Nurs FPX 4020 Assessment 1 Enhancing Quality and Safety

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Assessment 1: Enhancing Quality and Safety
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Capella University
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Course Name
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Prof Name
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Enhancing Quality and Safety
Patient safety utilizes safety science principles to establish a reliable healthcare delivery system
(Brigitta & Dhamanti, 2020). Medication administration errors (MAEs) pose a threat to patient life
and, if not fatal, can lead to treatment setbacks, prolonging hospital stays. Consequently, patient
trust in healthcare systems declines, accompanied by increased treatment costs. This study
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aims to examine factors contributing to MAEs and explore strategies for enhancing patient care
quality.
Factors Contributing to Patient Safety Risks
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To illustrate the primary elements contributing to patient safety risks in healthcare institutions, a
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medication error incident in a hospital is discussed. In a busy hospital, Nurse Ella inadvertently
administered rapid-acting insulin, at an elevated dose, to Mr. Wallace, a diabetic patient
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prescribed a long-acting insulin. Recognizing the error, the nurse promptly notified the charge
nurse and the physician, who intervened to address the symptoms of hypoglycemia.
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Nurses, responsible for drug administration, play a crucial role in ensuring safe and accurate
treatment. In an institutional-based cross-sectional study, 57.7% of participating nurses
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experienced MAEs, with 30.4% reporting errors occurring more than three times (Tsegaye et al.,
2020). Factors contributing to these errors include inadequate training, prescribing errors,
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stress, burnout, and communication gaps among healthcare professionals.
Lack of Knowledge and Training

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Inadequate knowledge about drug doses, interactions, contraindications, and potential adverse
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effects, coupled with a lack of experience, contributes significantly to medication administration

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errors. Research indicates that 78.7% of medication errors stem from insufficient nurse training
(Hassen et al., 2022). Nurses with advanced pharmaceutical knowledge and proper training
exhibit lower rates of medication administration errors.
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Communication Gap Between Healthcare Professionals

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Insufficient communication and collaboration among healthcare staff, including pharmacists,

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physicians, and nurses, can result in medication errors. Hospitals with communication gaps
among healthcare staff experience a higher incidence of medication administration errors
(Ghasemi et al., 2022).
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Prescribing Errors
Prescription errors, inaccurately prescribing medications leading to incorrect dosage and
inappropriate instructions, account for a substantial portion of medication administration errors.
In one study, incompletely written prescriptions contributed to 71% of prescription-related errors,
with transcription errors contributing to the remaining 29% (White et al., 2019).
Stress, Burnout, and Mental Health Challenges Among
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Healthcare Workers
Elevated stress levels among nurses, stemming from excessive workloads, long shifts, moral
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dilemmas, and a lack of social support, can lead to burnout and negatively impact mental
health. A study found that nurses with burnout were five times more likely to cause patient care
and medication errors (White et al., 2019).
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Evidence-Based Best Practices Solutions
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To enhance patient safety and reduce medication administration costs, evidence-based and
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best practice solutions are crucial. Several techniques, supported by academic or professional
sources, include
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1. QSEN Approach: Focusing on patient-centered care, teamwork, evidence-based
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practice, quality improvement, patient safety, and informatics in healthcare provision, the
QSEN approach significantly improves nurses' education on quality and safety
(Watanabe et al., 2021).
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2. Medication Reconciliation Procedures: Contrasting a patient's current pharmaceutical

regimen with prescriptions significantly improves patient safety during care transitions
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(Koprivnik et al., 2020).

3. Computerized Physician Order Entry (CPOE) Systems: Electronically submitting
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medicine orders through CPOE systems reduces the risk of adverse drug events
(Skalafouris et al., 2022).
4. Barcode Medication Administration (BCMA) Systems: Using patient identification
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and barcoded labels on pharmaceuticals enhances patient safety by preventing drug

errors (Ye, 2023).
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5. Clinical Decision Support System (CDSS): Offering research-based suggestions at

the point of care helps prevent negative outcomes by notifying healthcare professionals
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about potential medication issues.
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6. Value-Based Formulary Management Strategies: Choosing medicines based on
clinical potency, cost-effectiveness, and safety helps maintain high healthcare quality
while cutting pharmaceutical expenditures (Weinmeyer et al., 2021).
Nurse-Led Coordination to Optimize Patient Safety

