NURS FPX 4020 Capella University Quality Care and Patient Safety Paper
you will use a template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue. ***I will send a complete example of what they are looking for, also in an attachment**
**KEEP IN MIND THE TOPIC IS PERTAINING TO MEDICATION ADMINISTRATION! AND NOT FALLS!**
*THE ATTACHED EXAMPLE IS ABOUT PATIENT FALLS, THE EXAMPLE IS ONLY TO SHOW HOW THE LAYOUT SHOULD LOOK**
For this next one, we can choose from the following options as the subject of a root-cause analysis and safety improvement plan
1) The specific safety concern identified in your previous assessment (from our last ) pertaining to medication administration safety concerns.
2)The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.
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For this assessment, you will use a supplied template to conduct a root-cause analysis of a quality or safety issue in a health care setting of your choice and outline a plan to address the issue.
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections. Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 1: Analyze the elements of a successful quality improvement initiative.
Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
Create a viable, evidence-based safety improvement plan for safe medication administration.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
Competency 3: Identify organizational interventions to promote patient safety.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Professional Context
Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.
Scenario
For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:
The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.
Instructions
The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.
Use the Root-Cause Analysis and Improvement Plan Template [DOCX] to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.
Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand ;what is needed for a distinguished score.
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
Create a feasible, evidence-based safety improvement plan for safe medication administration.
Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.
Assessment 2 ;Example [PDF].
Additional Requirements
Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4-6 page root cause analysis and safety improvement plan pertaining to medication administration.
Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: Format references and citations according to current APA style.
Patient Safety Quality Improvement Project- Medication Errors in the Emergency Department Sample Approach
Patient Safety Quality Improvement Project: Sample Approach for Medication Errors in the Emergency Room
Medication mistakes in the emergency room (ED) are a major health problem in modern medicine. A lot of medication mistakes happen in the ED because of how it is set up and what goes on there. Such mistakes cause healthcare costs to go up, care to be of poor quality, patients to be unhappy, and rates of illness and death to be high. Every year, medication mistakes in the ED cost the health care industry more than $4 billion (Walsh et al., 2018). Communication, both in writing and in person, is a key part of reducing medication mistakes. This essay is about a project to improve patient safety in the emergency room by reducing medication errors and their effects.
Project Aims
Patient safety problems are often caused by poor communication and missing links. Medication mistakes happen more often in the ED because of how quickly things are done there. Medication mistakes in the ED are caused by wrong doses, not following rules, the fact that the ED is for emergencies, bad communication, and more work (Di Simone et al., 2018). The main goal of the project is to improve communication between nurses and other health care providers in three months to cut down on medication errors, make it easier to report medication errors, and lower the costs of care related to medication errors. Another goal is to improve or promote good communication during the process of giving medications. Another goal is to make sure that the patient’s medications are given correctly and quickly. The project also wants to improve how the emergency department reports how medicines are given. The process of giving medications and the process of evaluating them will be based on these goals and objectives.
What’s going on now
Drugs are given to patients by doctors or advanced practice registered nurses. Most of the time, you can buy these drugs at a department store, and the nurses give them out according to the prescription. In some cases, nurses give drugs to patients without written prescriptions in order to save lives. Most prescriptions are written by hand, so they can be hard to read or have missing files (Hassan, 2018). Also, transcription in the ER is done quickly, which makes mistakes more likely.
Medication errors in the ED can also happen when drugs, especially LASA drugs, are not put in the right order. This is because emergency departments are usually busy and people are in a hurry (Martyn, Palliadeli, & Perry, 2019). The prescription sheets are then used to give the drugs to the patients. The nurses on duty are in charge of giving these drugs, and at the end of every shift, the patients are handed over at the nursing desk. Medication errors aren’t reported as often in the ED because nurses who make mistakes are punished harshly (Dirik et al., 2019 NURS FPX 4020 Capella University Quality Care and Patient Safety Paper). There are many ways to make these practices better that need to be looked at.
Figure 1. Drug administration as it is done now.
Ideas for how to fix or change medication mistakes
Medication mistakes in the ED often happen because people don’t talk to each other well. Several interventions that have been shown to work well to improve communication. One solution is the ISBAR method of handing over patients at their bedsides (Marmor & Li, 2017). This method is very important because patients move around a lot in this department compared to other departments. This is because they are moved to other departments to make room for other patients. So, it is important to pay attention to the details of each patient (Di Simone et al., 2018). With this intervention, the nurses get to know the patients, and during each shift, they check the patient’s condition and medications to see if anything needs to be changed or adjusted. During this step, transcription errors can be avoided by good communication at the bedside (Marmor & Li, 2017). The method also keeps nurses from getting confused or forgetting about patients when they hand them over at the nursing desk. There is a lot of evidence that this intervention works, and it is a great way to cut down on medication mistakes.
Written communication is prone to mistakes like not being able to read the words or mistakes in the transcription. By using electronic health records, which help with ordering, transcription, and documentation in the process of giving medications, you can avoid making these mistakes (Ratwani et al., 2018). The information is also in the systems, where it can be checked and thought about at any time. These systems make the workplace more formal and are easier to use and more effective than older ones (Patient files). Electronic health records also increase accountability by making sure that accurate documentation is kept and that all healthcare providers can see the information. They also help track down medication mistakes in the ED (Alotaibi & Federico, 2017). Medication errors that are written down help hospitals keep track of their data, and they can also be checked up on to make sure they don’t happen again.
