NURS FPX 4020 Assessment 4
Phillip September 15, 2023 No Comments

NURS FPX 4020 Assessment 4 – Improvement Plan Tool Kit 

NURS FPX 4020 Assessment 4 –Improvement Plan Tool Kit 

Student Name

Capella University

NURS-FPX 4020: Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan Tool Kit

A safety improvement plan requires a handful of information that can be disseminated among the concerned group of people. In healthcare settings, all the information that is gathered for preparing a safety improvement plan is distributed among healthcare professionals, administrators, leaders, and other allied professionals connected with the healthcare facilities. This communication includes information from authentic, credible, and relevant evidence-based resources so that a justified safety improvement plan is implemented. In this assessment, an improvement plan tool kit is developed on medication administration errors (MAEs). The databases used to develop this tool kit are; Google Scholar, PubMed Central, Capella Online Library, CINAHL, ScienceDirect, and JSTOR. The purpose of this resource tool kit is to assist nurses and nurse leaders to implement the medication safety improvement plan with profound knowledge and understanding of the related concepts for achieving successful outcomes. 

Resource Tool Kit – Implementation and Sustainability 

This resource kit is categorized into four easy-to-understand categories which will help nurses and nurse leaders to specifically take assistance from the source which is related to the particular concern. These categories are; a) risk factors of medication administration errors, b) nurses’ and nurse managers’ role in medication safety, c) medication error reporting, and d) evidence-based solutions for improving medication safety. 

Risk Factors of MAEs

Assunção-Costa, L., de Sousa, I. C., Silva, R. K., do Vale, A. C., Pinto, C. R., Machado, J. F., Valli, C. G., & de Souza, L. E. (2022). Observational study on medication administration errors at a University Hospital in Brazil: Incidence, nature, and associated factors. Journal of Pharmaceutical Policy and Practice15(1). https://doi.org/10.1186/s40545-022-00443-x 

This resource used a prospective observational method to determine the incidence, and nature and identify the factors associated with medication administration errors. The professionals who undertook this study claimed that 36.2% of MAEs were observed in University Hospitals. Some of the factors identified through the study are interruptions, excessive workload, and errors in the route of administration. Moreover, the highest risk of MAEs was found in intravenous medications. Since medication administration errors are very common in healthcare practices, this study is useful for nurses and nurse leaders to enhance their knowledge about factors that can lead to medication administration errors. Knowledge of these factors with help them in identifying similar aspects in their hospitals and implement safety improvement plans accordingly to make achievable and sustainable reforms. Furthermore, IV medications can become life-threatening for patients if are wrongly administered. Thus, this resource assists healthcare professionals and their leaders to make constant efforts to improve the quality of care and ensure patients’ safety is a priority. 

Rostami, P., Heal, C., Harrison, A., Parry, G., Ashcroft, D. M., & Tully, M. P. (2019). Prevalence, nature and risk factors for medication administration omissions in English NHS Hospital Inpatients: A retrospective multicentre study using medication safety thermometer data. BMJ Open9(6). https://doi.org/10.1136/bmjopen-2018-028170 

In the study by Rostami and colleagues (2019), Medication Safety Thermometer Data was utilized to conduct a retrospective study to determine the prevalence, and risk factors related to specifically omission medication errors. Omission errors are defined as a lack of administration of a medicine or a dose (missed administration). The study revealed that medication omission errors are highly prevalent in hospitalized patients. One of the predictors of these errors is the high number of prescribed medications which led nurses to miss a dose of medicine during administration. Other factors that lead to these errors are refusals from patients, unavailability of drugs, and clinical reasons which may prevent medicines to be given. This study is aimed at preparing healthcare professionals especially nurses to identify the high-risk population who might experience omission errors and establish particular strategies to overcome these errors. NURS FPX 4020 Assessment 4 –Improvement Plan Tool Kit . This resource is helpful for nurses as the risk factors (patient refusal and unavailability of drugs) are very common issues faced in hospitals worldwide. In terms of patient refusal, patients must be informed about risks and benefits to ensure patient safety is maintained. Omission errors can also be due to excessive workload because of the high number of medicines. Thus, administrators of a hospital should take immediate action to eradicate these errors from the hospital as a safety improvement plan. 

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(1). https://doi.org/10.1186/s12912-020-0397-0 

This study is conducted in Ethiopia to examine the extent of medication administration errors and identify the causative factors which lead nurses to commit these errors. Lack of training and education, lack of experience, absence of standardized guidelines, and constant disruptions during administration and night shift duty were some of the associated factors recognized in this study. This study is useful for nurses and nurse leaders for example, they can identify some of these or other contributing factors in their workplaces using root-cause analysis which will further help them in modifying the safety improvement plan based on these factors. Furthermore, the study also recommends some the strategies like continuous educational training, preparation of standardized guidelines and making them available for nurses, creating a supportive and safe environment for nurses to administer drugs, and retaining experienced nurses for medication administration. The methods will assist nurses to provide quality care, reduce safety risks in terms of medication and improve patients’ satisfaction levels.  

