Enhancing Quality and Safety
Medication administration errors (MAEs) remain an issue of concern within hospitals and the entire healthcare delivery system. These types of errors can occur during the medication administration process. Medication administration errors can occur as instances of a medication overdose, wrong time of administration, bad point and route of administration, wrong patient, and medication administration at the incorrect rate. Medication overdose is a familiar MAE that is contributed mainly by other MAEs. MAEs, such as medication overdose, are a risk to the quality of care and safety of the patient. This paper will focus on the factors leading to medication overdose, evidence-based solutions for medication administration errors, the roles of nurses in care coordination for patient safety and quality enhancement, and the necessary stakeholders to enhance quality and safety during medication administration.
Factors Leading to Medication Administration Errors
The process of medication involves several various individuals and processes that, at a point, may lead to the occurrence of errors such as medication overdose in the process of administration. As nurses are more involved in the direct delivery of healthcare services, they are more likely to be involved in most errors occurring during medication administration within healthcare settings. However, they are not the only individuals who lead to the occurrence of the errors. Medication administration errors can result from human, system, and organizational failures. According to Keers et al. (2018), medication administration errors result from multiple interrelated factors such as system failures, work environment, medications used, and the complexity of tasks within clinical practice. Besides these, there are various interacting systems and human factors that contribute to errors in medication administration. For instance, nurses may cause administration errors due to human and organizational factors, such as insufficient workforce leading to increased workloads and burnouts, administering the wrong dose, or wrong patient due to neglect or miscommunication with the prescribing officer.
Evidence-Based and Best-Practice Solutions for Medication Administration and Reducing Costs
Resolving errors in medication administration and reducing costs should focus on fixing the contributing factors to the occurrence of the errors. A study by Cho and Choi (2018) concluded that teamwork, leadership, and continuous learning in nursing improved a nurse’s competencies toward patient safety. However, the relationship between the nurse’s attitudes toward a patient, safety skills, and knowledge varies among nurses (Cho & Choi, 2018). Nurses and healthcare workers should learn how to incorporate evidence from research, their expertise in healthcare, and patient-centeredness into their practices for care quality, safety, and individual and organizational performance improvement (Sonğur et al., 2018). To achieve these, Altmiller and Hopkins-Pepe (2019) recommend implementing the Quality and Safety Education for Nurses (QSEN) skills in practice to assist healthcare organizations in meeting the quality and safety education in nursing requirements. QSEN competencies include teamwork and collaboration, patient-centered care, implementation of EBP, development of quality implementation skills, nursing informatics in practice, and patient safety. These competencies can be considered within the nursing curriculum to improve the competencies of nurses in academia (Andtmiller & Hopkins-Pepe, 2019).
The Role of Nurses in Care Coordinate to Enhance Quality and Safety and Reduce Costs
Nurses are in the frontline during care delivery and are the leading contributors to medication administration errors. They also have a role in coordinating care to ensure better and safer care. There are various ways a nurse can coordinate the delivery of medical care. Nurses can coordinate care by sharing information on patient health and medications already administered to facilitate care transition. In addition, this also includes educating patients and their caregivers during discharge to facilitate the continuity of care after the transition. Additionally, nurses can coordinate care by collaborating with other healthcare providers in order to facilitate communication and the development of patient-centered care.
Stakeholders for Care Coordination for Quality and Safety Improvement in Medication Administration
Care coordination for quality and safety improvement during medication can be achieved by adopting an interdisciplinary team approach. Nurses need to collaborate with healthcare individuals involved in the process of medication; this means having a direct link to the prescribing officer, the pharmacists, and other nurses who may handle the medications. Besides the healthcare professionals, a nurse should also collaborate with the patient and other caregivers on safety and personal responsibility. It is recommended that the nurse use a pharmacist as a leader of the medication team throughout the medication process due to their expertise in medications. Research evidence shows that pharmacist-led interventions significantly reduce medication errors and utilize healthcare resources (de Oliveira et al., 2021).
Conclusion
Medication administration errors, especially medication overdose, compromise care quality and pose a risk to patient safety. Due to their direct service to patients, nurses have a critical role in developing evidence-based solutions and care coordination for better and safer patient care. Most importantly, nurses should collaborate with other healthcare providers to ensure a smooth information flow, significantly reducing medical errors.
References
Altmiller, G., & Hopkins-Pepe, L. (2019). Why Quality and Safety Education for Nurses (QSEN) Matters in Practice. Journal of Continuing Education in Nursing, 50(5), 199–200. https://doi.org/10.3928/00220124-20190416-04
Cho, S. M., & Choi, J. S. (2018). Patient Safety Culture Associated With Patient Safety Competencies Among Registered Nurses. Journal of Nursing Scholarship : An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 50(5), 549–557. https://doi.org/10.1111/JNU.12413
De Oliveira, G. S., Castro-Alves, L. J., Kendall, M. C., & McCarthy, R. (2021). Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Healthcare Resources Utilization after Transitions of Care: A Meta-analysis of Randomized Controlled Trials. Journal of Patient Safety, 17(5), 375–380. https://doi.org/10.1097/PTS.0000000000000283
Keers, R. N., Plácido, M., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. PLOS ONE, 13(10), e0206233. https://doi.org/10.1371/JOURNAL.PONE.0206233
Sonğur, C., Özer, Ö., Gün, Ç., & Top, M. (2018). Patient Safety Culture, Evidence-Based Practice and Performance in Nursing. Systemic Practice and Action Research , 31(4), 359–374. https://doi.org/10.1007/S11213-017-9430-Y
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Question 
For this assessment, you will develop a 3-5 page paper examining a safety quality issue concerning medication administration in a health care setting. You will analyze the problem and discuss potential evidence-based and best-practice solutions from the literature and the role of nurses and other stakeholders in addressing the issue.
Enhancing Quality and Safety
Healthcare organizations and professionals strive to create safe patient environments; however, maintaining safety can be challenging due to the healthcare system’s complexity. Since nurses comprise the largest group of healthcare 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 improve 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 about 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 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 must 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; contain 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.
References
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.
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in healthcare settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development a patient safety culture.
Scenario
Consider a previous experience or hypothetical situation about errors and how the error could have been prevented or alleviated with the use-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.
Instructions
This assessment aims to understand better the baccalaureate-prepared nurse’s role in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks in a healthcare setting of your choice. You will explore the professional guidelines and best practices from organizations such as QSEN and the IOM for improving and maintaining patient safety in healthcare settings. You will consider the nurse’s role in driving quality and safety improvements by looking through the lens of these professional best practices to examine your chosen organization’s current policies and procedures and the impact on patient safety measures surrounding medication administration. You will identify stakeholders in QI improvement and safety measures and consider evidence-based strategies to enhance the quality of care and promote medication administration safety in your chosen healthcare setting.
Be sure that your plan addresses the following, corresponding to the grading criteria in the scoring guide. Please study the scoring guide carefully to 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 clear, logical, and professional writing, with correct grammar and spelling, using the 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 five years old.
APA formatting: References and citations are formatted according to the current APA style.