BMJ Open Quality, 9(3), e000987. https://doi.org/10.1136/bmjoq-2020-000987

Integrating Barcoded Medication Administration (BCMA) systems has proven to be a pivotal strategy in enhancing patient safety and reducing medication errors. This approach utilizes barcoding technology to ensure that the correct medication is administered to the right patient at the appropriate time, thereby minimizing the risk of human error. To optimize the BCMA system, a series of Plan-Do-Study-Act (PDSA) cycles were implemented. Initially, baseline data on medication scanning compliance and pain reassessment documentation were established. Regular audits and feedback loops were then introduced to address non-compliance. Education sessions reinforced the importance of adhering to BCMA protocols. Further enhancements included the development of weekly compliance dashboards and a user non-compliance dashboard.

These tools provided real-time feedback to nursing staff and managers, highlighting areas needing improvement and recognizing high performers. A house-wide scanning competition also motivated staff to achieve higher compliance rates through positive reinforcement and recognition. Implementing these strategies led to significant improvements in medication scanning rates and pain reassessment compliance, demonstrating that continuous monitoring, feedback, and staff engagement are critical to sustaining high standards in patient safety practices. The project reduced medication errors and achieved substantial cost savings by preventing adverse drug events. Integrating BCMA systems, supported by structured PDSA cycles and performance monitoring, significantly enhances patient safety and reduces medication errors in healthcare settings.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Craswell, A., Bennett, K., Dalgliesh, B., Smith, B. M., Hanson, J., Flynn, T., & Wallis, M. (2020). The impact of automated medicine dispensing units on nursing workflow: A cross-sectional study. International Journal of Nursing Studies, 111, 103773. https://doi.org/10.1016/j.ijnurstu.2020.103773

The study evaluated the integration of automated medication dispensing units to enhance patient safety and reduce medication errors in a hospital setting. Most staff, including nurses and pharmacy assistants, were satisfied with the automated dispensing cabinets. However, concerns were raised regarding their impact on workflow, particularly medication access. Nurses from general wards generally reported more positive responses than those from specialty areas such as intensive care units and emergency departments. These differences in perception highlight the importance of considering the specific needs of different clinical areas when implementing such systems. Observational data revealed that the automated dispensing cabinets were widely utilized across various clinical areas, with the highest frequency of transactions observed in the inpatient medical ward. However, there were disparities in transaction times and queueing between different clinical areas, with nurses often experiencing delays in accessing medications.

This resulted in increased walking distances and interruptions, impacting workflow efficiency. While the automated dispensing cabinets offered benefits such as improved organization of medications and practical management of controlled drugs, there were also challenges, particularly regarding access delays and lack of integration with the clinical information system. These challenges underscore the importance of considering workflow management solutions and ensuring adequate staff training before implementation. The study highlights the importance of tailoring the deployment of automated dispensing cabinets to the specific needs of different clinical areas. For example, the hospital’s layout and the distribution of patient clusters should be considered to minimize nurses’ walking distances. Additionally, efforts should be made to address concerns raised by staff in specialty areas and improve system integration with existing workflows.

References

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Wei, H., Corbett, R. W., Ray, J., & Wei, T. L. (2020). A culture of caring: The essence of healthcare interprofessional collaboration. Journal of Interprofessional Care, 34(3), 1–8. https://doi.org/10.1080/13561820.2019.1641476

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Wianti, A., & Koswara, R. (2021). Description of the implementation of SBAR communication. Asian Community Health Nursing Research, 9. https://doi.org/10.29253/achnr.2021.3951

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NURS FPX 4020 Assessment 3 Improvement Plan in Service Presentation

William Adkins — Tue, 08 Oct 2024 13:14:05 +0000

NURS FPX 4020 Assessment 3 Improvement Plan in Service Presentation

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan In-Service

Welcome, everyone. Today, we focus on a critical aspect of our healthcare delivery: addressing medication errors at Massachusetts General Hospital (MGH). Our objective is to reduce errors and cultivate a culture of safety and continuous improvement throughout our institution. We must recognize the urgency of this issue, backed by data indicating the prevalence and impact of medication errors, especially during night shifts and care transitions. By implementing evidence-based strategies such as Computerized Physician Order Entry (CPOE) with Clinical Decision Support (CDS) and Barcode Medication Administration (BCMA) systems, along with standardized communication protocols like SBAR (Situation-Background-Assessment-Recommendation), we can significantly enhance patient safety. Moreover, emphasizing the role of interdisciplinary collaboration and the importance of meticulous practices among healthcare professionals underscores our commitment to preventing medication errors and ensuring the highest standards of care for all patients at MGH.

Agenda and Outcomes

Agenda

Introduce session purpose and goals.
Present data on the prevalence and impact of medication errors at MGH.
Discuss root causes of medication errors, including fatigue, communication breakdowns, and environmental factors.
Explain the implementation and benefits of CPOE with CDS.
Discuss BCMA systems and electronic verification.
Highlight standardized communication protocols like SBAR.
Emphasize the role of nurses in medication reconciliation and administration.
Share testimonials on the importance of interdisciplinary collaboration.
Develop action plans for integrating safety measures.
Q&A session.
Distribute resources such as handouts and guidelines.
Summarize key takeaways and encourage continuous improvement.

