Phillip January 25, 2024 No Comments

NURS FPX 8030 Assessment 1 Building the Case for Healthcare Improvement

NURS FPX 8030 Assessment 1 Building the Case for Healthcare Improvement

Name

Capella university

NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner

Prof. Name

Date

PRESENTATION OUTLINE

Medication or Drug Error as a Patient Safety Issue at Healthy Elite Metropolitan Medical Center

Objectives:

  • Identify internal practices necessitating change to address medication errors.
  • Determine organizational priorities in addressing medical errors.
  • Develop interventions and a Quality Improvement Project.

PATIENT SAFETY ISSUE: Medication/Drug Errors

  • Medication errors rank as the third leading cause of death in the United States (Ferrah et al., 2017).
  • One in seven patients in healthcare organizations falls victim to medication errors.
  • Key medical errors include technical errors, delayed diagnosis, medication errors, inadequate post-procedure monitoring, and failure to act on test results.

PATIENT SAFETY ISSUE: Medication Error at Healthy Elite Metropolitan Medical Center

  • Medication errors attributed to poor communication, administration of incorrect dosages, negligence by healthcare staff, and electronic medical record failures.

INTERNAL EVIDENCE OF MEDICATION/DRUG ERROR

  • Medication errors at Health Elite Metropolitan Medical Center contribute to increased lawsuits, patient deaths, and healthcare service costs.
  • The organization incurred a loss of over $17.4 million in lawsuits within the last 12 months.
  • Medication errors resulted in the layoff of over 20 healthcare workers, impacting healthcare service delivery.

INTERNAL EVIDENCE OF MEDICATION/DRUG ERROR

Timeframe
Number of Patients Involved
Rate of Readmission
Within 12 months 40
Within 4 weeks 15
Within 8 weeks 13

EXTERNAL EVIDENCE OF MEDICATION/DRUG ERROR

  • Medication errors are a common patient safety concern globally (Mulac et al., 2021; Ferrah et al., 2017).
  • Research indicates a 19% prevalence of medication errors in over 36 US healthcare organizations (Mulac et al., 2021).
  • Causes include unauthorized medication administration (4%), omission errors (43%), and wrong dosage administration (17%).

ORGANIZATIONAL PRIORITY FOR INTERVENTION

  • Medication/drug errors significantly impact patient health, organizational operations, and community health.
  • Consequences include severe physical, emotional, and psychological injuries, financial burdens, reduced community trust, and potential caregiver shortages.
  • Creating awareness among patients can reduce errors, and community concern arises from loss of loved ones and caregiver shortages.

QUALITY IMPROVEMENT PROJECT AND PATIENT OUTCOME

  • Quality improvement interventions:
    • Development of a verification system for medication prescriptions.
    • Use of barcodes.
    • Creating awareness about counterchecking lookalike drugs.
    • Implementing an effective medication error warning system.
    • Encouraging interdisciplinary collaboration.

REFERENCES

Ferrah, N., Lovell, J. J., & Ibrahim, J. E. (2017). Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents. Journal of the American Geriatrics Society, 65(2), 433-442.

Hines, S., Kynoch, K., & Khalil, H. (2018). Effectiveness of interventions to prevent medication errors: an umbrella systematic review protocol. JBI Evidence Synthesis, 16(2), 291-296.

Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy, 28(e1), e56-e61.

Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business. Australian prescriber, 41(3), 73.

NURS FPX 8030 Assessment 1 Building the Case for Healthcare Improvement

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