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NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

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    NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

    Student Name

     University Name

    NURS FPX 4020 Improving Quality of Care and Patient Safety

    Instructor Name


    Enhancing Quality and Safety

    Healthcare professionals should provide high-quality care treatments that do not compromise patients’ health and safety. All healthcare providers must improvise medical interventions tailored to their health needs and minimize the chances of adverse events. Medication errors are preventable adverse events that can impact patient safety and quality of life. The incidence of adverse drug events, including medication errors, accounts for 1.3 million emergency department visits and 350,000 hospitalizations annually (CDC, 2019). Nurses are primary medication managers for patients as they administer them into human bodies. It is paramount for nurses to strictly adhere to safe medication administration that promises patient safety and improved health outcomes, ultimately enhancing patients’ quality of life.

    Factors Leading to a Specific Patient Safety Risk

    On a fine day, Jenna worked as a registered nurse at Acadia General Hospital in the medicine ward. Jenna was doing an evening round and looked up to the prescribed medication record of a 50-year-old patient named Graham, who was admitted to the hospital due to unmanaged arthritis pain. The patient was prescribed “Celebrex,” a non-steroidal anti-inflammatory drug. The nurse went to the dispensing area and retrieved the wrong medicine bottle labeled “Celexa,” which sounded like the prescribed “Celebrex.”

    The nurse gave the patient “Celexa, ” an anti-depressant agent for mood disorders. Graham took the medication, unaware that it was the wrong drug. Later, Jenna reviewed his medication administration record and noticed she had administered incorrect medicines. She immediately reported to the medication safety team, and the patient was closely monitored. Fortunately, Graham did not experience severe side effects from the drug, but this incident raised concerns about the patient’s safety. 

    Numerous factors lead to patient safety risks, including negligent behavior toward medication administration, non-adherence to medication administration protocols, lack of technology-based medication administration use, and lack of training on medication administration. Nurses may exhibit negligent behavior toward medication administration due to heavy workloads and fatigue. This leads to non-careful medication administration, particularly for “look-alike-sound-alike” medications (Schroers et al., 2020).

    NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

    Moreover, non-adherence to medication administration standards and protocols, such as double-checking before administration and missing the “Five Rights of Medication Administration,” such as the right patient, right drug, correct dose, right time, and right route of administration, also pose safety risks to patients (Hanson & Haddad, 2022). Hospitals often lack technologies that facilitate safe medication administration, such as “barcode medication administration,” which can prevent medication administration due to wrong drug administration.

    Implementing BCMA can lower override rates to less than two percent in large healthcare settings (Boehme et al., 2022). Additionally, training inadequacies among nurses on safe medication administration are significant factors that lead to patient safety risks. One study showed that among work-related characteristics towards medication errors, about 185 nursing staff were not trained on safe medication, and 24 nurses administered the wrong drugs (Wondmieneh et al., 2020).

     Evidence-Based Practices to Improve Patient Safety in Medication Administration

    Healthcare professionals play a crucial role in improving patient safety in medication administration and reducing costs to patients and organizations by implementing the best available evidence-based solutions. One such evidence-based practice is developing and integrating medication administration protocols within the organization. When the organization develops policies on medication administration and strictly integrates them for all nursing staff, there will be fewer chances of medication errors. Patients will receive the correct medication, leading to fewer incidents of harm.

    Moreover, the costs incurred by patients will be reduced as the patient will not undergo additional treatments due to medication errors. Likewise, hospitals can be saved from heavy expenditures and requirements of further resources for treating medication errors (Vaismoradi et al., 2020). Another strategy is training mindful thinking for medication administration, where nurses must be mindful of their nursing practices, particularly during medication administration. This will reduce the onset of medication errors due to wrong drug administration due to lack of focused care. The study showed that mindfulness training in medication administration reduced medication errors by 73.3 %. This enhances patient safety as patients evade medication errors due to administering the wrong drugs. 

    NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

    Moreover, by focused medication administration, hospitals will prevent operations due to medication errors and save financial resources, which can be allocated efficiently to other required areas (Ekkens & Gordon, 2021).  Another strategy includes integrating BCMA technology, which can promote safe medication administration using the barcode mentioned on the medication label and the patient’s wrist. This will enable accurate and correct administration of drugs, preventing chances of wrong medication delivery. This technology will improve patient safety and reduce long-term costs incurred by the organization due to frequent medication errors occurring without technology (Zheng et al., 2020). 