Expected Outcomes

Participants will understand the root causes and impact of medication errors at MGH.
Knowledge of practical, evidence-based strategies like CPOE with CDS and BCMA systems to enhance medication safety.
Recognition of the importance of meticulous practices and collaboration among healthcare professionals in preventing medication errors.
Development of actionable plans for implementing safety improvements in daily work.
A renewed commitment to patient safety and continuous learning.
Active contribution to reducing medication errors at MGH.
Enhanced ability to measure the success of implemented strategies through predefined metrics, such as reducing medication error rates by a specific percentage within six months.
Participants can conduct mini-workshops or training sessions within their units to spread the knowledge gained, fostering a hospital-wide safety culture.
Creation of a follow-up plan to monitor progress and ensure that new practices are adhered to, including regular feedback sessions and audits.

Purpose and Goals

The primary purpose of this in-service session is to address the critical patient safety issue of medication errors at MGH. Medication errors, often stemming from human fatigue, communication breakdowns, and chaotic work environments, pose significant risks to patient safety. This session aims to educate healthcare professionals on these underlying causes and provide them with practical, evidence-based strategies to mitigate these risks. The specific goals are to Increase Awareness and enhance participants’ understanding of the prevalence and impact of medication errors at MGH. Data indicates that medication errors are more likely during night shifts, and poor communication accounts for 80% of primary medical errors during care transitions (Schroers et al., 2020).

Educate on Best Practices provides comprehensive knowledge about proven interventions such as Computerized Physician Order Entry (CPOE) with Clinical Decision Support (CDS), Barcode Medication Administration (BCMA) systems, and standardized hand-off communication protocols like SBAR (Hong et al., 2020). Promote Interdisciplinary Collaboration to foster a culture of teamwork among nurses, physicians, pharmacists, and IT specialists to improve medication safety. Studies show that collaborative approaches can reduce errors. Encourage Continuous Improvement to inspire a commitment to ongoing education and quality improvement initiatives to sustain medication safety efforts (Ali et al., 2023). This in-service session aims to significantly enhance patient safety and care quality at MGH by addressing medication errors through a comprehensive, evidence-based approach. It will equip healthcare professionals with the knowledge and tools to prevent medication errors and ensure a safer hospital environment.

Our Safety Improvement Plan

The Need and Process to Improve Safety Outcomes

Addressing the pressing issue of medication errors within MGH is imperative. Incident reports reveal a concerning pattern of errors occurring during patient hand-offs and medication administration, exacerbated by communication breakdowns, healthcare provider fatigue, and chaotic work environments. Specifically, medication order and administration discrepancies stand out as significant contributors to adverse events. We advocate for a comprehensive safety improvement plan to combat this issue effectively. This plan aims to bolster communication channels, streamline medication processes, and foster interdisciplinary collaboration by implementing evidence-based strategies and best practices.

Importance of Addressing the Current Situation

The urgency of addressing medication errors must be addressed. Beyond the ethical imperative of safeguarding patient well-being, pragmatic considerations are at play. Medication errors entail increased healthcare costs, expose the institution to potential legal liabilities, and erode trust in our healthcare delivery system. The Joint Commission exemplifies that regulatory bodies mandate stringent measures to prevent medication errors (Chernyak & Posten, 2022). Failing to address these concerns jeopardizes patient safety and undermines MGH’s standing as a paragon of excellence in healthcare provision.

Process to Improve Safety Outcomes

In the plan, adopting standardized hand-off communication protocols, such as the SBAR technique, ensures accurate transmission of vital information during care transitions, thereby reducing errors. Recent research from Chernyak & Posten (2022) highlights that institutions implementing standardized hand-off protocols experience a 23% reduction in medication errors, emphasizing the effectiveness of such measures. Technology integration is pivotal in enhancing medication safety. Implementing CPOE with CDS enhances medication ordering accuracy and provides real-time alerts for potential issues. Studies by Hong et al. (2020) consistently show substantial reductions in errors with the adoption of CPOE, with error rates decreasing by up to 55%. Integration of BCMA systems enables electronic verification of medications before administration, reducing the likelihood of errors. Research by Hong et al. (2020) indicates that hospitals implementing BCMA systems experience a 50% reduction in medication administration errors.

Incorporating Automated Medication Dispensing Systems (AMDS) streamlines medication management processes and minimizes errors related to manual entry or transcription mistakes. A study by Craswell et al. (2021) found that institutions with AMDS in place reported a 30% reduction in medication errors, emphasizing the efficacy of automation in enhancing safety outcomes. Fostering collaboration among healthcare professionals through dedicated medication safety committees harnesses collective expertise to identify systemic issues and implement targeted interventions proactively. A study by Kozel (2020) highlights the importance of interdisciplinary collaboration in reducing medication errors, with collaborative efforts leading to a 40% decrease in adverse drug events in a recent study.

Role and Importance of Audience

In our endeavor to address medication errors at MGH, the involvement of our staff audience is paramount. Their active participation and commitment are essential for the success of our safety improvement plan. The staff, including nurses, physicians, pharmacists, and other healthcare professionals, will be pivotal in implementing the improvement plan. They will be expected to adhere to standardized communication protocols, utilize technology solutions such as CPOE with CDS, BCMA systems, and Automated Medication Dispensing Systems (AMDS), and actively engage in interdisciplinary collaboration through medication safety committees (Ogundipe et al., 2022). The criticality of staff involvement must be balanced, particularly concerning patient safety issues related to medication errors. As frontline caregivers responsible for medication administration and patient hand-offs, nurses have a unique opportunity to impact patient safety outcomes directly. Their adherence to protocols and keen attention to detail are indispensable in preventing errors and ensuring safe care delivery.