Role of Nurses and Managers in Medication Safety

Abdulmutalib, I., & Safwat, A. (2020). Nursing strategies for reducing medication errors. Egyptian Journal of Nursing and Health Sciences1(1), 26–41. https://doi.org/10.21608/ejnhs.2020.80266 

This article is aimed at describing the factors that contribute to medication errors specifically related to nurses and recommends the intervention that can be done by nurse managers to prevent these errors. It explains that nurses are the last line of safety in the medication process thus they are responsible to identify these factors so that errors can be prevented. Some of the ways nurses and nurse leaders can adopt are increasing the workforce, eliminating or distributing workload, effectively managing their tasks, increasing their knowledge about drugs and their management, and nurse leader should encourage nursing staff to report medication errors. The strategies established in this resource help in improving patients’ safety. It is useful for the audience of the safety improvement plan as it gives concrete suggestions to be added in their workplaces so that effective results are achieved. Improving the quality of nursing care by utilizing these strategies eventually increases patient satisfaction, enhances safety, and quality healthcare is provided. 

Improvement Plan Tool Kit

Lappalainen, M., Härkänen, M., & Kvist, T. (2019). The relationship between Nurse manager’s transformational leadership style and medication safety. Scandinavian Journal of Caring Sciences34(2), 357–369. https://doi.org/10.1111/scs.12737 

Using a statistical analysis of a questionnaire about transformational leadership and its impact on medication safety, this study acts as an important resource for nurse leaders. Managers and leaders opting for a transformational leadership style encourage their staff to become confident in their expertise and enable them to perform much better than current practices. It also has positive impacts on nurses’ perceptions related to medication safety thus encouraging them to improve their practices. Nurse leaders of this safety improvement plan can adopt a transformational leadership style within their workplaces where they encourage nurses to be confident and improve their practices by bringing changes within themselves and in the environment. These changes will ensure that patients’ safety is kept on priority, especially in terms of medication administration and management. Moreover, this leadership style also creates a trustworthy and supportive environment for nursing staff to be transparent and rely on their leaders for any mishappenings if occurred. 

Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research21(1). https://doi.org/10.1186/s12913-021-06288-5 

This study presented a relationship among four components; nurse manager’s work, job satisfaction level of nurses, patient contentment levels, and medication errors. An organizational factor, the nurse-to-manager ratio, influences the job satisfaction level among nurses and eventually increases the risks of medication errors. This study presented some suggestions for the nurse manager to improve patient safety in terms of medication errors by; a) supporting and motivating nurses in their job roles to effectively manage and organize their tasks, and b) managers should promote a culture of safety and patient-centered care within their workplaces. Moreover, healthcare administrators should monitor the work of managers to ensure that managers are capable of balancing their work and organizational goals of providing quality care and achieving patient safety. This resource is useful for nurse leaders of this in-service safety improvement training to apply these practices within their workplaces to ensure the organization achieves patient-related safety goals.

Medication Error Reporting 

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research21(1). https://doi.org/10.1186/s12913-021-07187-5 

This study is an integrative review of 14 studies which was based on the identification of barriers that prevent healthcare professionals from reporting error incidences. Some of the barriers identified are; 1) unavailability of reporting systems, 2) inappropriate behavior of managers, 3) lack of knowledge about medication errors, 4) fear of management and legal obligations, and 5) certain individual intentions. This study is useful for nurses and nurse leaders to identify some of these barriers within their workplaces and collaboratively make efforts to eliminate these hindrances. Moreover, this study also recommends some of the changes for the audience to adopt for example the creation of an enabling environment with no or minimum punishments. Additionally, policymakers, leaders, and frontline nurses should together decide on a definition of medication errors and nurses should be trained about the reporting systems to ensure errors are reported and patients’ safety is ensured. 

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines8(9), 46. https://doi.org/10.3390/medicines8090046 

In this study, the authors conducted a methodological review of several articles on medication error reporting. It also recognized some of the effective strategies to prevent these errors by improving the reporting systems within the organization. The reporting system should be safe for the reporter in terms of identification and should support the reporter so that they are encouraged to improve in the future. The responsible group of this safety improvement plan can develop effective reporting software in their organization that maintains the confidentiality of the reporter. Moreover, it should be constantly monitored to identify the incidences. Nurse managers play a critical role here by supporting and encouraging nurses to report errors if committed or observed so that effective measures can be taken to reduce the risks to patients’ safety. 

Unal, A., & Seren İntepeler, S. (2019). Medical error reporting software program development and its impact on pediatric units’ reporting medical errors. Pakistan Journal of Medical Sciences36(2). https://doi.org/10.12669/pjms.36.2.732 

This literature is based on a quasi-experimental study where the development of a medical error reporting system took place. This study is not only based on medication errors but also covers other healthcare adversities however, our concern is to understand the need for a reporting system that can overall be beneficial for patients’ safety. This study showed that after introducing the error reporting system around 234% increment was observed in medication error reporting. The study concludes that the online reporting system is easy to use and it promotes the culture of patient safety among healthcare professionals. Thus, this resource becomes a useful one for the audience of the safety improvement plans to recognize the importance of establishing these reporting systems within their workplace and encouraging healthcare professionals to effectively use these systems for better provision of care. 

