Assessment 1 Instructions: Enhancing Quality and Safety 

Assessment 1 Instructions: Enhancing Quality and Safety 

Assessment 1 Instructions: Enhancing Quality and Safety 

A medication error is defined as any preventable event that can cause or end up in improper drug use or patient harm when the medication is under a healthcare professional, patient, or healthcare consumer. Medication errors transpire when prescribing pharmacological treatment, entering patients’ health information into an electronic database, or during drug preparation and dispensation (Zhou et al., 2018). Besides, medication errors are common in the healthcare systems occurring in almost all healthcare settings worldwide and are associated with significant morbidity and mortality rates in patients. The purpose of this paper is to discuss factors that contribute to patient-safety risk in medication administration, evidence-based solutions, and coordination of care to improve patient safety in medication administration.


Factors Leading to a Specific Patient-Safety Risk Focusing On Medication Administration

In my current healthcare facility, a new graduate registered nurse in the adult medical-surgical unit administered 20IU of Insulin Lispro to the wrong patient. This led to the patient becoming hypoglycemic since he had limited dietary intake due to nausea and vomiting. Fortunately, the situation was solved when another nurse noticed that the patient was sweating, trembling, and looked fatigued. The nurse quickly checked the patient’s RBS, which was at 1.2, and he was started on 50% Dextrose to boost the blood sugar. Medication errors can transpire at any phase of the drug use process, such as during prescribing, transcribing, dispensing, or administering (Tsegaye et al., 2020). However, most medication errors occur during the administration of medications. Registered nurses administer most medications in the inpatient settings.

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The commonly occurring medication administration errors (MAEs) include wrong patient, wrong drug, wrong dose, wrong route, wrong time, omission of doses, failure to document, and technical errors. Noise, chaotic working environments, and heavy nursing workloads create the ground for distractions and interruptions, leading to MAEs (Schroers et al., 2021). In addition, linguistic barriers lead to challenges in identifying the correct patient. Poor communication between nurses during change of shifts results in failure to communicate important patient treatment information, which contributes to MAEs.

Understaffing and heavy workloads on nurses lead to MAEs. Understaffed nurses report experiencing work pressure, lacking adequate time to attend to patients, and feeling rushed when administering medication. Working under pressure leaves room for errors. Besides, work pressure, heavy workloads, and understaffing are associated with nurse fatigue and physical exhaustion, contributing to MAEs (Schroers et al., 2021). In addition, lack of supervision, especially for novice nurses, contribute to MAEs since they feel pressured to deliver, which causes mental distractions. Lastly, poor physical working conditions, such as poor lighting in the wards, contribute to MAEs as the nurse may pick the wrong medication or read the wrong drug and dose.

Evidence-Based and Best-Practice Solutions to Improve Patient Safety Focusing On Medication Administration and Reducing Costs

Reducing MAEs is a major way to improve patient safety and reduce healthcare costs associated with complications from medication errors. Using computerized prescribing systems is one of the best practice solutions to reduce MAEs (Naidu & Alicia, 2019). The adoption of technology in administering medications has improved medication safety. Relevant technology includes the Barcode medication administration (BCMA) technology, which enhances patient identification and ensures that the right drug is administered to the right patient through the right route and at the right time. BCMA utilizes barcode labeling of patients, drugs, and patients’ records and electronically connects the prescribed drug and dose to the correct patient (Naidu & Alicia, 2019). Therefore, the nurse scans the barcode on the medication to ensure it is the right drug and scans the barcode on the patient’s armband to ensure the drug is administered to the right patient.

Another solution is for healthcare organizations to hire skilled and experienced nurses. Studies show that MAEs occur mostly because of a shortage of nurses and having less experienced nurses. Newly graduated nurses perpetrate more MAEs related to minimal work experience and inadequate pharmacological knowledge (Salar et al., 2020). Thus, the best practice is to have skilled, experienced nurses working alongside and supervising newly graduated nurses.