Similarly, physicians and pharmacists are responsible for error prevention and patient safety in prescribing, verifying, and reconciling medications (Mohamed et al., 2021). Embracing their role in the plan can bring tangible benefits to staff members and patients. By following standardized protocols and leveraging technology solutions, staff can streamline workflows, reduce administrative burdens, and ultimately enhance patient safety outcomes. Moreover, active participation in interdisciplinary collaboration fosters a culture of teamwork, mutual support, and continuous improvement, thereby creating a more cohesive and efficient healthcare environment (Sherman et al., 2020).

New Processes and Skills

Comprehensive Training on New Processes and Skills

Our staff will undergo immersive training sessions focused on vital processes such as standardized hand-off communication (utilizing the SBAR technique), medication reconciliation protocols, and the utilization of advanced technologies like CPOE with CDS and BCMA systems (Hong et al., 2020). These sessions will highlight the critical role of these processes in preventing medication errors and emphasize the importance of clear communication, thorough medication review, and effective technology utilization for ensuring patient safety.

Engaging Practice Activities and Inquiry Opportunities

Through interactive simulation exercises, our staff will engage in real-world scenarios reflective of clinical settings, allowing them to apply newly acquired skills in a simulated yet realistic environment. Role-playing scenarios will simulate various clinical roles, enabling staff to refine communication, medication verification, and documentation skills. Dynamic workshops and interactive Q&A sessions will allow staff to ask questions, exchange insights, and address uncertainties regarding the new processes and skills (McEwan, 2021). These sessions will harness collective expertise to enhance skill development and process understanding by fostering open dialogue and collaborative problem-solving.

Preemptive Addressing of Likely Concerns

In our training materials’ notes section, we will proactively address potential questions and concerns that staff may have. Anticipated queries may include inquiries about integrating new technology into existing workflows, navigating medication reconciliation protocols, and overcoming communication challenges during hand-offs. Providing comprehensive responses supported by evidence-based practices, organizational directives, and practical examples will alleviate staff concerns, boost their confidence, and cultivate a culture of proactive engagement and continuous improvement (Paiva et al., 2023).

Developed Activity for Staff Engagement

Additionally, we will create interactive workshops where staff can actively practice newly acquired skills and engage in hands-on activities related to medication reconciliation, medication administration using BCMA systems, and effective communication strategies during hand-offs (Marshall et al., 2024). These workshops will provide a safe space for staff to apply their knowledge, seek clarification, and receive feedback from peers and facilitators, fostering a culture of continuous learning and improvement. By deploying these dynamic resources and immersive activities, we are poised to equip our staff with the knowledge, skills, and confidence necessary to navigate the complexities of safety improvement initiatives effectively. By promoting hands-on practice, fostering dialogue, and encouraging a culture of inquiry, we will drive meaningful progress toward sustained excellence in patient care (Marshall et al., 2024).

Soliciting Your Feedback

Soliciting feedback is paramount to refining our patient safety improvement initiatives, ensuring they resonate with our staff and align with organizational goals. Leveraging the insights gained from recent sessions on medication errors at MGH, we will deploy a multifaceted approach to gather and integrate feedback seamlessly. Dynamic feedback sessions will foster a culture of engagement and collaboration, allowing staff to share thoughts, questions, and suggestions openly, enriching our understanding of the improvement plan’s impact (Green et al., 2020). Additionally, offering individualized discussions between staff and designated facilitators will provide a platform for more personalized feedback, encouraging individuals to express opinions candidly.

Harnessing the power of MGH’s intranet and dedicated online forums will democratize feedback collection, ensuring inclusivity and accessibility through the utilization of digital platforms (Ascione et al., 2021). Integration of Feedback for Future Advancements involves transparent communication of feedback-driven changes and their rationale to all staff members, fostering a sense of ownership and collective responsibility and galvanizing staff commitment to ongoing improvement efforts. Through meticulous feedback mechanisms and integration strategies, we establish a robust feedback loop driving continuous improvement in patient safety initiatives at MGH. Embracing feedback as a catalyst for positive change elevates our standards of care and fortifies our commitment to excellence (Zajac et al., 2021).

Conclusion

Our session has successfully addressed the pressing issue of medication errors at MGH. By providing comprehensive insights into their prevalence, root causes, and effective mitigation strategies. By emphasizing the importance of interdisciplinary collaboration, implementing evidence-based interventions like CPOE with CDS and BCMA systems, and promoting standardized communication protocols, we are poised to enhance patient safety and care quality significantly. With a renewed commitment to continuous improvement and a clear action plan, we are well-positioned to reduce medication errors, foster a safety culture, and ensure better outcomes for all our patients at Massachusetts General Hospital.

