NURS-FPX 4020 Assessment 4 Improvement Plan Tool Kit

This improvement plan tool kit is intended to offer nurses the information needed to initiate changes in the care setting, implement corrective measures, and sustain the safety improvement controls intended to prevent medication errors at the HRI Clinic. The various insights discussed in the paper offer crucial recommendations for nurses and other healthcare workers, targeting human and organizational factors underlying medication errors. The tool kit is organized under four categories having various annotated sources. The categories discussed include the following: the elements of a successful quality improvement initiative, the factors that contribute to patient safety risks (medication errors) during medication administration, organizational interventions to promote patient safety improvement initiatives, and the application of evidence-based strategies to support safe and effective patient care.

Annotated Bibliography

The Elements of a Successful Quality Improvement Initiative

Ahmed et al.. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14.

Ahmed et al. (2019) note that medical errors have a high economic cost implication and are a significant source of poor health for patients, even though many of these adverse events are preventable. The study done in Kuwait explores the causes, types, and risks of medical errors in state-run healthcare organizations. The survey covered 203 healthcare professionals, including nurses, physicians, and pharmacists, among others, on the frequency of medical errors. The findings showed that the frequency of medical errors was 60.3 per cent, and the effects include longer hospital stays, life-threatening complications, and death for some patients. The primary causes of the medical errors were the high workload of the healthcare professionals, high stress the inadequacy of training, lacking workplace support, poor communication and collaboration, medical negligence, and non-adherence to safety measures. The article’s information will be crucial for the research paper because it discusses the major causes of medication errors, the views, and the challenges that many healthcare professionals face. More importantly, the research highlights the actions and the changes to make towards addressing the problem of medical errors in healthcare.

Sealock, K et al.. (2021). Lilley’s Pharmacology for Canadian Health Care Practice – E-Book (Fourth Edition). Toronto, ON: Elsevier.

The book on pharmacology in Canada provides crucial information, guidelines, and insights on mastering the complicated field of nursing pharmacology, which is a leading cause of medical errors. The fourth edition of Liley’s pharmacological guidelines explores the crucial information that nurses to promote patient safety through safe medication prescription and administration. The material is different from others on the subject because of its vibrant design that includes visuals and engaging text to foster practitioner understanding of the fundamental concepts required in the healthcare setting. One of the excellent views is the key drug approach that explores the medication information a practitioner needs to administer drugs safely. The book is a crucial resource for the research leading to the clinic’s root-cause analysis and in-service training, noting that it offers all the pharmacological information needed to master medication prescribing and administration towards fostering patient safety. The information will be essential in fashioning the strategies and changes needed to minimize or prevent medication errors.

Yousef, N., & Yousef, F. (2017). Using a total quality management approach to improve patient safety by preventing medication error incidences. BMC Health Services Research, 17, 1- 16.

The journal article reviews the prevalence of medical errors, reporting that the incidence rate is as high as 6.7 cases for every 100 administrations. Using the sigma approach, the researchers propose a strategy to reduce the number of medication errors to below 1 case for every 100 medication administrations by fostering healthcare professionals’ education and the clarity and quality of handwritten prescriptions. The study done in a General government hospital carried the process in various steps, including the systematic study of the current medication usage and processes, employing the six sigma approach to uncover the real causes of medication errors, and figuring out the solutions to the identified problems. The findings show that targeting behavioral change effectively improved the clarity of handwritten medication orders, which reduced the number of medication errors and thus fostered patient safety. The article is a crucial resource in guiding the clinic’s management and practitioners in formulating the root-cause analysis and in-service training to minimize the number of medication errors and improve patient safety standards.

NURS-FPX 4020 Assessment 4 Improvement Plan Tool Kit

The Factors that Contribute to Patient Safety Risks (Medication Errors) during Medication Administration

Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329-342.

The article explores the effects of practitioner communication during the transfer process from one stage of care to another. The article notes that effective communication is crucial because it fosters the practitioners’ understanding of the patient, identifying issues and the best nursing diagnosis based on their needs and goals. The information drawn from the patient’s careful understanding must be communicated between one healthcare practitioner and the other during the transfer process, which is essential in preventing adverse events such as medical errors that could be prevented. For example, by communicating all crucial information on the patient, such as allergies and potential drug interactions, the exiting nurse can ensure that the one taking over offers the best care, preventing adverse events such as medication errors. The article discusses the best practices for effective communication during the transfer of care to ensure that registered nurses (RNs) play an active role during handover processes to prevent adverse events such as medication errors. The article is a crucial resource for the root-cause analysis of medication errors and the report on the in-service training that nurses and other practitioners should receive to address the problem.

Flynn et al.. (2016). Progressive Care Nurses Improving Patient Safety by Limiting Interruptions during Medication Administration. Critical Care Nurse, 36(4), 19-35.

