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Capella 4020 Assessment 4

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    Capella 4020 Assessment 4

    Capella 4020 Assessment 4 Improvement Plan Tool Kit

    Student Name

    Capella University

    NURS-FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name

    Date

    Improvement Plan Toolkit-Medication Error

    A toolkit for improvement planning is essential for healthcare professionals, as it enables them to acquire knowledge and reflect on their mistakes. A comprehensive toolkit in a healthcare setting serves as a valuable resource for nurses, enabling them to access relevant information and enhance their skills and practices. Unfortunately, medication errors are prevalent in the medical field, prompting government departments and researchers worldwide to study their causes and effects.

    This resource toolkit focuses on medication administration errors which aims to provide nurses with a comprehensive set of tools for implementing a medication safety improvement plan. The toolkit was developed using various reputable databases, including Google Scholar, PubMed, Capella Online Library, CINAHL, and ScienceDirect. Its purpose is to equip healthcare professionals with in-depth knowledge and a clear understanding of the relevant concepts, enabling them to effectively execute the improvement plan and achieve positive outcomes.

    Resources for Implementing and Sustaining a Safety Improvement Initiative

    The resource kit has been deliberately organized for nurses to find the material they need to address their particular challenges. An in-depth analysis of the overview, prevalence of medication administration errors, factors contributing to the errors, an explanation of the prevention plan for medication errors, and inter professional collaboration to improve medication safety practices are all included. Healthcare professionals may acquire the necessary information and direction necessary for putting up an efficient strategy to increase the safety of medications by using this user-friendly format.

    Overview and Prevalence of Medication Administration Error

    Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07187-5

    Medication errors are a significant concern in the United States healthcare system, posing risks to patient safety and leading to substantial healthcare costs. This study suggests the prevalence of medication errors in the United States. According to the report, medication errors harm an estimated 1.5 million people in the United States annually. Medication errors can occur at various stages of the medication process, including prescribing, dispensing, administering, and monitoring. Common types of medication errors described in the article are the incorrect dosages, prescribing or administering the wrong medication, drug interactions, and medication administration at the wrong time.

    Common factors along with the consequences which contribute to medication errors in a healthcare setting were also elaborated. To address the issue of medication errors, healthcare organizations and regulatory bodies in the United States have implemented various initiatives and strategies. These include the use of technology, such as electronic prescribing systems and barcode medication administration, to reduce errors in prescribing and administration. Additionally, efforts are being made to improve communication and collaboration among healthcare providers, enhance medication safety protocols, and promote medication reconciliation practices.

    Capella 4020 Assessment 4

    Alqenae, F., Steinke, D., & Keers, R. N. (2020). Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review. Drug Safety, 43(6), 517–537. https://doi.org/10.1007/s40264-020-00918-3

    This study provides the prevalence of medication administration errors ranging from 5% to 74%, with an average rate of around 19% in a tertiary care hospital. Long-term care settings such as nursing homes reported 16% of medication administration errors. Ambulatory care settings such as clinics and outpatient departments, experience medication errors 7.5% of medication administrations. In pediatric populations, the prevalence of medication administration errors ranges from 0.45% to 27.3%, with an average rate of around 10%. Addressing the prevalence of medication administration errors requires a multifaceted approach. This includes educating and training healthcare professionals on medication safety practices, implementing effective protocols and procedures, improving communication and teamwork, utilizing technology solutions, and fostering a culture of safety. 

    Factors Contributing to Medication Errors

    Insufficient Staffing and Heavy Workload

    Khalil, H. P. S. A., & Huang, C. (2020). Adverse drug reactions in primary care: A scoping review. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-019-4651-7

    Errors in the administration of medication are more likely to occur when there is insufficient staffing and a heavy workload. Nurses play a critical role in ensuring safe medication administration, but when they are overwhelmed with excessive patient loads and time constraints, the risk of errors significantly increases. A systematic study conducted on this issue demonstrated a direct link between the number of nurses on duty and medication errors. When there are fewer nurses available to administer medications, they may feel rushed and pressured, leading to potential mistakes. Inadequate staffing levels also contribute to interruptions and distractions, further compromising the concentration and focus required for accurate medication administration.