References

Ali, F., Abdullah, M. A., Ahmed, A., Alzaqli, A., Rashed, N., Alzaqli, A. A., Musaad, O., Dossray, A., Omran, K., Alsaad, K., Mubarak, R., Alghobari, M., Hussin, A., Masham, A., Mohammed, A., Htealh, M. A., Mane, A., Ageel, A. A., Rashid, S., & Saeeda, S. A. (2023). Saudi Arabia 4 radiological technology, wadi aldwaser hospital, wadi aldwaser, Saudi Arabia 5 sociology specialist, maternity and children hospital, najran, Saudi Arabia 6 nurse technician, maternity and children hospital, najran, Saudi Arabia 7 physical therapy technician. Medical Rehabilitation Administration. https://doi.org/10.36348/sjmps.2023.v09i12.001

Ascione, R. (2021). The future of health: How digital technology will make care accessible, sustainable, and human. In Google Books. John Wiley & Sons. https://books.google.com.pk/books?hl=en&lr=&id=YZRFEAAAQBAJ&oi=fnd&pg=PR1&dq=to+reduce+medication+error+dedicated+online+forums+will+democratize+feedback+collection

Chernyak, M., & Posten, C. (2022). Quality of care improvement: A process to standardize handoff communication between anesthesia providers and post-anesthesia care unit nurses. DNP Scholarly Projects. https://digitalcommons.lasalle.edu/dnp_scholarly_projects/2/

Craswell, A., Bennett, K., Hanson, J., Dalgliesh, B., & Wallis, M. (2021). Implementation of distributed automated medication dispensing units in a new hospital: Nursing and pharmacy experience. Journal of Clinical Nursing, 30(19-20). https://doi.org/10.1111/jocn.15793

Green, S., Markaki, A., Baird, J., Murray, P., & Edwards, R. (2020). Addressing healthcare professional burnout: A quality improvement intervention. Worldviews on Evidence-Based Nursing, 17(3), 213–220. https://doi.org/10.1111/wvn.12450

Hong, J. Y., Ivory, C. H., VanHouten, C. B., Simpson, C. L., & Novak, L. L. (2020). Disappearing expertise in clinical automation: Barcode medication administration and nurse autonomy. Journal of the American Medical Informatics Association, 28(2). https://doi.org/10.1093/jamia/ocaa135

Marshall, J., Supervised, W., Hoi, J., Wong, K., & Malinen, S. (2024). Healthcare technology adoption: A social-organisational perspective. https://ir.canterbury.ac.nz/bitstreams/a5d51a58-eff7-4e30-ad62-f530fdb6a768/download

NURS FPX 4020 Assessment 3 Improvement Plan in Service Presentation

McEwan, K. (2021). Improving the nurse patient assignment process on a medical surgical unit. Doctor of Nursing Practice. https://scholarworks.boisestate.edu/dnp/34/

Mohamed, A., Adawy, F. E., Mahfouz, L., Elshamy, A., Ibrahim, M., Youssef, H., & Abdelmotaleb, A. (2021). Medications errors prevention and its role in patient safety management. Medicine Updates, 0(0). https://doi.org/10.21608/muj.2021.101396.1076

Ogundipe, A., Sim, T. F., & Emmerton, L. (2022). Health information communication technology evaluation frameworks for pharmacist prescribing: A systematic scoping review. Research in Social and Administrative Pharmacy. https://doi.org/10.1016/j.sapharm.2022.09.010

Paiva, S. G., Lobão, M. J., Simões, D. G., Fernandes, J., Donato, H., Carrillo, I., Mira, J. J., & Sousa, P. (2023). Key factors for effective implementation of healthcare workers support interventions after patient safety incidents in health organisations: A scoping review. BMJ Open, 13(12), e078118–e078118. https://doi.org/10.1136/bmjopen-2023-078118

Schroers, G., Ross, J. G., & Moriarty, H. (2020). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

Sherman, D. W., Flowers, M., Alfano, A. R., Alfonso, F., Santos, M. D. L., Evans, H., Gonzalez, A., Hannan, J., Harris, N., Munecas, T., Rodriguez, A., Simon, S., & Walsh, S. (2020). An integrative review of interprofessional collaboration in health care: Building the case for university support and resources and faculty engagement. Healthcare, 8(4), 418. https://doi.org/10.3390/healthcare8040418

NURS FPX 4020 Assessment 3 Improvement Plan in Service Presentation

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: A team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6(1). https://doi.org/10.3389/fcomm.2021.606445

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NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

William Adkins — Tue, 08 Oct 2024 13:09:33 +0000

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Root-Cause Analysis and Safety Improvement Plan

The recent medication error incident at Massachusetts General Hospital (MGH) highlights critical patient safety concerns stemming from communication breakdowns, fatigue among healthcare professionals, and environmental factors. The misadministration underscores the need for robust strategies to prevent such errors. Root cause analysis identifies extended work hours, inadequate hand-off communication, and frequent interruptions as crucial contributors to medication errors. Implementing evidence-based solutions such as Computerized Physician Order Entry (CPOE) systems, Barcode Medication Administration (BCMA) technology, and standardized communication protocols are essential to enhancing medication safety and preventing future errors at MGH.

Analysis of the Root Cause

A recent incident at MGH involved a nurse administering the wrong medication dosage to a patient due to a miscommunication during a shift change. The patient was scheduled to receive 5 mg of a drug, but the nurse administered 50 mg, resulting in adverse effects. The nurse was working an extended shift and was on duty for over 12 hours, leading to fatigue and impaired judgment. Furthermore, the outgoing nurse did not effectively communicate the correct dosage during the hand-off, and the incoming nurse did not verify the medication order against the patient’s records. This error occurred during a peak hour with frequent interruptions from other staff and patient alarms, leading to a lapse in concentration.