Evidenced-based Solutions

Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to the implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J10, 45-46. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2019/03/Commentary-14.pdf 

This literature review is based on analyzing two different closed-loop medication management systems; a computerized provider order entry system and a bar-coded medication administration system. The study recommends that both of these systems combined can prevent up to 72% of medication errors. This resource is helpful for the audience of the safety improvement plan where they can establish these systems in their organizations to achieve improvement in medication safety. CPOE and BCMA help healthcare professionals to follow the standard of medication safety while prescribing, dispensing, and administering. Moreover, these are tech-generated systems that can identify errors before the drugs are managed. Hence, enabling healthcare professionals to immediately address the errors and reduce patient harm. 

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety11, 204209862096830. https://doi.org/10.1177/2042098620968309 

This literature review is focused on providing certain interventions like providers’ education, medication reconciliation, development of medication management systems, and interprofessional collaboration among policymakers, nurses, doctors, and nurse leaders to ensure that medication errors are reduced in the hospitals and patient safety is preserved. Stakeholders of this safety improvement plan should promote a culture of collaboration among nurses, pharmacists, and doctors so that the medication management process from prescription to administration is well-established and errors are identified at the professionals’ level before harming the consumers. This resource gives a holistic approach to all the steps of medication management and thus is the most reliable, relevant, and effective resource for nurses and nurse leaders to bring about changes within their organizations. 

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences13, 100235. https://doi.org/10.1016/j.ijans.2020.100235 

This study is based on Irani hospitals where medication errors are very common. It piloted some of the strategies to overcome existing adversities and prevent further errors. These strategies are training and development of healthcare professionals, nurses should enhance their abilities to read medication orders appropriately, and healthcare professionals must be informed about legal obligations which if not fulfilled may lead to legal cases and safety measures about high-risk medications. Moreover, nurses should be accredited for their medication practices to ensure that only credentialed nurses are practicing medications. This resource is helpful for the audience to initiate some of these strategies within their hospitals to ensure nurses are capable of medication administration and patients are in safe hands. Moreover, these strategies also focus on the fulfillment of international criteria for nurses’ accreditation. 

Conclusion

This improvement plan tool kit is full of credible and relevant resources for nurses, nurse leaders, administrators, and policymakers to use within their hospitals to bring positive reforms in terms of medication safety. This complete package will assist stakeholders to implement a safety improvement plan and make it sustainable for their organization. It is essential to train healthcare professionals, establish standard guidelines, bring technological advancements, and collaborate among the interprofessional team to improve medication safety consequently enhancing the quality of care and patients’ safety. 

References

Abdulmutalib, I., & Safwat, A. (2020). Nursing strategies for reducing medication errors. Egyptian Journal of Nursing and Health Sciences1(1), 26–41. https://doi.org/10.21608/ejnhs.2020.80266 

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research21(1). https://doi.org/10.1186/s12913-021-07187-5 

Assunção-Costa, L., de Sousa, I. C., Silva, R. K., do Vale, A. C., Pinto, C. R., Machado, J. F., Valli, C. G., & de Souza, L. E. (2022). Observational study on medication administration errors at a University Hospital in Brazil: Incidence, nature, and associated factors. Journal of Pharmaceutical Policy and Practice15(1). https://doi.org/10.1186/s40545-022-00443-x 

Lappalainen, M., Härkänen, M., & Kvist, T. (2019). The relationship between nurse manager’s transformational leadership style and medication safety. Scandinavian Journal of Caring Sciences34(2), 357–369. https://doi.org/10.1111/scs.12737 

Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J10, 45-46. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2019/03/Commentary-14.pdf 

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety11, 204209862096830. https://doi.org/10.1177/2042098620968309 

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines8(9), 46. https://doi.org/10.3390/medicines8090046 

NURS FPX 4020 Assessment 4 –Improvement Plan Tool Kit 

Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research21(1). https://doi.org/10.1186/s12913-021-06288-5 

Rostami, P., Heal, C., Harrison, A., Parry, G., Ashcroft, D. M., & Tully, M. P. (2019). Prevalence, nature and risk factors for medication administration omissions in English NHS Hospital Inpatients: A retrospective multicentre study using medication safety thermometer data. BMJ Open9(6). https://doi.org/10.1136/bmjopen-2018-028170 

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. https://doi.org/10.1016/j.ijans.2020.100235 

NURS FPX 4020 Assessment 4 –Improvement Plan Tool Kit

Unal, A., & Seren İntepeler, S. (2019). Medical error reporting software program development and its impact on pediatric units’ reporting medical errors. Pakistan Journal of Medical Sciences36(2). https://doi.org/10.12669/pjms.36.2.732 

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(1). https://doi.org/10.1186/s12912-020-0397-0