    Additionally, a heavy workload can impact the ability of nurses to properly assess patients, verify medication orders, and provide thorough patient education regarding their medications. Without sufficient time and resources, nurses may be more prone to errors such as administering the wrong medication, incorrect dosages, or overlooking important drug interactions.

    Poor Knowledge of LASA Drugs

    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. https://doi.org/10.1007/s12630-023-02434-1

    This study talks about the risks taken by healthcare providers who may inadvertently select the wrong medication due to these similarities. Confusion and errors during medication administration often arises from the presence of similar names or packaging of medications which also poses a significant risk to patient safety. To address this issue, the article desribes that guidelines suggested by the Institute for Safe Medication Practices (ISMP). They developed a comprehensive list known as Look-Alike and Sound-Alike (LASA) medications.

    The LASA list serves as a valuable resource for healthcare professionals in identifying medications that have a high potential for confusion due to their similar names or packaging. The list includes medications that share similar characteristics in spelling, pronunciation, or appearance, making them more likely to be confused with one another during the medication administration process. By raising awareness about these LASA medications, the nurses aim to prevent medication errors and improve patient safety. 

    Decreased Job Satisfaction in Nurses 

    Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research21(1). https://doi.org/10.1186/s12913-021-06288-5

    This study highlights the interconnectedness of several key factors in relation to medication errors, including the nurses’ job satisfaction, patient satisfaction, and patient safety. To improve patient safety and reduce medication errors, the study offers valuable suggestions for nurse managers. Nurse managers should provide support and motivation to nurses in their roles, helping them effectively manage and organize their tasks. This support can contribute to reducing stress and workload, leading to improved job satisfaction and, in turn, a decreased likelihood of medication errors.

    Furthermore, healthcare administrators have an important responsibility in monitoring the work of nurse managers to ensure they can effectively balance their workload and meet the organization’s goals of providing high-quality care and achieving patient safety. This oversight helps to ensure that nurse managers have the necessary resources and support to effectively carry out their roles and responsibilities.

    Prevention of Errors to Improve Quality in Medication Administration

    Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: Benefits, risks, and strategies for success. Npj Digital Medicine, 3(1). https://doi.org/10.1038/s41746-020-0221-y

    This article proves highly up-to-date guidelines and policies related to medication administration. These guidelines provide evidence-based recommendations and best practices, enabling the role group to align their practices with established standards. 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. Errors in medication administration can be reduced with the help of barcoding technology and Electronic Medication Administration Records (eMAR) systems, which improve and ensure reliability in healthcare safety. Barcoding and eMAR systems can be utilized in such an environment. Additionally, the Institute for Safe Medication Practices (ISMP) provides information on recommended procedures for labeling, storing, and preparing medications, as well as guidelines and tools for safe drug administration.

    Razzak, M. I., Imran, M., & Xu, G. (2019). Big data analytics for preventive medicine. Neural Computing and Applications32(9), 4417–4451. https://doi.org/10.1007/s00521-019-04095-y

    Another useful resource which suggests multiple strategies to prevent medication administration error is comprehensive training materials. These materials ensure that the role group is equipped with the necessary knowledge and skills to carry out their responsibilities effectively. In a long-term care facility, training modules on proper medication storage, administration techniques, and documentation can greatly enhance the competency of staff members, reducing the risk of medication errors. Secondly, implementing decision support systems, such as computerized physician order entry (CPOE) systems or electronic medication administration record (eMAR) systems, proves immensely beneficial.