Medication errors are a critical patient safety issue in healthcare settings. At MGH, this recent incident necessitated a thorough root cause analysis to identify and address the underlying factors contributing to these errors. This analysis will examine human factors, communication breakdowns, and environmental factors that contribute to medication errors, focusing on the role of nurses and other healthcare professionals. Extended work hours, especially night shifts, contribute to fatigue among nurses, impairing their clinical performance. High patient loads and demanding work environments exacerbate stress and burnout, impacting concentration and increasing the likelihood of errors (Caruso et al., 2022). Inadequate communication during shift changes and patient transfers is a significant contributor to medication errors. Poor communication during hand-offs occurs frequently, leading to errors in medication administration (Chernyak & Posten, 2022). Busy healthcare environments with frequent interruptions pose significant risks to medication safety. Nurses are interrupted frequently while administering medications, leading to distractions and an increased likelihood of errors (Alshammari et al., 2022).

Several evidence-based solutions can be implemented to address the root causes of medication errors at MGH. Integrating a CPOE system with Clinical Decision Support (CDS) can minimize transcription errors and provide real-time alerts for potential medication issues (Karajizadeh et al., 2021). Establishing robust medication reconciliation protocols during all care transitions can ensure accuracy and reduce discrepancies. Adopting BCMA systems can electronically verify medications before administration, reducing the likelihood of errors (Wetzel, 2022). Enhancing education and training is also crucial. Conducting regular training sessions on safe medication practices, effective communication during hand-offs, and promoting a culture of continuous learning through ongoing education and refresher courses can improve adherence to best practices. Creating a safer work environment by implementing “no interruption” zones or periods during critical tasks and reevaluating staffing levels and shift patterns to reduce fatigue and ensure adequate rest for healthcare professionals are also essential (Alshammari et al., 2022).

Application of Evidence-Based Strategies

MGH recognizes the critical importance of addressing medication errors to ensure patient safety. To effectively tackle this issue, MGH will implement evidence-based strategies focusing on leveraging technology and enhancing decision support systems. Integrating CPOE with CDS technology streamlines medication ordering processes, minimizing transcription errors and ensuring accurate prescription orders. Real-time alerts for potential issues such as drug interactions or incorrect dosages empower healthcare providers to make informed decisions, preventing errors before they occur. This strategy enhances accuracy and efficiency in medication ordering, verification, and administration, thereby reducing the risk of errors related to incorrect prescriptions or dosages (Karajizadeh et al., 2021).

Adopting BCMA systems enhances medication safety by electronically verifying medications before administration. Nurses scan barcodes to confirm patient identity, medication, dosage, and route, reducing the likelihood of errors such as administering the wrong medication or dosage. BCMA systems provide real-time error prevention by ensuring medication is administered to the right patient at the right time (Wetzel, 2022). Investing in automated medication dispensing systems equipped with advanced error prevention features reduces the risk of errors caused by manual entry or transcription mistakes. Barcode scanning technology and electronic medication administration records ensure accurate medication dispensing and administration. This strategy streamlines medication management processes, reducing the likelihood of errors caused by manual entry or transcription mistakes (Craswell et al., 2021).

Integrating point-of-care decision support tools into the electronic health record system provides real-time guidance to healthcare providers during medication-related tasks. Evidence-based recommendations, alerts for potential drug interactions or contraindications, and dosing calculators ensure safe and appropriate medication prescribing and administration. This strategy enhances accuracy and efficiency in medication prescribing and administration, ultimately improving patient outcomes (Nanji et al., 2021).

Improvement Plan with Evidence-Based and Best-Practice Strategies

Medication errors remain a pressing concern at MGH, necessitating a comprehensive safety improvement plan. The plan will address various contributing factors, including communication breakdowns, fatigue among healthcare professionals, and technological deficiencies, with evidence-based strategies tailored to enhance medication safety and reduce errors. Implementing standardized communication protocols during patient hand-offs and transitions is foundational to improving information exchange among healthcare providers.

By adopting protocols like the SBAR technique, MGH aims to enhance accuracy and efficiency in information transfer, thereby reducing errors associated with communication breakdowns. Research by Chernyak & Posten (2022) underscores the effectiveness of standardized protocols in minimizing errors during transitions. Furthermore, integrating Automated Medication Dispensing Systems (AMDS) will streamline medication management processes and reduce the risk of errors caused by manual entry or transcription mistakes. AMDS has advanced error prevention features, such as barcode scanning technology and electronic medication administration records, which ensure accurate medication dispensing and administration (Craswell et al., 2021).

Integrating technology solutions such as CPOE with CDS and BCMA systems enhances medication safety. These systems’ real-time alerts and streamlined workflows have significantly reduced errors (Qureshi et al., 2021). By leveraging technology, MGH can enhance accuracy and efficiency in medication administration. Additionally, fostering interdisciplinary collaboration through medication safety committees will enable continuous review of incidents and collaborative interventions. By bringing together nurses, physicians, pharmacists, and quality improvement specialists, MGH can effectively address medication errors and enhance patient safety. Through regular review and collective problem-solving, the committees will drive continuous improvement in medication safety practices (Kozel, 2020). This comprehensive plan underscores MGH’s commitment to providing high-quality, safe patient care.

