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Capella 4020 Assessment 1

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    Capella 4020 Assessment 1

    Capella 4020 Assessment 1 Enhancing Quality and Safety

    Student Name

    Capella University

    NURS-FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name


    Enhancing Quality and Safety – Medication Administration Errors

    A significant global public health issue and a primary cause of mortality is medication errors. It refers to preventable mistakes that occur during the process of prescribing, dispensing, or administering medication. These errors can have serious implications for patient safety and the quality of healthcare. Healthcare providers can improve quality and safety in a number of ways by addressing and eliminating medication administration errors. This involves protecting patients from risk, optimizing patient outcomes, increasing medication accuracy, and lowering healthcare expenditures. Overall, reducing drug administration errors is crucial for enhancing patient care as well as making sure of a higher standard of healthcare in quality and safety (Wu & Busch, 2019).

    Case Scenario

    In the Vila Health organization a similar scenario for medication errors was observed whereby a nurse, Sarah, is responsible for giving medication to several patients in a medical-surgical unit at a busy hospital. A patient, Emily, a 24 year old female, who has been hospitalized with pneumonia, has a medication order of Amoxicillin 500 mg oral every 8 hours. The nurse, due to distraction and workload, prepared an intravenous dosage of Amoxicillin for her patient and administered the medication. Within a short interval of time, Emily suffers an adverse reaction that includes anaphylaxis-like symptoms such as low blood pressure and dizziness. The emergency response team is contacted, and Emily receives timely treatment for the reaction. Luckily, there were no long-term consequences, and the patient recovered. This incident brought attention to medication administration errors (MAEs) in healthcare settings.

    Factors Leading to Medication Administration Errors

    Medication administration is a crucial aspect of patient care, but it also carries inherent risks. Multiple factors can contribute to patient safety risks in medication administration. Some of the evidence-based factors are:

    1. Errors in the administration of medication are more likely to occur when there is insufficient staffing and a heavy workload. In a systematic study that was published in the Journal of Patient Safety, it was shown that there is a direct link between the number of nurses on duty and medication errors (Khalil & Huang, 2020). 
    2. Confusion and errors during medication administration may arise from similar names or packaging. The Institute for Safe Medication Practices (ISMP) possesses a list of look-alike and sound-alike medications (LASA) that are more likely to cause errors in medication (Orser et al., 2023). 
    3. Risks associated with medication administration can be attributed to patient-related variables, such as allergies, complications, and a lack of health literacy. According to Wondmieneh and colleagues (2020), patients with low health literacy had a greater chance of misinterpreting drug instructions and making medication mistakes.

    Solutions to Improve Patient Safety Focusing on Medication Administration 

    In healthcare settings, patient safety and cost-reduction are two major important aspects of healthcare. For this purpose, actions and procedures are required which are aimed at minimizing risks, preventing medical errors, cost-effectiveness, and ensuring a safe and risk-free environment for patients. To improve the well-being and quality of care of patients, identifying and solving potential risks and dangers as well as improving processes are necessary.

    Barcoding and eMAR systems are supported by the American Society of Health-System Pharmacists (ASHP), which also offers materials on their advantages and recommended practices (Khalil & Huang, 2020). Moreover, installing barcode systems and eMAR will initially be costly, however, the reduction in errors will help in reducing extra costs associated with medical errors. The Institute for Safe Medication Practices (ISMP) also provides information on recommended procedures for labeling, storing, and preparing medications which acts as guidelines and tools for safe drug administration (Vaismoradi et al., 2020). Following these guidelines can reduce errors and their associated expenditures.

    Healthcare professionals’ skills and expertise in regulating drugs are improved by training and education on medication safety. Enhancing communication and collaboration between healthcare professionals, and patients help reduce errors in patient safety. Employing strategies such as structured communication tools like SBAR handsoff and open communication can improve medication administration processes.

    Adhering to the fundamental principles of Six Rights of Medication Administration which includes the right patient, right medication, right dose, right route, right time, and right documentation also ensures that medications are administered correctly, reducing the risk of errors and improving patient safety. Facilitating multidisciplinary teamwork, using data and analytics for monitoring and enhancement, using evidence-based practices, and encouraging an attitude of safety is also significant (Andrews et al., 2019). Such efforts seek to improve patient experiences, minimize harm, and enhance healthcare outcomes.

