Category: NURS-FPX4020

Capella 4020 Assessment 4 Improvement Plan Tool Kit Name Capella university NURS-FPX 4020 Improving Quality of Care and Patient Safety Prof. Name Date Introduction – Improvement Plan Tool Kit Medication errors cause unwanted damage to individuals, healthcare professionals, and healthcare systems. Nurses must recognize and promote strategies that enhance drug administration safety. A safety enhancement strategy necessitates an insignificant quantity of knowledge that can be shared among the relevant individuals (Amaniyan et al., 2020). A Medication Administration Error (MAE) improvement plan tool kit is created in this assessment. Google Scholar, PubMed Central, Capella Online Library, and CINAHL databases were used to generate this tool kit. This resource tool kit aims to help nursing staff and other healthcare providers execute the drug safety improvement plan with a comprehensive understanding and awareness of the associated ideas to accomplish effective outcomes.  Resource Tool Kit – Implementation and Sustainability  This resource kit is divided into four groups, allowing nurses to seek guidance from the most pertinent resources. These areas are: a)  Implementation of quality medication administration b) Best practices of MAE reporting and improved patient safety  c) Evidence-based strategies for safety improvement plan d) Staff-led interventions in medication safety Implementation of Quality Medication Administration Savva, G., Papastavrou, E., Charalambous, A., Vryonides, S., & Merkouris, A. (2022). Exploring nurses’ perceptions of medication error risk factors: Findings from a sequential qualitative study. Global Qualitative Nursing Research, 9, 23333936221094857. https://doi.org/10.1177/23333936221094857 This resource used a prospective observational study method to determine the incidence, and nature and identify the factors associated with MAEs. This study also focuses on interventions to reduce the risk factors. The resource group focuses on an improvement plan to enhance patient safety. This study claimed that most MAEs occur in intravenous doses of medications with 35% of total MAEs. The study has highlighted various MAEs attributed risk factors. One of the significant factors is staff, including nurses-related risk factors such as knowledge, expertise, patient medical condition, workload, and poor communication among staff members. Procedure-related mistakes are also common during the medication delivery process. Exclusions and deviations from safe medication administration protocols are typical procedural mistakes. This study can assist nurses and healthcare staff discover more about the factors leading to MAEs. Comprehension of these risk variables can assist them in finding similar aspects in their organizations and implementing appropriate safety enhancement programs to achieve and sustain reforms. Furthermore, intravenous medication errors can be fatal to patients. Therefore, this study aids medical staff and nurses in their continual efforts to enhance the standard of care and guarantee the safety of patients. Capella 4020 Assessment 4 Improvement Plan Tool Kit Rozenblum, R., Rodriguez-Monguio, R., Volk, L. A., Forsythe, K. J., Myers, S., McGurrin, M., Williams, D. H., Bates, D. W., Schiff, G., & Seoane-Vazquez, E. (2020). Using a machine learning system to identify and prevent medication prescribing errors: A clinical and cost analysis evaluation. The Joint Commission Journal on Quality and Patient Safety, 46(1), 3–10. https://doi.org/10.1016/j.jcjq.2019.09.008  The authors investigated using a machine learning system to identify and prevent pharmaceutical dispensing mistakes. Furthermore, the article intends to assess medical procedures and economic implications following the implementation of this technology-based approach. This study showed that this technology-based method is crucial for reducing errors. It has detected a significant reduction in prescription errors. Preventing MAEs resulted in lower expenditures. This demonstrated that machine learning systems can generate clinically acceptable drug mistake alarms, which conventional clinical decision-support tools commonly fail to do. This technique can detect drug errors in advance. It helps the healthcare providers in developing strategies for drug delivery improvement plans.  Brito D. A., M., Carneiro, C. T., Bezerra, M. A. R., Rocha, R. C., & Da Rocha, S. S. (2022). Effective communication strategies among health professionals in neonatology: An integrative review. Enfermeria Global, 21(3), 578-591. https://doi.org/10.6018/eglobal.502051 Capella 4020 Assessment 4 Improvement Plan Tool Kit This study examines methods for improving communication among multidisciplinary groups. The study emphasizes the significance of efficient interaction in promoting patient safety in hospitals. Poor communication results in increased adverse events of MAEs. The World Health Organization (WHO) has identified efficient collaboration among professionals as the second global aim for improving the security of patients and the standard of treatment. The authors suggest inter-professional communication enhancement strategies. These strategies will improve patient safety. The implementation of communication devices, exchange reporting, direct discussion, and the incorporation of efficient communication strategies in training sessions are all examples of successful communication approaches. Regular discussions, multidisciplinary rounds, verification, and quick responses to interdisciplinary teammates are also effective strategies. The absence of