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NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Outcomes, Measures, Issues, and Opportunities

This draft report directs the outcome measure and opportunities, including a change model strategy that measures all patient care aspects. Medication errors are preventable adverse events that cause 44,000 to 98,000 mortalities in U.S. healthcare organizations annually. Out of every 100 admissions, 6.5 patients experience medication error-related adverse events in acute care hospitals (Carver et al., 2019). There are different types of medication errors, such as medication errors in the peri-discharge period, prescription, transcription, administration, and monitoring errors. These errors impact patients’ health in one way or another, resulting in various adverse health outcomes such as disabilities, paralysis, comorbidities, and mortalities. Therefore, it is essential to identify performance issues, evaluate outcomes, measures, and opportunities to tackle these issues, and make prospective improvements to promote medication safety.

Organizational Functions, Processes, and Behaviors in High-Performing Organizations

High-performing healthcare organizations work for continuous improvements and identify potential opportunities for betterment. To prevent medication errors, high-performance healthcare setups implement training and educational programs to ensure the healthcare staff is well aware of medication safety and the risks of medication errors. The healthcare authorities develop and implement various plans and strategies, including incidence reporting systems and technology-based medication management, to achieve safe medication administration and monitoring. Furthermore, healthcare organizations promote medication reconciliation at times of transition of care and admission, using computerized physician order entry (CPOE), clinical decision support systems (CDSS), EHR, and barcode medication administration (BCMA) (Carver et al., 2019). These processes and functions help healthcare professionals minimize medication errors due to prescription, transcription, administration, and monitoring. 

High-performing organizations promote a blame-free environment to encourage immediate reporting of medication errors through incidence reporting systems. Moreover, these organizations ensure that adequate healthcare staff is available to reduce staff burnout which contributes to the incidence of medication errors (Kwon et al., 2021). Another way high-performing organizations promote medication safety is by fostering a culture of leadership roles where team leads communicate effectively with other staff members on medication management and safe administration to keep all actions aligned (Ledlow et al., 2023). The identified knowledge gaps and uncertainty areas that hinder this analysis include how these organizations maintain these functions and processes during resource downturns and economic constraints. Additionally, how these organizations manage the nurse shortage and increased turnover rates and prevent medication errors during these circumstances requires further information to improve the analysis.

Determining Impact of Organizational Functions, Processes, and Behaviors on Outcome Measures

Healthcare organizational functions, processes, and behaviors related to medication errors and their prevention impact outcome measures positively and negatively that directly impact patient safety. For instance, a healthcare organization with a robust leadership and governance role prioritizes medication errors by providing effective guidelines on medication safety, adequate allocation of resources, and training, that facilitates safe medication management. This supports positive health outcomes for patients by reducing medication errors. Likewise, organizational behaviors that support blame-free reporting of medication errors encourage healthcare professionals to report and learn from adverse events related to medication error and ensures prompt action to mitigate adverse events related to medication errors. Furthermore, the implementation of barcode medication administration (BCMA) identifies the right patient with the right medication prescribed through barcode matching. It promotes safe medication administration, enhancing patient safety and satisfaction (Mulac et al., 2021).

Contrarily, the lack of leadership, interprofessional collaboration, and transparent communication on medication management adversely affects health outcomes as the medication error rates increase. An organizational culture that imposes penalties and termination to healthcare professionals on the incidence of medication errors leads to under-reporting and further progresses medication errors and patient harm (Musharyanti et al., 2019). These processes and behaviors of an organization impact outcomes about medication errors leading to high medication-associated mortality rates. The assumptions and reasons on which determination is based include that appropriate preventive measures for medication errors like technology use, leadership, and accountability governance promotes safe medication administration and management. Moreover, the need for interprofessional collaboration, hands-off communication, and technology-based medication management promotes medication errors.