    Coordinating Care to Increase Patient Safety 

    To reduce costs and provide medicine safely, nurses play a vital role in care coordination. By performing medication reconciliation, educating patients, fostering effective communication, adhering to drug administration processes, and monitoring and notifying adverse events, they could potentially make a significant impact. By explaining the purposes, dose, frequency, and possible adverse effects of prescribed medications, nurses can properly educate patients and their families regarding their medications. Patient education can offer via interactive technology, textual materials, or one-on-one counseling sessions.

    Nurses help to improve the quality of care and safeguard healthcare costs by encouraging pharmaceutical security and patient involvement. Standardized drug administration procedures and best practices should be followed by nurses (Wu & Busch, 2019).

    To avoid infections, nurses ought to follow aseptic procedures while administering intravenous (IV) drugs. Nurses optimize patient safety, minimize errors and save expenses associated with avoidable adverse medication events by constantly adhering to established guidelines. Nurses should pay close attention to patients for signs of adverse drug reactions and report them promptly.

    Moreover, reporting negative incidents also enables quality improvement projects and the detection of systemic problems that can result in affordable modifications and stop recurrences. Their role as care coordinators and advocates for patients is crucial in promoting safe medication practices and contributing to standard healthcare quality improvement. Nurses can advocate for the implementation and adherence to standardized medication administration practices within their healthcare organization.

    By following consistent protocols and guidelines, such as double-checking medication orders or using barcode scanning systems, nurses help reduce errors and enhance patient safety. Standardized practices also contribute to cost reduction by promoting efficient and streamlined medication administration processes. Nurses along with interdisciplinary teams can greatly improve patient safety with medication administration and help healthcare facilities cut costs by actively participating in care coordination and using these practices.

    Significant Role of Stakeholders

    To improve the quality and safety of drug delivery, nurses must work together with a variety of stakeholders. They play important roles in enhancing quality and safety in medication administration. The interdisciplinary team which includes patients, families, physicians, pharmacists, nurse managers, supervisors, regulatory agencies or accreditation organizations, and members of the quality improvement and patient safety committees are among the key stakeholders.

    Stakeholders collaboratively contribute to improving the quality and safety of medicine delivery by acknowledging and carrying out their roles and responsibilities (Concannon et al., 2018). Their cooperation, communication, shared-decision making for shared-goals, and dedication to patient safety results in better outcomes in terms of patients safety, and cost effectivness, which fosters an excellent culture in healthcare organizations.


    To conclude, the healthcare system encounters numerous challenges in management and healthcare delivery. The World Health Organization has recognized medication administration errors as a significant concern, highlighting the need for comprehensive and patient-centered healthcare. Addressing the challenges in a healthcare system requires a multidimensional approach, including clear communication, standardized processes, adequate staffing, robust technology systems, and patient engagement strategies to ensure safe medication administration practices. Collaborating with stakeholders and employing evidence-based solutions, can enhance patient safety in medication administration while reducing costs related to medication errors and adverse events.


    Andrews, C. N., Southworth, M., & Silva, J. R. (2019). Extended reality in medical practice. Current Treatment Options in Cardiovascular Medicine, 21(4).

    Concannon, T. W., Grant, S., Welch, V., Petkovic, J., Selby, J. V., Crowe, S., Synnot, A., Greer-Smith, R., Mayo-Wilson, E., Tambor, E. S., & Tugwell, P. (2018). Practical guidance for involving stakeholders in health research. Journal of General Internal Medicine, 34(3), 458–463.

    Khalil, H. P. S. A., & Huang, C. (2020). Adverse drug reactions in primary care: A scoping review. BMC Health Services Research, 20(1).

    Orser, B. A., Hyland, S., & Byrick, R. (2023). Preventing neuraxial administration of tranexamic acid. Canadian Journal of Anesthesia/Journal Canadien D’anesthésie, 70(5), 811–816.

    Vaismoradi, M., Tella, S., Logan, P., Khakurel, J., & Vizcaya-Moreno, M. F. (2020). Nurses’ Adherence to Patient Safety Principles: A Systematic Review. International Journal of Environmental Research and Public Health, 17(6), 2028.

    Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1).

    Wu, A. W., & Busch, I. M. (2019). Patient safety: A new basic science for professional education. PubMed, 36(2).