standardization and insufficient recording of information about patients in the healthcare record are two challenges to successful communication. The authors support the procedures described to ensure effective interaction within the multidisciplinary group and boost patient safety. Efficient communication leads to better care. This article is a valuable asset for nurses adopting pharmaceutical quality improvement strategies. Best Practices of Medication Errors Reporting and Improved Patient Safety 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. BioMed Central Health Services Research, 21, 1-10. https://doi.org/10.1186/s12913-021-07187-5 The significance of developing measures to mitigate medication-related damage is discussed in this article. Nurses need to report errors to reduce errors and enhance patient safety. The researchers conducted an integrative study to identify hurdles to nurses reporting MAEs. The investigators examined a variety of primary resources, and two significant concepts developed: organization and profession challenges, and behavioral barriers. A lack of an adequate reporting system, ambiguous definitions of pharmaceutical errors, and organizational behaviors have been identified as organizational hurdles. The absence of a proper MAE reporting system rendered reporting procedures difficult, mainly using the MAE reporting form, which is a primary hurdle to reporting and documenting MAEs.  There is an imprecise description of ME inside the healthcare system, and differences over what should be considered reporting are a barrier to reporting MAEs.  The negative response of the administrators toward nursing staff results in the lack of error reporting and the absence of feedback after error investigation. Personal concerns like fear of embarrassment and job loss are professional and behavior impediments. Other challenges include a lack of awareness about errors and patient damage from the MAEs.  This resource’s knowledge can assist healthcare systems and stakeholders address challenges to

Capella 4020 Assessment 3 Improvement Plan in Service Presentation Name Capella university NURS-FPX 4020 Improving Quality of Care and Patient Safety Prof. Name Date Improvement Plan In-Service Presentation Greetings! My name is Priscilla, and I’m here to give you the safe medication administration improvement plan, which will address Medication Administration Errors (MAEs) that result in Adverse Drug Events (ADEs), as mentioned in assessment two. Outline This presentation will cover the following topics: Health care problem Purpose and goals of the in-service session Need and process to improve safety outcomes Role and importance of audience Resources and activities for engagement Medication Administration Errors  MAEs are defined as errors that occur during drug administration. The administration procedure is the final step in pharmaceutical management before final documentation. Most of these errors are made by nurses, the most significant medical personnel delivering medications to patients (Asefa et al., 2021). These errors can arise because of the administration of the incorrect medicine, dosage, or procedure at the incorrect time or to the incorrect patient (Ayorinde & Alabi, 2019). Medication administration must be done safely to safeguard patient safety and avoid ADEs. ADEs can cause mild to severe side effects, leading to in serious complications or mortality. In medical facilities, ADEs are responsible for adverse patient safety effects (Bangwal et al., 2020). The safe drug administration improvement plan is a holistic effort aimed at addressing the issues raised by MAEs. Purpose and Goals of In-Service Session Purpose This in-service session on safe drug administration, focusing on reducing MAEs that cause ADEs, improves nurses’ understanding, abilities, and compliance with standard procedures (Wondmieneh et al., 2020). The session’s objective is to equip nurses with updated knowledge on ADEs to prevent the adverse effects of medication interactions caused by MAEs. The implementation of Electronic Health Record (EHR) and Barcoding Medication Administration (BCMA) systems assists in the reduction of MAEs and enables nurses to manage ADEs better (Grailey et al., 2023). Nurses can render informed judgments during medication administration if they better understand the adverse effects of MAEs, particularly ADEs. The training session encourages nurses to practice analytical abilities or strategies when administering drugs. Nurses can help to prevent adverse occurrences by recognizing and minimizing risks through their expertise (Marufu et al., 2022). Goals The following objectives are pertinent and attainable during the in-service session: Provide nurses with easily accessible tools, such as pharmaceutical reference guides, medication interaction databases, and organizational regulations and guidelines, to support informed decision-making and MAE management (Shahmoradi et al., 2021). Nurses will be aware of high-alert or complex drugs, their particular managing demands, administering practices, and measures to reduce the possibility of MAEs (Zyoud et al., 2019). By the end of the session, nurses will understand error prevention strategies and tools, including BCMA, verification, and digital prescriptions through EHR systems, to improve proficiency and validation procedures during administering drugs (Lunt & Mathieson, 2020). The session will encourage nurses to report and gain insight into drug errors. The seminar will emphasize the significance of report systems for incidents, for example, the use of a Medication