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NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

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    NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

    Student Name

    Capella University

    NURS-FPX 6212 Health Care Quality and Safety Management

    Prof. Name


    Planning for a Change: A Leader’s Vision

    Hello everyone, I am ——, and I welcome you all to this presentation on planning for a change in minimizing medication errors.

    Presentation Agenda  

    This presentation will provide the primary plan to revamp outcomes and foster a culture of quality and safety within a healthcare organization. For this purpose, first, I would like to review the importance of safety and quality outcomes in healthcare organizations and then summarize critical aspects of the plan that ensure an enhanced safety culture. Then we will begin discussing how the existing organizational functions, processes, and behaviors impact safety and quality regarding medication errors. Then, we will cover existing outcome measures regarding quality and safety, followed by the required ways to attain improved health outcomes. Lastly, we will create an organizational future vision on developing and preserving a safety culture and how nurse leaders can play an influential role in developing this culture. So, let’s begin.

    Importance of Safety and Quality Outcomes in Healthcare Systems

    Safety and quality outcomes are the cornerstones of every healthcare organization to ensure patients’ safety and well-being. Acquiring good quality care and treatment is a basic right of every patient, and it is the hospital’s responsibility to provide patients with appropriate and timely care treatments to lower the risk of medical errors and relevant complications. Moreover, safe and high-quality care treatments improve patient satisfaction and impart public trust in healthcare systems and their services (WHO, 2021). Healthcare organizations can retain professionals when safety and quality care outcomes are achieved as the care providers get a supportive environment where the primary goal is to deliver safe and high-quality care treatment to patients. Additionally, when the quality of care brings safe and quality outcomes, it aligns with the ethical principles of care treatment by preventing harm and delivering the proper treatment to the right people leading to the best possible health outcomes.

    Key Aspects of Plan to Achieve Culture of Safety

    In achieving a culture of safety while providing medication treatment in a healthcare organization, it is crucial to include several aspects of care treatment, such as:

    • Fostering an environment where healthcare professionals can openly communicate with each other on medication management. This includes encouraging healthcare professionals, particularly nurses, to report adverse events or near-miss incidences and use appropriate hand-off communication on medication administration to avoid medication errors (Hong et al., 2019).
    • Adherence to standardized procedures of medication prescription, dispensing and administration to lower the risk of variability and errors due to wrong medication management process. This is employed by implementing a leadership strategy where team leaders guide relevant healthcare professionals on following SOPs for medication administration and delivery to foster a safety culture (Alghamdi et al., 2019).
    • Developing a robust system for reporting adverse and near-miss events while ensuring a blame-free policy that works for inculcating safety by prompt actions instead of bombarding healthcare professionals with detention and penalties which prevents initial reporting and promotes higher incidence of adverse medication errors
    • Healthcare organizations that support staff training and education on providing the right care treatments through proper medication prescription, dispensing and administration foster a safety culture (Rodziewicz & Hipskind, 2020).

    These critical aspects significantly promote a safety culture while managing medication in the clinical care setup. Healthcare organizations must endeavor to consider and integrate these aspects into practice to achieve quality and safety outcomes and reduce medication errors.

    Existing Organizational Processes, Functions, and Behaviors Influencing Quality and Safety

    There are various existing organizational functions, processes and behaviors that impact the quality and safety of medication management. I will discuss a few of these functions and behaviors in terms of medication management which lead to medication errors adversely impacting the quality of care and patient safety, along with the possible solutions to tackle these functions and behaviors. Lack of interdisciplinary collaboration and communication is a significant cause of medication errors as proper communication is not ensured, which leads to misunderstandings, non-clarity, and confusion in medication management, the consequences of which have to be significantly tolerated by the patient. This behavioral issue can be tackled by implementing electronic health records (EHR), so all healthcare professionals are aligned with the medication history, prescribed drugs and related information to manage medication. 

    Furthermore, the existing functions that rely on traditional methods of medication prescription, dispensing and administration are more vulnerable to the onset of medication-associated adverse events. The traditional methods for medication management may result in medication errors due to prescription, transcription, dispensing and administration. This can be overcome by safety and risk management through the integration of modern technologies that reduce the risks of medication errors. These technologies include barcode medication administration (BCMA), Automated Dispensing Cabinets (ADC) and computerized physician order entry (CPOE) (Carver et al., 2019).