Nurses, in collaboration with other healthcare administrators, significantly improve medication
administration accuracy. Clear communication between nurses, physicians, pharmacists, charge
nurses, and IT personnel decreases the likelihood of errors. Interventions such as
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double-checking and collaboration with pharmacists reduce prescription transcribing errors and
contribute to patient safety and cost-effectiveness in healthcare (Alrabadi et al., 2021).
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Enhancing Quality and Safety
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Nurses can enhance cost-effectiveness by collaborating with pharmacists in developing
value-based formularies (Weinmeyer et al., 2021). Collaboration with IT personnel enables the
effective use of technology tools (CPOE, BCMA, and CDSS) to prevent medication
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administration errors (Ye, 2023). A holistic care approach, promoted through interdisciplinary
teams and compliance with regulatory requirements, reduces error risks, ensuring patient safety
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and cost-effectiveness in healthcare.
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Nurses' Coordination with Other Stakeholders
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Improving medicine delivery involves collaboration between nurses, physicians, pharmacists,

patients, and nursing leadership. Quality improvement teams and nursing staff can work
together to evaluate challenges in healthcare settings and implement effective strategies and
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processes. Efficient collaboration between nurses and IT personnel is essential for the correct
use of informatics, ensuring better adherence and patient satisfaction. Patient safety is
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prioritized at the organizational level by involving medication safety officers and administrators,
while professional associations offer tools for continuous advancement in medical practices.
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Conclusion
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Medication administration errors pose significant risks to patients and increase treatment costs.
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Identifying contributing factors and implementing suitable remedial plans, such as medication
reconciliation, technological advancements, teamwork, value-based approaches, and the QSEN
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approach, can prevent these errors. Efficient collaboration between nurses and other
stakeholders significantly enhances patient care quality, contributing to improved healthcare
outcomes.
Call Us Now (612) 234-7670
References
Alrabadi, N., Shawagfeh, S., Haddad, R., et al. (2021). Medication errors: A focus on nursing
practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86.
https://doi.org/10.1093/jphsr/rmaa025
Ghasemi, F., Babamiri, M., & Pashootan, Z. (2022). A comprehensive method for the
quantification of medication error probability based on fuzzy SLIM. PLOS ONE, 17(2),
e0264303. https://doi.org/10.1371/journal.pone.0264303
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Hassen, A., Abozied, A., Mahmoud, E., & El-Guindy, H. (2022). Mental health nurses’
knowledge regarding patients’ rights and patients’ advocacy. NILES Journal for Geriatric and
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Gerontology, 5(2), 307–324. https://doi.org/10.21608/niles.2022.243510
Koprivnik, S., Albiñana-Pérez, M. S., López-Sandomingo, L., et al. (2020). Improving patient
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safety through a pharmacist-led medication reconciliation program in nursing homes for the
elderly in Spain. International Journal of Clinical Pharmacy, 42(2), 805–812.
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https://doi.org/10.1007/s11096-020-00968-
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Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult
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medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1),
1–29. https://doi.org/10.1177/2042098620968309
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Skalafouris, C., Reny, J.-L., Stirnemann, J., et al. (2022). Development and assessment of
PharmaCheck: An electronic screening tool for the prevention of twenty major adverse drug
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events. BMC Medical Informatics and Decision Making, 22(1).

https://doi.org/10.1186/s12911-022-01885-8
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Watanabe, Y., Claus, S., Nakagawa, T., et al. (2021). A study for the evaluation of a safety
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education program for nursing students: Discussions using the QSEN safety competencies.
Journal of Research in Nursing, 26(1-2), 97–115. https://doi.org/10.1177/1744987121994859
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Weinmeyer, R. M., McHugh, M., Coates, E., et al. (2021). Employer-led strategies to improve
the value of health spending: A systematic review. Journal of Occupational & Environmental
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Medicine, 64(3), 218–225. https://doi.org/10.1097/jom.0000000000002395

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Ye, J. (2023). Patient safety of perioperative medication through the lens of digital health and
artificial intelligence. JMIR Perioperative Medicine, 6(1), e34453. https://doi.org/10.2196/34453
Call Us Now (612) 234-7670

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Assessment 1: Enhancing Quality and Safety

Factors Contributing to Patient Safety Risks

stress, burnout, and communication gaps among healthcare professionals.

Lack of Knowledge and Training

effects, coupled with a lack of experience, contributes significantly to medication administration

Communication Gap Between Healthcare Professionals

Insufficient communication and collaboration among healthcare staff, including pharmacists,

Stress, Burnout, and Mental Health Challenges Among

2. Medication Reconciliation Procedures: Contrasting a patient's current pharmaceutical

(Koprivnik et al., 2020).

and barcoded labels on pharmaceuticals enhances patient safety by preventing drug

5. Clinical Decision Support System (CDSS): Offering research-based suggestions at

about potential medication issues.

Nurse-Led Coordination to Optimize Patient Safety

Improving medicine delivery involves collaboration between nurses, physicians, pharmacists,

events. BMC Medical Informatics and Decision Making, 22(1).

Medicine, 64(3), 218–225. https://doi.org/10.1097/jom.0000000000002395

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