    Capella 4020 Assessment 4

    These systems provide real-time alerts and reminders, assisting healthcare professionals in identifying potential medication interactions, allergies, or dosing errors. Reporting and monitoring tools are vital resources that enable the role group to identify and address medication errors or near misses. Incident reporting systems and error tracking databases help in recognizing patterns and trends, allowing for targeted interventions and process improvements. For instance, in a community pharmacy setting, the utilization of a reporting system can facilitate the identification of recurring medication errors, leading to targeted training and workflow modifications to prevent their recurrence.

    Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499956/ 

    This paper discussed the prevention plan for medical error reduction in improving the quality of healthcare. Inter-professional collaboration is an invaluable resource for the role group responsible for implementing quality and safety improvements. By fostering open communication and sharing of knowledge among different healthcare professionals, valuable insights can be gained, leading to improved medication practices. For example, in a collaborative care team involving physicians, nurses, and pharmacists, regular interdisciplinary meetings can facilitate the exchange of ideas, identification of challenges, and development of strategies to optimize medication safety.

    Siman, A. G., Braga, L. M., De Oliveira Fani Amaro, M., & Brito, M. J. M. (2019). Practice challenges in patient safety. Revista Brasileira De Enfermagem, 72(6), 1504–1511. https://doi.org/10.1590/0034-7167-2018-0441

    Capella 4020 Assessment 4

    This article is aimed at describing the continuous education and training opportunities that play a vital role in enhancing medication administration practices among healthcare professionals. The field of medicine is constantly evolving, with new medications, technologies, and best practices emerging regularly. By providing ongoing education and training, healthcare professionals can stay abreast of these advancements and update their knowledge and skills accordingly.

    One of the key benefits of continuous education and training is the opportunity to learn about the latest safety measures and guidelines related to medication administration. Healthcare professionals can gain insights into strategies for error prevention, such as double-checking procedures, barcode scanning systems, and medication reconciliation processes. They can also stay informed about the proper handling and storage of medications, as well as the importance of accurate documentation and reporting of medication errors.

    Furthermore, continuous education and training foster a culture of lifelong learning among healthcare professionals. It encourages them to actively seek knowledge and engage in professional development to provide the best possible care to their patients. By investing in their own education, healthcare professionals demonstrate their commitment to staying updated and delivering high-quality, safe medication administration.

    Inter-Professional Collaboration in Medication Safety 

    Mandal, L., Seethalakshmi, A., & Rajendrababu, A. (2020). Rationing of nursing care, a deviation from holistic nursing: A systematic review. Nursing Philosophy, 21(1). https://doi.org/10.1111/nup.12257

    This article describes inter-professional collaboration in medication safety which refers to the collaborative efforts and communication between healthcare professionals from different disciplines involved in the medication administration process. It recognizes that medication safety is a shared responsibility that requires the collective expertise and input of various healthcare team members. Effective interprofessional collaboration in medication safety involves teamwork, communication, and mutual respect among professionals such as doctors, nurses, pharmacists, and other allied healthcare professionals. Each team member brings their unique knowledge and skills to ensure safe medication practices.

    Through this collaboration, healthcare professionals can work together to identify and address potential medication errors, share important patient information, discuss medication plans, and make informed decisions regarding medication administration. This collaborative approach helps to minimize the risk of errors, improve patient outcomes, and enhance overall medication safety. It also promotes a culture of open communication and shared decision-making. Healthcare professionals can exchange their perspectives, ask questions, and clarify any concerns related to medication orders, dosages, allergies, or drug interactions.

    Capella 4020 Assessment 4

    This collaborative process helps to identify and resolve any potential issues or discrepancies in medication administration, ensuring that patients receive the right medication, at the right dose, and through the right route. It also involves engaging patients and their families in medication safety discussions, empowering them to actively participate in their own care and medication management. By involving patients as partners in the medication safety process, healthcare professionals can gain valuable insights into their medication history, preferences, and potential barriers to adherence.