 Quality and Safety Outcomes with Associated Measures

Types of Medication Errors Medication Errors Associated Quality and Safety OutcomesData Obtained in 2022Preventive Measures
Prescribing Errors Patient Harm 30%Patient harms due to prescription errors can be reduced by hands-off communication on medication management and use of computerized physician order entry (CPOE) to avoid misunderstandings due to handwritten prescriptions.
Mortality Rate10% Mortality rates due to prescription errors can be reduced by implementing medication reconciliation during care transitions and involving the interprofessional teams to align with medication management, including physicians, nurses, and pharmacists. 
Patient Satisfaction7% Due to prescription errors, patient satisfaction reduces, which requires appropriate care treatment provision by clinical decision support systems to align medication management procedures and minimize prescription errors and improve patient satisfaction through the right medication management (Sutton & Pincock, 2020). 
Dispensing ErrorsPatient Harm30% Implement double-check strategy to avoid dispensing errors  and promote pharmacist involvement in ensuring drug accuracy and dosage calculation to reduce patient harm due to dispensing errors. 
Mortality Rate20%Use technology-based systems such as automated dispensing through robotic systems and promote double-check and confirm labeling and packaging so that dispensing mistakes are reduced and mortality rates due to dispensing errors can be declined. 
Patient Satisfaction5% Reducing dispensing errors and providing correct care treatment by well medication management will enhance patient satisfaction
Administration ErrorsPatient Harm35% Training nurses on the right medication administration techniques to avoid patient harm due to administration errors. Medication reconciliation during care transitions ensures accurate information on patient medication, providing fewer chances of medication errors as the right remedy will be administered and patient safety will be improved, reducing the mortality rates (Guisado-Gil et al., 2019). 
Mortality Rates20%Implement double-checks, confirm medication with patient’s prescription to prevent wrong administration, and use BCMA technology to ensure safe medication administration and reduce mortality rates 
Patient Safety6%Technology-based systems like BCMA help reduce administration errors and ensure patient safety (Carver et al., 2019).

Performance Issues or Opportunities

Healthcare organizations may face several performance issues or opportunities associated with particular organizational functions related to medication error prevention. For instance, poor communication among interprofessional team members may increase misunderstandings and non-clarity of medication and dosages, leading to medication errors. Furthermore, a lack of staff training on proper medication administration and BCMA or CPOE technology use can enhance the risks of medication errors due to poor knowledge. Some organizations may need documentation issues where complete or accurate medication-related information is documented, leading to fragmented care delivery, difficulty in monitoring medication management, and delayed interventions. Moreover, overburdening of healthcare staff may cause work burnout and stress in high turnover cases leading to rushed medication administration and lack of double-checking and medication verification, resulting in higher medication error rates (Kwon et al., 2021). 

Therefore, healthcare organizations must look for opportunities associated with the performance and behaviors where prospective improvements can be made and sustained to reduce medication errors and enhance patient safety. Healthcare organizations can foster interdisciplinary collaboration for medication management and enhance transparent and open communication with hands-off communication so that communication barriers in medication delivery can be overcome. Moreover, the technology integration should be followed by adequate training and education to use medication administration and management technologies effectively (Mulac et al., 2021). These opportunities will positively affect health outcomes by providing the right treatment and medication administration to the right patient, reducing patient harm, and enhancing patient satisfaction. This will ultimately reduce the length of stays in hospitals and improve the quality of care.

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

The areas of uncertainty, unanswered questions, and missing information related to performance issues and opportunities within organizational functions and behaviors include the underlying causes of lack of communication in ensuring safe medication administration. Why is adequate healthcare staffing unavailable, causing work burnout and stress among limited staff? Why is the organization unable to retain adequate healthcare staff to streamline workflow? If the technologies are integrated, why are healthcare staff not provided adequate training and education on using the technologies?

Outlined Strategy: DMAIC Model

The change model ensuring all aspects of patient care are measured with adequate knowledge-sharing among staff can be implemented through the DMAIC model. The DMAIC model includes a five-steps (Define, Measure, Analyze, Improve, and Change) methodology. To tackle medication error issues in a healthcare organization, the DMAIC model can be implemented in the following way:

Define: In the first step, types of medication errors are clearly defined and identified, which may be administration-associated errors, dosage mistakes, prescription, and transcription-based errors. For this purpose, the desired goals are established, for instance, achieving the target number of medication errors in a month or reducing the medication errors to a specific percentage. Moreover, the interprofessional team is recruited to foster shared-decision making and align prospective improvements collaboratively. 

Measure: This will include data collection on medication errors using incident reports, EHRs, and patient satisfaction surveys. Moreover, the base-line medication error rate is also calculated to estimate starting point for new improvements. To pinpoint the deviated steps in safe medication management, process mapping of medication administration and the whole medication management process will be fruitful.