Existing Organizational Resources

Identifying existing organizational resources at MGH to enhance the patient safety improvement plan addressing medication errors is crucial for effective implementation. Several resources within the organization can be leveraged and prioritized based on their potential impact. MGH can harness the expertise of its clinical staff, including nurses, physicians, and pharmacists. Their frontline experience and knowledge of medication management practices make them invaluable contributors to refining protocols and processes to prevent errors. MGH can benefit from their insights and enhance medication safety practices by engaging them in the improvement plan (Wang & Manskow, 2024). MGH’s health information technology (IT) infrastructure, including the existing CPOE system, CDS tools, and BCMA systems, presents a significant resource. Optimizing these systems to ensure they are user-friendly and seamlessly integrated into clinical workflows can enhance medication management efficiency and accuracy. Real-time alerts and decision support these systems provide can further reduce errors (Heikkinen, 2022).

MGH likely has established quality improvement (QI) teams focused on identifying areas for improvement in patient care and safety. These teams are equipped with expertise in data analysis and performance improvement methodologies. By engaging QI teams in the improvement plan, MGH can effectively analyze medication error trends and implement targeted interventions to address them (Kozel, 2020). Furthermore, MGH’s education and training resources can be leveraged to provide targeted training on medication safety practices. Incorporating medication safety modules into existing training programs and offering regular educational sessions on best practices can ensure that staff remain informed and proficient in medication safety protocols (Alshammari et al., 2022).

Existing interdisciplinary collaboration platforms at MGH, such as regular team meetings or committees, provide opportunities for healthcare professionals from different disciplines to collaborate on patient safety initiatives. By leveraging these channels, MGH can foster teamwork and communication among staff involved in medication management, facilitating the implementation of the improvement plan (Kozel, 2020). By identifying and prioritizing these existing organizational resources, MGH can enhance the effectiveness of its patient safety improvement plan targeting medication errors. Leveraging the expertise of clinical staff, optimizing health IT infrastructure, engaging QI teams, utilizing education and training resources, and fostering interdisciplinary collaboration will collectively contribute to improving medication safety and enhancing patient care at MGH.

Conclusion

Addressing medication errors requires a multifaceted approach that addresses human factors, communication breakdowns, and environmental challenges. MGH is committed to implementing evidence-based strategies such as integrating technology solutions like CPOE with CDS and BCMA systems, establishing standardized communication protocols, and fostering interdisciplinary collaboration. By leveraging existing organizational resources, optimizing health IT infrastructure, and prioritizing continuous education and training, MGH aims to enhance medication safety practices and ensure high-quality, safe patient care. This comprehensive approach reflects MGH’s dedication to mitigating medication errors and promoting a patient safety culture.

References

Alshammari, W. A., Alharbi, S. A., Aldhafeeri, A. M., Aldhafeeri, M. O., Alharbi, S. A., & Aldhafeeri, W. O. (2022). Medication administration time study (MATS): Health professionals performance of medication administration. Chelonian Research Foundation, 17(2), 1522–1530. http://www.acgpublishing.com/index.php/CCB/article/view/472

Caruso, C. C., Arbour, M. W., Berger, A. M., Hittle, B. M., Tucker, S., Patrician, P. A., Trinkoff, A. M., Rogers, A. E., Barger, L. K., Edmonson, J. C., Landrigan, C. P., Redeker, N. S., & Chasens, E. R. (2022). Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector. American Journal of Industrial Medicine. https://doi.org/10.1002/ajim.23363

Heikkinen, I. (2022). Barcode medication administration and patient safety: A narrative literature review. Www.theseus.fi. https://www.theseus.fi/handle/10024/745259

Karajizadeh, M., Zand, F., Vazin, A., Nasiri, M., & Sharifian, R. (2021). Identification and prioritization of clinical decision support functionalities built within a computerized provider order entry system. Health Scope, 10(1). https://doi.org/10.5812/jhealthscope.104607

Kozel, V. (2020). Reducing medication errors through addition of a pharmacist and standardized communication to interdisciplinary team rounding: A quality improvement project. Sigma.nursingrepository.org. https://sigma.nursingrepository.org/handle/10755/20590

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Nanji, K. C., Garabedian, P. M., Shaikh, S. D., Langlieb, M. E., Boxwala, A., Gordon, W. J., & Bates, D. W. (2021). Development of a perioperative medication-related clinical decision support tool to prevent medication errors: An analysis of user feedback. Applied Clinical Informatics, 12(05), 984–995. https://doi.org/10.1055/s-0041-1736339

Qureshi, I., Baig, M. T., Shahid, U., Arif, J. M., Jabeen, A., Pirzada, Q. A., Mirza, A. S., Huma, A., & Toor, M. N. (2021). Computerized physician order entry system: A review on reduction of medication errors. Journal of Pharmaceutical Research International, 27–33. https://doi.org/10.9734/jpri/2020/v32i3931021

Wang, B., & Manskow, U. S. (2024). Health professionals’ experience and perceived obstacles with managing patients’ medication information in Norway: cross-sectional survey. BMC Health Services Research, 24(1). https://doi.org/10.1186/s12913-023-10485-9