    Moreover, preventive measures that ensure medication safety and improve the quality of care and patient safety can be used proactively before adverse situations arise. Likewise, high-performing organizations which promote staff education and training on medication reconciliation and management and integrate leadership and interprofessional collaboration principles (Guisado-Gil et al., 2019), our organization can utilize such effective measures as well. These changes in processes and behaviors will ensure effective collaboration, manage risk, positively impact care quality, and enhance patient safety.

    Knowledge Gaps, Unknown and Missing Information

    The knowledge gaps, unknown and missing information that hinder an accurate analysis of present organizational functions, processes and behaviors that impact quality and safety include information about existing resources to initiate sustainability plans, leadership commitment towards the change-making, and staff acceptance for the change. Further research and information are required to better analyze the successful operations of these processes and behaviors in a healthcare organization.

    Current Outcome Measures

    In this section, we will discuss the current outcome measures related to the safety and quality of medication management, along with their weaknesses and strengths. Healthcare organizations are currently using various outcome measures to evaluate the safety and quality of medication management. These outcome measures include patient harm, mortality rates, and patient satisfaction based on the type of medication errors, such as prescription errors, dispensing errors and administration errors that cause these safety and quality outcomes. Some healthcare systems use medication reconciliation accuracy and hospital readmission rates as outcome measures. Patient harm reveals the clinical impact a medication error imposes on the patient, along with severity grading in terms of mild harm, moderate harm, severe harm or death. Mortality rates occurring due to medication errors; tell the severity of medication errors and guide healthcare organizations on reducing mortality rates through root-cause analysis.

    The lower patient satisfaction rates depict poor quality and safety in providing care treatment and medication management due to several factors, including medication errors. By finding the data on these outcome measures, healthcare professionals can evaluate the rooms for improvement; for example, patient satisfaction and patient harm direct healthcare staff to take preventive measures to ensure safe and right medication management is delivered to patients as per their health needs. Likewise, mortality rates can guide healthcare professionals on the major medication errors that lead to mortality and by utilizing strategies and plans, they can prevent these errors.

    NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

    Hence, these outcome measures facilitate a culture of safety and quality in a healthcare organization. These outcome measures holds specific weaknesses, such as underreporting by nurses which can prevent detection, leading to delayed intervention (Roumeliotis et al., 2019). The strengths of the outcome measures indicate that mortalities have a significant clinical impact that directs toward the seriousness of medication errors and thus, organization will take prompt actions. Moreover, patient satisfaction levels inspire healthcare leaders to keep improving. 

    Moreover, this can drive a change in processes of medication management where patient safety is prioritized. Using this outcome measure raises ethical and emotional questions as the mortality rate reveals the number of human lives lost due to medication errors. Patient satisfaction incorporates patients’ perspectives regarding medication management and treatment quality and safety (Nurmeksela et al., 2021). This outcome measure needs to be more vital regarding inaccurate dissemination of information related to medication-related issues due to knowledge gaps and the need for more education among patients. 

    Steps Required to Achieve Improved Outcomes

    Following are the ways or steps needed to secure improved outcomes in healthcare systems in terms of minimizing medication errors:

    • The first step is to gather data on medication errors through EHR systems or documented data in catalogs or dashboard metrics. This can be done by nurses and quality control department personnel collaboratively. Further, the data are analyzed by healthcare professionals and administrators to find the number of medication errors and the types occurring. The baseline measurement data is collected from which improvements can be initiated. Next, healthcare professionals will conduct a root cause analysis of medication errors to find the missed steps and deviated protocols that led to the incidence of medication errors. Once the root causes are identified, the risk-to-benefit ratio of improving the changes is calculated. 
    • Once the problem is identified, prospective planning changes the overall system. For instance, integrating technologies like CPOE and BCMA. CPOE ensures electronic prescription and reduced medication errors due to prescription and transcription. Moreover, the BCMA assures nurses that the correct medication is being administered by matching patient identification with medication through the barcode mentioned on the patient’s bed or wrist and medication container. This technology prevents medication administration errors (Mulac et al., 2021).   
    NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision
    • Moreover, adequate staff training on medication safety can be an effective preventive measure to assure safe medication management. Staff will be trained and aware of medication errors and will assure interprofessional collaboration and implementation of standardized protocols. 
    • Leadership roles in medication management will improve the quality of care as the nurse leaders practice according to protocols and lead others by becoming a real-life example; novice nurses follow the leader’s footsteps and promote a culture of safe medication delivery and management.