Analyze: Next, the gathered data will be analyzed via root-cause analysis to estimate the patterns and trends of medication errors. This will provide a vision of improvement opportunities by giving particular areas of improvement which cause medication errors. 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Improve: In this step, the interprofessional team exchanges information and valuable insights by analyzing reports and data to create robust changes that promise improvement in reducing medication errors. Once the staff adequately shares knowledge on improvements, shared-decision making is fostered, and improvement plans are established by training and guiding novice nurses on new strategies and implementing them on patients.

Control: In the last step, the healthcare organization monitors the improved changes and evaluates achieving desired goals. This is estimated by looking back through EHRs and patient satisfaction surveys and ensuring sustaining these changes if the goals are achieved by standardizing and revising policies on the new improvements made or if medication errors persist (Trakulsunti et al., 2020). This leads to a continuous improvement of reduced medication errors and covers all aspects of patient care from diagnosis to medication delivery and monitoring through effective collaboration among healthcare professionals with adequate knowledge sharing.

Conclusion

The primary focus of this draft report is to raise awareness of the outcome measures, performance issues, and opportunities to reduce medication errors in a healthcare organization. For this purpose, the functions, processes, and behaviors of high-performing organizations in reducing medication errors are observed, followed by their impact on outcome measures. Furthermore, outcome measures associated with medication error quality and safety outcomes are detailed, concluding it with the DMAIC model strategy to ensure all aspects of patient care are fulfilled along with adequate knowledge-sharing among staff.

References

Carver, N., Hipskind, J. E., & Gupta, V. (2019). Medical error. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430763/ 

Guisado-Gil, A. B., Mejías-Trueba, M., Alfaro-Lara, E. R., Sánchez-Hidalgo, M., Ramírez-Duque, N., & Santos-Rubio, M. D. (2019). Impact of medication reconciliation on health outcomes: An overview of systematic reviews. Research in Social and Administrative Pharmacy. https://doi.org/10.1016/j.sapharm.2019.10.011 

Kwon, C.-Y., Lee, B., Kwon, O-Jin., Kim, M.-S., Sim, K.-L., & Choi, Y.-H. (2021). Emotional labor, burnout, medical error, and turnover intention among south korean nursing staff in a university hospital setting. International Journal of Environmental Research and Public Health, 18(19), 10111. https://doi.org/10.3390/ijerph181910111 

Ledlow, G. R., Ledlow, J. R. R. R., Bosworth, M., & Maryon, T. (2023). Leadership for health professionals: Theory, skills, and applications. In Google Books. Jones & Bartlett Learning. https://books.google.com.pk/books?hl=en&lr=&id=Ro6kEAAAQBAJ&oi=fnd&pg=PP1&dq=lack+of+leadership+in+healthcare+organizations+&ots=rUGES8DdOr&sig=e_bHaBAD69AuD_OJYCzzODIQBxA&redir_esc=y#v=onepage&q=lack%20of%20leadership%20in%20healthcare%20organizations&f=false 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 

Musharyanti, L., Claramita, M., Haryanti, F., & Dwiprahasto, I. (2019). Why do nursing students make medication errors? A qualitative study in indonesia. Journal of Taibah University Medical Sciences, 14(3), 282–288. https://doi.org/10.1016/j.jtumed.2019.04.002 

Peltonen, J., Leino-Kilpi, H., Heikkilä, H., Rautava, P., Tuomela, K., Siekkinen, M., Sulosaari, V., & Stolt, M. (2019). Instruments measuring interprofessional collaboration in healthcare – a scoping review. Journal of Interprofessional Care, 34(2), 1–15. https://doi.org/10.1080/13561820.2019.1637336 

Sutton, R., & Pincock, D. (2020). An overview of clinical decision support systems: Benefits, risks, and strategies for success. NPJ Digital Medicine, 3(1), 1–10. https://doi.org/10.1038/s41746-020-0221-y Trakulsunti, Y., Antony, J., Dempsey, M., & Brennan, A. (2020). Reducing medication errors using lean six sigma methodology in a thai hospital: An action research study. International Journal of Quality & Reliability Management. https://doi.org/10.1108/ijqrm-10-2019-0334