Using an Helpant or medication administration companion is another good way to cut down on mistakes when giving drugs. Most medication errors are caused by mistakes with how the medicine is given (Gomes et al., 2021). Due to time pressure, there are more mistakes in the emergency room than in other parts of the hospital. When giving drugs by yourself, you might not notice mistakes, but if you have a friend with you, you can check. Usually, a qualified and experienced nurse makes sure that drug administration rights are followed. Having someone with you when you take a drug makes it work better and keep you safe (Douglas et al., 2018). Drug mix-ups like LASA (look-alike, sound-alike) drugs don’t happen when you have a friend with you. It also helps fix any other mistakes that might have happened during the ordering and typing. Drug administration mistakes are much less likely to happen when the intervention is used instead of just one nurse. The mentioned interventions will be important parts of the change project because they will improve communication, increase accuracy and effectiveness, and make it easier for people in the ED to report medication errors.
Taking a look at the project
The Assessment will be based on the project’s goal. As was already said, the goal of the project is to cut down on medication mistakes in the ED. According to Parasrampuria and Henry (2019), the most accurate and relevant way to figure out how well the project worked is to look at hospital data and records. The hospital records have information like how often medication errors happen in the ED on average and how many people die or get sick because of medication errors. The effects of the proposed project would be clear from an analysis of this information. The patient self-reported satisfaction report analysis will also show how well the ideas for change are working.
The cost-benefit analysis will be a key part of figuring out how well this project is going. The cost-benefit analysis involves comparing the costs of doing a project with the benefits it brings (Mishan & Quah, 2020). For the project to be thought about, the benefits must be more than the costs. The project has a lot of health care costs, like training health care workers and setting up information systems for health care. The project’s benefit is lowering the number of deaths and illnesses and lowering the costs of healthcare that are caused by medication errors. The analysis of these costs and benefits gives a basis for making decisions about how to implement the process.
Conclusion
Nursing is a dynamic field that requires change and new ways of doing things. Medication mistakes in nursing threaten the quality of care and the safety of the patient, especially in the emergency room. They are also a big reason why health care costs are going up. Nurses must figure out how things are done now and where the systems are broken so they can come up with effective ways to prevent medication errors and other big problems in nursing. Also, technological progress is a big part of how practice changes. Assessments before and after a project is put into action are very important. An Assessment helps figure out if a project is useful and what its benefits are, which saves money.
NURS FPX 4020 Capella University Quality Care and Patient Safety Paper References
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety. Saudi Medical Journal, 38(12), 1173–1180. DOI: https://doi.org/10.15537/smj.2017.12.20631
Dirik, H. F., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5-6), 931-938. https://doi.org/10.1111/jocn.14716
Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 22(5), 346. Doi: 10.4103/ijccm.IJCCM_63_18
Douglass, A. M., Elder, J., Watson, R., Kallay, T., Kirsh, D., Robb, W. G., Kaji, A. H., & Coil, C. J. (2018). A randomized controlled trial on the effect of a double check on the detection of medication errors. Annals of emergency medicine, 71(1), 74-82. https://doi.org/10.1016/j.annemergmed.2017.03.022
Gomes, A. N. H., da Silva, R. S., Alves, E. B., da Silva Moura, G., & de Oliveira, H. M. (2021). Safety in the administration of injectable medications: Scoping review. Research, Society and Development, 10(6), e1510615381-e1510615381. https://doi.org/10.33448/rsd-v10i6.15381
Hassan, I. (2018). Avoiding medication errors through effective communication in a healthcare environment. Movement, Health & Exercise, 7(1), 113-126. http://dx.doi.org/10.2139/ssrn.3573437
Marmor, G. O., & Li, M. Y. (2017). Improving emergency department medical clinical handover: Barriers at the bedside. Emergency Medicine Australasia, 29(3), 297-302. https://doi.org/10.1111/1742-6723.12768
Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication: Nursing behaviors beyond the five rights. Nurse Education in Practice, 37, 109-114. https://doi.org/10.1016/j.nepr.2019.05.006
Mishan, E. J., & Quah, E. (2020). Cost-benefit analysis. (6th Ed.). Routledge.
Parasrampuria, S., & Henry, J. (2019). Hospitals’ Use of Electronic Health Records Data, 2015-2017. ONC Data Brief, 46, 1-13.
Ratwani, R. M., Savage, E., Will, A., Arnold, R., Khairat, S., Miller, K., Fairbanks, R. J., Hodgkins, M., & Hettinger, A. Z. (2018). A usability and safety analysis of electronic health records: a multi-center study. Journal of the American Medical Informatics Association, 25(9), 1197-1201. https://doi.org/10.1093/jamia/ocy088
Walsh, E. K., Hansen, C. R., Sahm, L. J., Kearney, P. M., Doherty, E., & Bradley, C. P. (2017). Economic impact of medication error: a systematic review. Pharmacoepidemiology and Drug Safety, 26(5), 481-497. https://doi.org/10.1002/pds.4188