    The implemented changes are observed and evaluated through dashboard metrics and outcome measures, and further improvements are brought accordingly if the medication errors are under control. Changes are sustained by policymaking and adequate surveillance systems. These steps are performed using the DMAIC change model of the six-sigma strategy that promises continuous improvement in any organization.


    The underlying assumptions of this change plan include the following:

    • Well-trained staff on proper medication management, including prescription, dispensing and proper administration techniques, can lower the risk of medication errors.
    • Integrating technologies for medication error prevention can reduce human-error-based adverse events of medication errors.
    • Policy development of prompt incidence reporting and surveillance systems can promote a culture of safety and quality regarding medication errors.

    Future Vision

    In the future, I visualize an organization where interprofessional collaboration establishes an adequate culture of safety and quality to ensure medication safety. This interprofessional collaboration is deep-rooted by solid leadership roles and administration policy development. This culture of safety and quality will be solely based on open, transparent and seamless communication among physicians, nurses, pharmacists and healthcare administrators for effective and efficient delivery of care treatments and medication management.

    Moreover, healthcare organizations will have at least one integrated technology for safe medication delivery to reduce medication errors, such as BCMA, CPOE, or EHR (Carver et al., 2019). Patient safety remains the cornerstone for all healthcare professionals and organizational authorities for effective policies, such as prompt incidence reporting policy and compliance to standardized protocols on safe medication delivery, to be developed and implemented. Nurse leaders will be crucial in thriving a safe medication culture as they advocate for patient safety by fostering necessary resources, demanding healthcare technologies and practical training for novice nurses to ensure safe medication management.

    Moreover, through transformational leadership and collaborative leadership, nurse leaders will work for a desired future where all healthcare professionals align to provide productive and proper medication to speed up patients’ recovery and improve the quality of care. Nurse leaders will foster a culture of reporting medication errors that follows adequate education and training to prevent future medication errors. I envision that healthcare systems will be able to provide safe and quality through keen attention and efforts for the welfare of patients. Therefore, I propose these changes to foster a culture of quality and safety in healthcare organizations.


    To conclude, we discussed the critical aspects of developing a safety culture in healthcare organizations, including transparent communication, effective interprofessional collaboration, staff training and adherence to a standardized protocol. Furthermore, we identified the functions and behaviors that persist in organizations affecting quality and safety, followed by outcome measures related to medication errors, such as mortality rates, patient harm and patient satisfaction. Later, we discussed how the DMAIC model of the five-step methodology could achieve improved outcomes of improved quality and safety in medication management. Lastly, I shared my future vision that fosters a culture of quality and safety and the nurse’s role as leader in developing that potential within a healthcare system.


    Alghamdi, A. A., Keers, R. N., Sutherland, A., & Ashcroft, D. M. (2019). Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: A systematic review. Drug Safety, 42(12).

    Carver, N., Hipskind, J. E., & Gupta, V. (2019, April 28). Medical error. StatPearls Publishing. 

    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.  

    NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

    Hong, K., Hong, Y. D., & Cooke, C. E. (2019). Medication errors in community pharmacies: The need for commitment, transparency, and research. Research in Social and Administrative Pharmacy, 15(7), 823–826.

    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.  

    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). 

    Rodziewicz, T., & Hipskind, J. (2020). Medical error prevention (pp. 1–37). 

    Roumeliotis, N., Sniderman, J., Adams-Webber, T., Addo, N., Anand, V., Rochon, P., Taddio, A., & Parshuram, C. (2019). Effect of electronic prescribing strategies on medication error and harm in hospital: A systematic review and meta-analysis. Journal of General Internal Medicine, 34(10), 2210–2223. 

    NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

    WHO. (2021). Global patient safety action plan 2021-2030: Towards eliminating avoidable harm in health care. In Google Books. World Health Organization.