Wetzel, H. E. G. (2022). Barcode medication administration software technology use in the emergency department and medication error rates. CIN: Computers, Informatics, Nursing, 40(6). https://doi.org/10.1097/cin.0000000000000846

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NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

William Adkins — Tue, 08 Oct 2024 11:49:12 +0000

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Enhancing Quality and Safety

Medication errors in Massachusetts General Hospital (MGH) stem from various factors, including human elements like fatigue among healthcare professionals and communication breakdowns during hand-offs. Additionally, chaotic work environments with frequent interruptions pose significant challenges to medication safety. However, evidence-based solutions such as implementing Computerized Physician Order Entry (CPOE) with Clinical Decision Support (CDS), medication reconciliation processes, Barcode Medication Administration (BCMA) systems, and comprehensive education and training programs for healthcare professionals have demonstrated effectiveness in reducing these risks. Nurses, pivotal care coordinators, are instrumental in implementing these solutions and collaborating with stakeholders such as physicians, pharmacists, and health information technology specialists to enhance patient safety through streamlined medication management protocols and interdisciplinary teamwork.

Factors Leading to a Patient-Safety Risk

Medication errors pose a noteworthy patient safety risk in MGH. These errors occur at different stages of the medication use process. Below, each factor leading to medication errors is discussed along with relevant data, evidence, and standards.

Human Factors

Fatigue among healthcare professionals, particularly nurses and doctors, significantly contributes to medication errors. Extended work hours, especially night shifts, exacerbate this issue. Data indicates that the rate of medication errors is 3.5 times higher during the night shift compared to the day shift. Research found that extended shifts of more than 12 hours are associated with a substantial increase in errors, highlighting the detrimental impact of fatigue on clinical performance. To address this, the Accreditation Council for Graduate Medical Education (ACGME) has established standards limiting resident work hours to 80 hours per week, aiming to reduce fatigue-related errors and improve patient safety (Caruso et al., 2022).

Communication Breakdowns: Hand-off Errors

Inadequate communication between shifts or departments during patient hand-offs is a critical factor leading to medication errors. According to The Joint Commission, poor communication occurs during care transitions in 80% of primary medical errors. Implementing standardized hand-off protocols can reduce errors by 23%. To mitigate this risk, the Joint Commission mandates using a consistent approach to hand-off communications like the SBAR (Situation-Background-Assessment-Recommendation) technique. This ensures that vital information is accurately conveyed during transitions, enhancing patient safety (Chernyak & Posten, 2022).

Environmental Factors

Busy and chaotic healthcare environments with frequent interruptions pose a significant risk to medication safety. A study found that nurses are interrupted up to 11 times per hour while administering medications. These disruptions are linked to a rise in clinical errors of 12.1% and a rise in procedural failures of 12.7%. To address this issue, the Institute for Safe Medication Practices (ISMP) recommends creating “no interruption” zones or periods to minimize distractions during critical tasks. Implementing such measures helps maintain focus and reduces the likelihood of errors, thereby improving patient safety (Alshammari et al., 2022).

Evidence-Based and Best Practice Solutions

Medication errors are a major concern in MGH, affecting risks to increasing costs and patient safety. Addressing this requires implementing evidence-based and best-practice solutions. Below are effective strategies to improve safety and reduce costs by mitigating medication errors. Implementing CPOE with CDS significantly reduces medication errors. CPOE minimizes transcription errors, while CDS provides real-time alerts for potential issues. Meta-analyses consistently show substantial reductions in errors with CPOE. Leadership support and adequate resources are crucial for implementation. Multidisciplinary collaboration ensures effective integration into workflows. Continuous monitoring and evaluation identify areas for improvement (Qureshi et al., 2021). Medication Reconciliation ensures that reviewing medication lists at care transitions ensures accuracy and reduces discrepancies, significantly decreasing errors and improving safety. Strong leadership establishes reconciliation as standard practice. Multidisciplinary collaboration ensures effective communication and coordination. Continuous evaluation enhances accuracy and adherence (Konrad, 2020).

BCMA systems ensure correct medication administration by allowing electronic verification. Studies show a substantial decrease in errors with BCMA adoption. Leadership support is critical for overcoming implementation challenges. Collaboration among IT specialists, nurses, and pharmacists ensures successful integration. Continuous evaluation and staff training ensure sustained accuracy and efficiency (Heikkinen, 2022). Education and Training Programs for healthcare professionals on safe medication practices significantly decrease errors and increase staff confidence. Continuous education ensures adherence to best practices. Studies demonstrate effectiveness in reducing errors and improving safety protocols. Leadership support is essential for resource allocation and promoting a culture of continuous learning. Multidisciplinary collaboration ensures programs meet specific needs. Continuous evaluation enables refinement to meet evolving safety needs (Ciapponi et al., 2021). Implementing these evidence-based solutions and best practices can significantly improve patient safety, reduce medication errors, and lower costs in MGH.