    Lastly, establishing training and educational programs on safe medication administration can improve patient safety, reducing medication errors. These training programs will teach nurses ways to reduce medication errors, such as double-checking medications, following protocols and guidelines for safe medication administration, and techniques for medication delivery through correct administration routes (Koyama et al., 2019).  This will reduce financial implications on hospitals when preventive strategies are employed to diminish medication errors. As a result, hospital readmission rates, length of hospital stays, and hospital-acquired infections will be reduced. All these events that require massive income to manage patients’ health will be saved, and costs will be reduced for both organizations and patients. 

    Nurses’ Role in Coordinating Care 

    Nurses play a crucial role in achieving care coordination in hospitals. Nurse-led coordinated care can enhance patient safety in medication administration and reduce costs. Nurse leaders can organize training sessions and educational awareness programs for junior and fellow nurses where information on safe medication administration can be disseminated. Moreover, nurses can foster a culture of an interdisciplinary approach to the safe administration of drugs, from prescribing to delivering the drug. Nurses can utilize BCMA and other relevant technologies to reduce costs associated with medication errors without using healthcare technologies (Zheng et al., 2020).

    Additionally, nurses can play their role in accurately documenting medication administration and adverse events to make further informed decisions and reduce the risk of redundant medications (Vaismoradi et al., 2020). This will reduce costs associated with additional treatments and extended hospital stays.  In the abovementioned case, Jenna could have prevented the medication error by double-checking the medicine before administration (Koyama et al., 2019). Moreover, she could have collaborated with the pharmacist to dispense the correct medication. Lastly, Jenna needed to implement five medication administration rights, ensuring the right patient acquires the right drug. These measures could have saved Graham from taking the wrong drug, and his health safety could have been enhanced. Furthermore, the costs associated with using an antidote and managing side effects could have been avoided.

    Coordination with Stakeholders to Drive Quality and Safety Enhancements

    Nurses must maintain a synergistic relationship with vital stakeholders to foster quality and safety in medication administration. Pharmacists are indispensable in ensuring drug clarity, verifying dosage accuracy, and addressing potential contraindications; hence, their expertise is pivotal for correct medication dispensing. Physicians are central to this coordination process; clear communication with them guarantees that prescriptions are precise and tailored effectively.

    Furthermore, patients are invaluable partners in this journey, as their feedback and adherence to medication regimens can often be the first indicators of potential issues. By educating patients, nurses can minimize self-administration errors and bolster compliance. Lastly, alignment with the Healthcare Administration is vital. They ensure that the necessary infrastructure, training, and policies are in place, facilitating a cohesive environment to prioritize patient safety.


    Healthcare professionals aim to improve patients’ lives, enhance the quality of care, and prevent danger to them. Unfortunately, medication administration errors are those adverse events that effective measures can prevent. In the presented case, patient Graham encountered a medication error due to the wrong drug due to the nurse’s negligent behavior and lack of mindfulness. This calls for implementing strategies like developing policies on medication management, training nurses on mindfulness, using BCMA technology, and establishing nurses’ training on safe medication management. Nurses enhance care coordination in increasing patients’ safety with medication administration through collaboration and education. They can collaborate with physicians, pharmacists, and administrators to enhance quality and safety with context to medication administration.


    Boehme, S., Wohlt, P., Valentine, J., & Ensign, R. (2022). Sustained barcode medication administration rates less than 2 percent in a large healthcare system. Journal of Patient Safety and Risk Management, 27(6), 268–274. 

    CDC. (2019). Medication safety basics. 

    Ekkens, C. L., & Gordon, P. A. (2021). The mindful path to nursing accuracy. Holistic Nursing Practice, 35(3). 

    Hanson, A., & Haddad, L. M. (2022). Nursing rights of medication administration. PubMed; StatPearls Publishing. 

    Koyama, A. K., Maddox, C.S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2019). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety, 29(7), 595–603. 

    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). 

    NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

    Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15. 

    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(4), 1–9. 

    Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2020). The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review. Research in Social and Administrative Pharmacy, 17(5), 832–841.