The article discusses the rising numbers of interruptions in the medication administration environment and the strategies adopted to limit their impact, which have been studied in previous studies. The article’s focus was reviewing the effectiveness of the evidence-based best practices and strategies adopted to limit the numbers and effects of interruptions during peak medication administration times in cardiac care units. The study also studied the impact of limiting or eliminating interruptions on the healthcare setting’s number of medication errors. The evidence-based study’s findings included that implementing the evidence-based best practices that limit interruptions by more than half in the medication environment decreased the number of medical errors in the cardiac care units. The effects of the change included an increase in patient safety levels, highlighting the importance of evidence-based best practices in addressing the problem of medication errors. The article is a crucial resource for the research on root-cause analysis and in-service training by highlighting some potential changes and practices that can reduce the number of medication errors.

NURS-FPX 4020 Assessment 4 Improvement Plan Tool Kit

Organizational Interventions to Promote Patient Safety Improvement Initiatives

Gates et al.. (2019). Standardizing the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931-939.

Gates et al. (2020) investigate the harm caused by medication errors, noting that classifying the problem is labor-intensive and time-consuming due to the lack of a universal process and a standardized reporting method. In light of classifying the harm caused by medical errors, the research describes the defining elements systematic process for studying medical errors and its strengths and controlling the weaknesses of current harm classification tools towards understanding the harm related to medical errors. The new system and tool offer a useful model that can be effectively employed in clinical and research settings. The new tool will reduce the risks of misclassification of the harms of medical errors while also generating results that can be compared across studies. The article is a crucial resource for root-cause analysis and in-service training because it offers a systematic tool for use in healthcare organizations. The information, findings, and evidence it presents will be crucial when studying the harm caused by medication errors in the root-cause analysis and in-service training, which is the primary focus of the current study.

Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1-7.

The article discusses the crucial role that nurses should play in fostering practice by becoming authors to communicate and articulate their views and practice experience as advocates and crucial sources of guidance. Further, the information that nurses author can and should guide critical thinking and viewpoints when planning and executing holistic practice. More importantly, becoming authors holds the potential to make these practitioners better nurses and clinicians and greatly contribute to the quality of care they render. The specific impacts of becoming an author include getting them in the right mental frame to communicate effectively in verbal and written attempts, clarifying the communication channels, and cultivating an enabling climate. The article is a crucial resource for root-cause analysis and in-service training on medication errors because it provides a framework for nurses to offer a maximum contribution to the practices and changes needed to address the problem.

Mazer et al., C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267.

The article explores the adverse impacts of medication errors in the US, noting that the number that dies due to these adverse events remains debatable. Despite the uncertainty and the disparities in the estimates in academic and media reports, the numbers reported are highly compelling and indicate the extensive potential harms. Using the “meme” concept fashioned by Richard Dawkins, the researchers highlight that the compelling estimates present potential harm by communicating the wrong message to the various stakeholders. The article recommends that physicians gather and disseminate more accurate estimates of the problem and encourage sobriety in public discussions on medical errors. Additionally, these practitioners should contextualize the complex social and biological systems surrounding the medical practice. The article is crucial to the research on root-cause analysis and in-service training because it emphasizes the practitioner’s role in gathering accurate information on the number of medical errors while also exploring the contexts surrounding the adverse events.

Polnariev, A. (2016). Using the Medication Error Prioritization System to Improve Patient Safety. P T., 41(1), 54-59.

The article discusses incident reporting as a mechanism for healthcare organizations to promote organizational safety practices and patient well-being; despite that, the previous study has shown mixed results. The commentary article discusses the practices employed by a multi-location healthcare organization in medical error reporting that entailed massive support from the leadership and collaboration from various professionals from different disciplines to prioritize the actions to take. The change error reporting initiative’s focus was prioritizing the actions required to improve medicating safety across all areas of the organization. The article is a crucial resource for root-cause analysis and in-service training because it offers medication error prioritization systems as an ideal way to promote organizational safety. Using the practices employed by the multi-location healthcare organization, the clinic’s management and their staff can initiate the changes needed to address medical errors.

NURS-FPX 4020 Assessment 4 Improvement Plan Tool Kit

Application of Evidence-based Strategies to Support Safe and Effective Patient Care

Rezaei, T. (2019). Analysis of medication errors by RCA method and implementation of reducing strategies to improve patient safety in Hujjat Kuh-Kamari Hospital in Marand – 2017. J Inj Violence Res., 11(Suppl 2), 1-2.

The article discusses the impacts of medical errors in the healthcare sector, noting how they threaten patient safety and adversely affect organizational outcomes. The article notes that the common types of medication errors remain a major challenge for the US healthcare system, which has caught the attention of stakeholders across the sector. Apart from the US, medical errors are a leading problem for healthcare organizations and systems worldwide because they cause death, injury and inflate care services delivery costs. The 2017 study sought to address the problem and studied the importance of promoting patient safety by reducing the number of medical errors, focusing on the strategies and best practices needed to reduce these adverse events in Hujjat Kuh-Kamari Hospital. The article is crucial to the research leading to the root-cause analysis and in-service training for the clinic, noting that it presents the best practices and strategies needed to address healthcare organizations’ problems.