Nurses should be encouraged to report MAEs without punitive measures to help them learn from them and prevent similar cases in the future. Hong et al. (2019) assert that it is crucial to identify the type of MAE and support nurses to reveal the errors. When nurses participate in sessions about the causes of MAEs and their identification, it reduces the incidence of errors and their recurrence. Reporting helps identify the MAE and thus prevent its consequences and realize approaches to prevent similar medication errors in the future. Approximately half of the nurses are reluctant to report medication errors since they are scared of disciplinary action, which delays the efforts toward reducing MAEs (Salar et al., 2020). Therefore, every healthcare facility should foster an environment that supports and promote non-punitive reporting to encourage nurses to report any MAEs and implement measures to mitigate the consequences of the error.

How Nurses Can Help Coordinate Care to Increase Patient Safety with Medication Administration and Reduce Costs

Nurses can help in care coordination to improve patient safety through proper medication administration and thus lower healthcare costs. One way to do this is through medication reconciliation, especially during transitions to another healthcare setting, to minimize adverse drug events. Medication reconciliation entails comparing a patient’s current drug regimen against the physician’s admission, discharge, or transfer orders to spot discrepancies (Mardani et al., 2020). Therefore, nurses would need to collaborate with physicians and clinical pharmacists during medical reconciliation since the physician prescribes treatment and the pharmacist has expert knowledge on drugs, including drug-drug interactions and adverse effects. Nurses can also increase patient safety by obtaining accurate medication histories, especially in geriatric patients with multiple prescriptions (Mardani et al., 2020). This can help identify and prevent numerous medication discrepancies, potentially preventing adverse drug events and related costs for healthcare for patients.

Stakeholders with Whom Nurses Would Coordinate To Drive Safety Enhancements with Medication Administration

Nurses will need to coordinate with other stakeholders to improve safety with medication administration, including clinical pharmacists, physicians, and patients. Nurses would need to coordinate with clinical pharmacists to reduce the numerous causes of error related to pharmacists. The pharmacist’s roles include supervising patients’ drug treatment and informing the clinician of discrepancies (Hong et al., 2019). They can coordinate care by encouraging pharmacists prevents mediation errors by: Dispensing the correct drug dosage, Identifying drug contraindications; Identifying drug allergies; Monitor medications with narrow therapeutic indexes; Identify drug interactions (Zhou et al., 2018). Besides, nurses can ensure pharmacists provide patients with the necessary drug knowledge, such as potential side effects and that they double-check patients’ understanding of the dose and drug allergies.

Nurses would coordinate with physicians to ensure they write legible prescriptions, avoid using drug abbreviations, and always include the patient’s age and diagnosis in each prescription. In addition, nurses need to coordinate patient follow-up visits and ensure physicians evaluate patients’ progress to treatment, and conduct diagnostic tests such as liver and renal function (Zhou et al., 2018). Nurses also need to coordinate patients by ensuring they are well-versed with their medications, including the drug’s dose, indications, and potential side effects.


The common forms of medication errors are incorrect patient and incorrect drug. Factors that result in MAEs include interruptions and distractions, communication barriers, understaffing and heavy workloads, work-related pressure, lack of time, lack of supervision, and unhealthy physical working conditions. Solutions to reducing MAEs include using computerized prescribing systems, hiring skilled and experienced nurses, and encouraging nurses to report MAEs without punitive measures. Nurses can coordinate care through medical reconciliation and should coordinate with pharmacists, physicians, and patients.


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 Pharmacy15(7), 823-826.

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.

Naidu, M., & Alicia, Y. L. Y. (2019). Impact of barcode medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health11(05), 511.

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences13, 100235.

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: a qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety47(1), 38-53.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine13, 1621.

Zhou, S., Kang, H., Yao, B., & Gong, Y. (2018). Analyzing Medication Error Reports in Clinical Settings: An Automated Pipeline Approach. AMIA … Annual Symposium proceedings. AMIA Symposium2018, 1611–1620.


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. Quality 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.

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.
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 risks.
Explain factors leading to a specific patient-safety risk focusing on medication administration.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
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.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from

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

Professional Context

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 QSEN 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 administration.
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.
Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements

Length of submission: 3–5 pages, plus title and reference pages.
Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: References and citations are formatted according to current APA style.

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