Nurses’ Role in Coordinating Care

Nurses are essential in coordinating care to reduce costs and increase patient safety, especially concerning medication errors in MGH. One way nurses contribute is through medication reconciliation. Nurses meticulously review medication lists during transitions to ensure accuracy, preventing discrepancies and errors. For instance, nurses compare medications with records during admission, addressing discrepancies and ensuring alignment with patient history, minimizing errors, and reducing expenses (Konrad, 2020). Additionally, nurses are crucial in medication administration, following protocols to ensure accuracy. Through BCMA, nurses verify medications electronically before administration, reducing errors such as wrong dosage or medication. When using BCMA, nurses scan barcodes to confirm patient, medication, dosage, and route, enhancing safety and minimizing complications, optimizing resource utilization (Heikkinen, 2022). Nurses facilitate interdisciplinary collaboration, serving as effective communicators and advocates for safety. They communicate with team members to relay critical information, discuss concerns, and implement coordinated care plans. For example, nurses collaborate with pharmacists to conduct medication reviews, identify interactions, and recommend interventions, fostering teamwork and accountability, reducing errors, and improving care quality (Kozel et al., 2020).

Identifying Stakeholders

Nurses play a critical role in healthcare, collaborating with various stakeholders to drive safety enhancements regarding medication errors in MGH. Identifying these stakeholders and understanding their relevance and potential importance is crucial for effective coordination.

As primary prescribers, physicians are key collaborators for nurses in medication management. Nurses work closely with physicians to clarify medication orders, discuss concerns, and ensure appropriate prescribing practices to enhance patient safety. Pharmacists provide valuable insights into medication safety and interactions with their expertise in medication therapy. Nurses collaborate with pharmacists to verify orders, review patient profiles, and discuss medication-related issues to prevent errors (Alsaloom et al., 2022). Health Information Technology (IT) specialists support implementing and maintaining electronic health record (EHR) systems, including CPOE and BCMA systems. Nurses collaborate with IT specialists to ensure effective technology use, troubleshoot issues, and optimize functionalities to prevent errors. Quality Improvement (QI) teams focus on identifying areas for improvement in patient care and safety. Nurses collaborate with QI teams to analyze data, identify root causes, and implement interventions to prevent errors, promoting continuous improvement (Kozel et al., 2020).

Patient advocates represent patient interests and concerns. Nurses engage with advocates to gather feedback, address concerns and involve patients in treatment decisions. Hospital administrators oversee operations and resource allocation. Nurses collaborate with administrators to advocate for investments in patient safety initiatives, such as training programs and technology upgrades, to mitigate errors and enhance outcomes (Alshammari et al., 2022). Regulatory agencies, like the Food and Drug Administration (FDA) and the Joint Commission, establish standards and guidelines for medication safety in healthcare settings. Nurses collaborate with regulatory agencies to ensure compliance with medication safety standards, participate in accreditation processes, and implement best practices to meet regulatory requirements and enhance patient safety. By coordinating with these stakeholders, nurses drive safety enhancements, reduce errors, and improve patient outcomes in MGH (Stawicki & Firstenberg, 2022).

Conclusion

Medication errors pose a significant patient safety risk in MGH due to human fatigue, communication breakdowns, and chaotic work environments. Implementing evidence-based solutions such as CPOE with CDS, medication reconciliation, BCMA systems, and education programs for healthcare professionals is crucial for mitigating these risks. Nurses play a central role in coordinating care and advocating for safety measures. At the same time, collaboration with stakeholders ensures the effective implementation of strategies to enhance patient safety and reduce medication errors. Addressing these factors through comprehensive approaches is essential for substantially improving patient outcomes and healthcare quality.

References

Alsaloom , M. S. M., Alsaloom , H. A. H., Alsaloom , H. A. M., Humayyim , M. M. M. B., Lasloum, M. J. S., Lsloom, D. N. M., & Lasloum, A. R. A. M. (2022). Enhancing medication safety through the implementation of a double check system: Strategies, benefits, and challenges. Advances in Clinical and Experimental Medicine, 9(4). https://journal.yemdd.org/index.php/acamj/article/view/247

Alshammari , W. A., Alharbi , S. A., Aldhafeeri , A. M., Aldhafeeri , M. O., Alharbi , S. A., & Aldhafeeri , W. O. (2022). Medication administration time study (MATS): Health professionals performance of medication administration. Chelonian Research Foundation, 17(2), 1522–1530. http://www.acgpublishing.com/index.php/CCB/article/view/472

Chernyak, M., & Posten, C. (2022). Quality of care improvement: a process to standardize handoff communication between anesthesia providers and post-anesthesia care unit nurses. DNP Scholarly Projects. https://digitalcommons.lasalle.edu/dnp_scholarly_projects/2/

Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., Perdomo, H. A. G., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Elorrio, E. G. (2021). Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2

Heikkinen, I. (2022). Barcode medication administration and patient safety: A narrative literature review. Www.theseus.fi. https://www.theseus.fi/handle/10024/745259

Konrad, S. (2020). Medication reconciliation: A quality improvement project, a doctoral project submitted in partial fulfillment of the requirements for the degree of doctor of nursing practice. http://sonapp.fullerton.edu/FacultyStaff/DNP/FinalProject/ProjectPDF/Sharon%20Konrad%20DNP_Final_PDF.pdf

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Stawicki, S. P., & Firstenberg, M. S. (2022). Contemporary topics in patient safety: Volume 1. In Google Books. BoD – Books on Demand. https://books.google.com.pk/books?hl=en&lr=&id=FtJuEAAAQBAJ&oi=fnd&pg=PA9&dq=Regulatory+agencies

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