Assessment 1: Enhancing Quality and Safety Essay

Assessment 1: Enhancing Quality and Safety Essay

 

Enhancing Quality and Safety

Medication errors, which can occur at any stage in the medication use process, can have serious consequences for patients. Common types of errors include prescribing the wrong medication or dose, administering the medication to the wrong patient, and not following established protocols. Strategies to reduce the risk of medication errors include double-checking medication orders, using computerized prescribing systems, and providing staff with education and training on medication safety practices. The purpose of this paper is to summarize an experience where a medication error occurred, analyze patient safety risks from this scenario, provide potential evidence-based preventive solutions, explain how nurses can coordinate this prevention, and identify stakeholders with whom the nurse should coordinate.

Experience Summary

Mr. X, a 52-year-old black male, had been admitted to our inpatient unit for the past three days. During this admission, he was diagnosed with stage II hypertension. Among his regimen was Lisinopril tabs for hypertension. His physician had prescribed 10mg tabs once daily on the day of his discharge from the hospital. A pharmacist, who was licensed, dispensed the medication and checked that it was the correct medication and had not expired. However, the pharmacist made a mistake in filling the prescription and gave the patient 20 mg tablets of Lisinopril instead of the prescribed 10 mg tablets. The patient, who was a nurse, took the medication as directed and experienced severely low blood pressure and dizziness, requiring treatment at the emergency department the following day.

Patient Safety Risks from This Scenario

In the scenario described, the patient experienced a range of patient safety risks due to the medication error, including an adverse drug reaction, a delay in treatment, inconvenience, and financial costs (Vaismoradi et al., 2020). The adverse drug reaction was caused by the patient receiving a higher than the prescribed dose of Lisinopril, which resulted in symptoms such as hypotension and dizziness. The delay in treatment and inconvenience resulted from the patient having to go to the emergency department for treatment. The financial costs included the cost of treatment at the emergency department and any additional medical care that may be required. This situation highlights the importance of addressing potential issues in the medication use process to ensure the safety of patients.

Potential Evidence-Based Preventive Solutions

Medication errors pose significant risks to patient safety and are a common problem in healthcare settings. In the scenario described, a patient experienced an adverse drug reaction due to receiving a higher than the prescribed dose of Lisinopril, which caused symptoms such as hypotension and dizziness. The patient also experienced a delay in treatment, inconvenience, and financial costs as a result of the error. Several evidence-based preventive solutions can be implemented to prevent similar errors and improve patient safety. For example, using computerized prescribing systems can help reduce the risk of errors by alerting healthcare professionals to potential issues with prescriptions. Implementing a policy of double-checking medication orders and administration can also help reduce the risk of errors. Standardizing processes for prescribing, dispensing, and administering medication can also help reduce the risk of errors, as can providing education and training on medication safety practices to healthcare professionals (Mohanna et al., 2022). This healthcare organization can help reduce the risk of medication errors and improve patient safety by implementing these and other evidence-based preventive solutions.

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Nurse Coordination to Reduce Costs and Improve Patient Medication Administration Safety

In healthcare settings, nurse coordination can be a useful tactic for cutting costs and enhancing patient drug administration safety. The administration of medications can be made more efficient and less error-prone by collaboration between nurses and other healthcare providers. Nurses can act as a central point of contact for organizing medication orders to ensure that the right medication is prescribed, distributed, and provided to the right patient at the right time. They can be crucial in monitoring and assessing the efficacy of medications, as well as in spotting and resolving any potential problems that may arise during prescription use (Williams et al., 2021). Nurses can assist lower costs and increasing patient safety by lowering the chance of prescription errors by coordinating their efforts and collaborating closely with other healthcare professionals.

Coordinating Stakeholders

An efficient method for enhancing medication safety in hospital settings is nurse coordination. Nurses can engage with various stakeholders, such as doctors, pharmacists, patients, caregivers, and quality improvement teams, to accomplish this (Russ-Jara et al., 2021). Nurses can assist in ensuring that the appropriate medication is prescribed, supplied, and provided to the appropriate patient at the appropriate time by working with these stakeholders. They can be crucial in monitoring and assessing the efficacy of medications, as well as in spotting and resolving any potential problems that may arise during prescription use (Mardani et al., 2020). Nurses can improve the quality and safety of drug administration and contribute to the safety of their patients by collaborating with other healthcare providers.

Conclusion

Medication errors can have serious consequences for patients and can occur at any stage in the medication use process. Strategies to reduce the risk of errors include double-checking medication orders, using computerized prescribing systems, and providing education and training on medication safety practices. Nurse coordination can help reduce costs and improve patient safety by streamlining the medication use process, coordinating medication orders, and monitoring and evaluating the effectiveness of medications. Nurses can coordinate with stakeholders such as physicians, pharmacists, patients, caregivers, and quality improvement teams to drive quality and safety enhancements with medication administration. By implementing these strategies, healthcare organizations can help reduce the risk of medication errors and improve patient safety.

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References

Mardani, A., Griffiths, P., & Vaismoradi, M. (2020). The role of the nurse in the management of medicines during transitional care: A systematic review. Journal of Multidisciplinary Healthcare13, 1347–1361. https://doi.org/10.2147/JMDH.S276061

Mohanna, Z., Kusljic, S., & Jarden, R. (2022). Investigation of interventions to reduce nurses’ medication errors in adult intensive care units: A systematic review. Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses35(4), 466–479. https://doi.org/10.1016/j.aucc.2021.05.012

Russ-Jara, A. L., Luckhurst, C. L., Dismore, R. A., Arthur, K. J., Ifeachor, A. P., Militello, L. G., Glassman, P. A., Zillich, A. J., & Weiner, M. (2021). Care coordination strategies and barriers during medication safety incidents: A qualitative, cognitive task analysis. Journal of General Internal Medicine36(8), 2212–2220. https://doi.org/10.1007/s11606-020-06386-w

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 Health17(6), 2028. https://doi.org/10.3390/ijerph17062028

Williams, R., Aldakhil, R., Blandford, A., & Jani, Y. (2021). Interdisciplinary systematic review: does alignment between system and design shape adoption and use of barcode medication administration technology? BMJ Open11(7), e044419. https://doi.org/10.1136/bmjopen-2020-044419

Assessment 1 Instructions: Enhancing Quality and Safety

For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best- practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Ouality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000— 440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.

You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

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
    • Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
  • Competency 2: Analyze factors that lead to patient safety
    • Explain factors leading to a specific patient-safety risk focusing on medication
  • Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce
    • Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.

Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.

  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that

supports safe and effective patient care.

Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.

 

o Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA

References   format.

Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-  hospitals.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system.

Washington, DC: National Academy Press.

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

Consider a previous experience or hypothetical situation pertaining to medication errors, and consider how the error could have been prevented or alleviated with the use of evidence-based guidelines.

Choose a specific condition of interest surrounding a medication administration safety risk and incorporate

evidence-based strategies to support communication and ensure safe and effective care.

 

For this assessment:

 

  • Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as OSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.

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 that you know what is needed for a distinguished score.

  • Explain factors leading to a specific patient-safety risk focusing on medication
  • Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
  • Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.

 

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