Rodziewicz et al.. (Oct 17, 2020). Medical Error Prevention. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL). Retrieved from: https://pubmed.ncbi.nlm.nih.gov/29763131/

The resource, authored by leading authorities in healthcare working with leading universities and healthcare systems, focuses on preventing medical errors, which remain a leading public health concern in the US. The healthcare experts discuss the challenge of uncovering the leading causes of medical errors and finding befitting solutions that prevent a recurrence. However, the experts recommend the strategy of uncovering the factors leading to adverse events, learning from them, and formulating the strategies required to prevent them from minimizing the number of events. The solution’s crucial elements include maintaining a culture that works and supports safety towards reducing the incidence of omission errors and commission errors. The resource will be useful to the research leading to the clinic’s root-cause analysis and in-service training, noting that it presents an ideal strategy to learn from medical errors towards minimizing incidence levels. More importantly, the resource recommends the changes needed to cultivate solutions to the problem, including creating a safety culture, fashioning supporting goals, practising accountability, and using root-cause analyses to expose the underlying causes.

Toney-Butler et al. (2020 Apr 6). Dose Calculation Desired Over Have Formula Method. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK493162/

The resource discusses the three main medication dosage calculation methods, including ratio proportions, dimensional analysis, and the desired over have method (Formula). The resource’s focus is the Over Have or Formula Method, one of the most common and prevalently used drug calculation methods in solving the problem of unknown drug quantities using ratio formulation. When using the Over Have Formula, the fundamental knowledge needed is to convert amounts from different measures, such as liters, to milliliters. The method offers a useful model for practitioners working with different units, confirming drug calculation accuracy and double-checking or triple-checking amounts. The resource is crucial to the research leading to the clinic’s root-cause analysis and in-service training because it explores the usefulness of the Over Have method of drug calculation method. In practice, the clinic’s practitioners will use the resource when formulating the guidelines for drug calculation methods and setting the standards for drug amount verification by the practitioners or their counterparts towards fostering patient safety by preventing medication errors.

Conclusion

The improvement plan tool kit offers nurses crucial information on patient safety concerning medication errors. The focal areas include the elements of a successful quality improvement initiative, including the views of healthcare professionals on the issue, the guidelines offered in different resources, and the use of tools such as total quality management to prevent medication errors. The second focus area is the factors that contribute to patient safety risks, including the importance of practitioner communication and the improvement actions taken to improve safety. The third focus is organizational interventions to promote patient safety improvement initiatives, including standardizing the classification of medication errors, the role that nurses must play, and some tools to use to improve patient safety. The final focus is applying evidence-based strategies to support safe and effective patient care, including the methods to improve patient safety, medical error prevention, and the tools to use to improve outcomes.

References

Ahmed, Z., Saada, M., Jones, A.M., & Al-Hamid, A.M. (2019). Medical errors: Healthcare professionals’ perspective at a tertiary hospital in Kuwait. PLoS ONE, 14(5), 1-14. https://doi.org/10.1371/journal.pone.0217023

Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329-342. https://doi.org/10.1016/j.aorn.2015.07.009

Flynn, F., Evanish, J.Q., Fernald, J.M., Hutchinson, D.E., & Lefaiver, C. (2016). Progressive Care Nurses Improving Patient Safety by Limiting Interruptions during Medication Administration. Critical Care Nurse, 36(4), 19-35. https://doi.org/10.4037/ccn2016498

Gates, P.J., Baysari, M.T., Mumford, V., Raban, M.Z. & Westbrook, J. I. (2019). Standardizing the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 42, 931-939. https://doi.org/10.1007/s40264-019-00823-4

Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1-7. http://cjni.net/journal/?p=5022

Mazer, B.L., & Nabhan, C. (2019). Strengthening the Medical Error “Meme Pool.” Journal of General Internal Medicine, 34, 2264-2267. https://doi.org/10.1007/s11606-019-05156-7

Polnariev, A. (2016). Using the Medication Error Prioritization System to Improve Patient Safety. P T., 41(1), 54-59. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699487/

Rodziewicz, T. L., Houseman, B., & Hipskind, J.E. (Oct 17, 2020). Medical Error Prevention. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL). Retrieved from: https://pubmed.ncbi.nlm.nih.gov/29763131/

Sealock, K., Seneviratne, C., Lilley, L.L., Collins, S.R., & Snyder, J.S. (2021). Lilley’s Pharmacology for Canadian Health Care Practice – E-Book (Fourth Edition). Toronto, ON: Elsevier. https://books.google.co.ke/books id=6LgDEAAAQBAJ&printsec=frontcover&dq=Lilley %27s+Pharmacology+for+Canadian+Health+Care+Practice+-+E-Book+ (Fourth+Edition)&hl=en&sa=X&ved=2ahUKEwi3_pWDtq3uAhXEyIUKHU4UB8YQ6AEwA HoECAMQAg#v=onepage&q=Lilley’s%20Pharmacology%20for%20Canadian%20Health %20Care%20Practice%20-%20E-Book%20(Fourth%20Edition)&f=false

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Question

For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.