    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. https://doi.org/10.1007/s11606-018-4738-6

    Stakeholders play a crucial role in preventing and addressing medication errors within healthcare systems. The above article shares the insight about their involvement and collaboration, how they are vital in promoting patient safety and ensuring effective medication management. Healthcare providers, including physicians, nurses, and pharmacists, are directly involved in medication administration. Their role includes accurate medication order entry, verification, proper dosage calculation, safe administration techniques, and monitoring for any adverse effects or drug interactions. They should also report and document any medication errors or near misses to promote learning and improvement.

    Capella 4020 Assessment 4

    Patients and their families are also active participants in their healthcare journey. Moreover, pharmacists play a crucial role in preventing medication errors through their expertise in medication management. Healthcare administrators and policymakers have a responsibility to establish policies, procedures, and guidelines that promote medication safety. They allocate resources for training and education, collaborating with regulatory bodies to develop and enforce standards related to medication management. Collaboration between healthcare providers and the pharmaceutical industry is essential to stay updated on new medications, safety warnings, and best practices.

    Quality Improvement Initiatives

    Koyama, A., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

    The above resource explains explicitly about the quality improvement initiatives in a healthcare setting. The term quality improvement initiatives refer to systematic and continuous efforts undertaken by healthcare organizations to enhance the quality of care and services they provide. These initiatives aim to identify areas for improvement, implement changes, and monitor the outcomes to ensure that the desired improvements are achieved. The primary goal of these initiatives is to enhance patient outcomes, safety, and satisfaction. These initiatives focus on various aspects of healthcare delivery, including clinical processes, patient experiences, organizational systems, and healthcare outcomes. By implementing evidence-based practices and adopting a data-driven approach, healthcare organizations can identify gaps in care, prevent errors, and optimize the overall quality of healthcare services.

    Quality improvement initiatives involve multiple steps, including data collection, analysis, action planning, implementation, and evaluation. Healthcare organizations collect and analyze data to identify areas of improvement, such as high-risk processes, medication errors, patient complaints, or gaps in clinical guidelines adherence. Based on the findings, action plans are developed and interventions are implemented to address the identified issues. Furthermore, continuous monitoring and evaluation play a crucial role in quality improvement initiatives. Regular assessment of the implemented changes allows healthcare organizations to track progress, identify any unintended consequences, and make further adjustments if needed. This iterative process enables organizations to sustain improvements over time and continually enhance the quality of care.

    Conclusion

    Medication errors pose a significant challenge to patient safety and healthcare quality. 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. By keeping healthcare professionals well-informed and equipped, these initiatives contribute to the overall improvement of patient safety and the delivery of quality healthcare services. 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.

    References

    Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07187-5

    Alqenae, F., Steinke, D., & Keers, R. N. (2020). Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review. Drug Safety, 43(6), 517–537. https://doi.org/10.1007/s40264-020-00918-3

    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. https://doi.org/10.1007/s11606-018-4738-6

    Khalil, H. P. S. A., & Huang, C. (2020). Adverse drug reactions in primary care: A scoping review. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-019-4651-7

    Koyama, A., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

    Mandal, L., Seethalakshmi, A., & Rajendrababu, A. (2020). Rationing of nursing care, a deviation from holistic nursing: A systematic review. Nursing Philosophy, 21(1). https://doi.org/10.1111/nup.12257

    Capella 4020 Assessment 4

    Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06288-5

    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. https://doi.org/10.1007/s12630-023-02434-1

    Razzak, M. I., Imran, M., & Xu, G. (2019). Big data analytics for preventive medicine. Neural Computing and Applications, 32(9), 4417–4451. https://doi.org/10.1007/s00521-019-04095-y

    Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK499956/ 

    Siman, A. G., Braga, L. M., De Oliveira Fani Amaro, M., & Brito, M. J. M. (2019). Practice challenges in patient safety. Revista Brasileira De Enfermagem, 72(6), 1504–1511. https://doi.org/10.1590/0034-7167-2018-0441

    Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. Npj Digital Medicine3(1). https://doi.org/10.1038/s41746-020-0221-y

    Capella 4020 Assessment 4