Error Reporting System (MERS). It also emphasize on the implementation of preventative measures to avoid such mistakes in the future. (Afaya et al., 2021). Need and Process to Improve Safety Outcomes Need  To prevent ADEs, there is a need to enhance safety outcomes related to MAEs (Kuklik et al., 2019). According to research, approximately 7000 deaths occur in the United States because of MAEs, with almost 400,000 occurrences of avoidable patient harm. MAEs caused ADEs in 25% of those admitted to hospitals. According to Fathy et al. (2020), the global financial effect of MAE costs approximately 42 billion dollars annually. This evidence highlights the critical need for comprehensive strategies to reform the medical sector to provide safety and more effective care. It is critical to deal with MAEs holistically and establish procedures that successfully reduce the incidence of avoidable MAEs, which result in ADEs and compromise patient safety (Kuklik et al., 2019). Process The safety improvement process intends to develop suitable medication administration practices to minimize ADEs in medical centers. This approach comprises evidence-based efforts to encourage patient safety. The first stage in the process is providing educational opportunities and training to medical staff to acquire the appropriate knowledge and competencies. Drug security expertise and comprehension also encourage involvement in continuing learning activities (Farzi et al., 2020). The second step is the execution of the Medication Reconciliation (MR) strategy. The MR involves assessing new drug prescription to those already in use, checking correctness, and eliminating disparities.  MR has been shown to help lower MAEs and prevent potential ADEs during hospitalization. Nurses can help minimize adverse effects of medication and promote patient safety by doing MR carefully (Ceschi et al., 2020) In the third step of the process to improve safety, technological tools are employed to eliminate MERs and increase performance. Incorporating BCMA and EHR systems assists in lowering the probability of serious medical complications. Nurses can reliably validate medication codes and dispense medications to patients appropriately by using BCMA (Barakat & Franklin, 2020). Furthermore, drug administration processes are built using the Computerized Physician Order Entry (CPOE) system. Nurses can use CPOE to describe pharmacological interactions to improve medication accuracy and avoid adverse events (Mogharbel et al., 2021). The final step of the improvement process involves enhancing the culture for MAE reporting, learning, and continuous improvement and enabling nurses and other healthcare providers to report MAE incidents if they happen (Obaid et al., 2023). These strategies focused on improving interactions, such as structured communication tools and interdisciplinary training, to lessen drug delivery mistakes and improve patient safety. Nurses can reduce drug-related hazards and promote safer drug administration methods by taking part in open communication and cooperating with other medical personnel (Dirik et al., 2019). Role and Importance of Audience To develop a successful improvement plan based on safe drug delivery, properly communicating the audience’s role is critical. The audience’s awareness of their duties can be improved by open communication, helps in the effectiveness of the plan (Dirik et al., 2019). Policymakers and the board of director’s members must be involved in developing supportive guidelines, distributing adequate funds, and offering strategic leadership. Their dedication and participation in the improvement plan are critical to its accomplishment, as they

Capella 4020 Assessment 1 Enhancing Quality and Safety Name Capella university NURS-FPX 4020 Improving Quality of Care and Patient Safety Prof. Name Date Enhancing Quality and Safety Medication errors are the most significant factor of preventable patient harm in the global medical care setting. Medication Administration Errors (MAEs) are one of the more frequently occurring medical mistakes, which have severe implications for patients, medical personnel, and medical organizations (Wondmieneh et al., 2020). The World Health Organization (WHO) reported that the worldwide economic impact of drug errors is anticipated to be nearly 42 billion dollars yearly (Asefa et al., 2021). MAEs cause the mortality of around 7000 patients and cause approximately 400,000 occurrences of unnecessary patient damage in the United States each year (Wondmieneh et al., 2020). This study will examine a case illustrating the drug administration’s safety and quality challenges.  Scenario  Mr. John, a 52-year-old man with a diagnosis of cardiac myopathy, was hospitalized for prolonged care and treatments. A mistake in medicine administration happened during Mr. John’s hospitalization. Instead of his prescribed drugs, he was provided with the wrong medication by a nurse who misinterpreted the medication’s prescription. Tragically, the mistake was ignored until Mr. John’s condition progressively declined.  The drug he acquired by mistake had a detrimental interaction with his other medicines. He had an elevated cardiovascular rate and breathing problems, which exacerbated his condition. The physician and the medical professionals evaluated Mr. John’s condition, and the MAE was found as a possible cause. Mr. John was then given immediate medical attention to help manage his health.  This tragic event reminded the medical professionals in the healthcare setting of the importance of the safety of the medication.  Factors Leading to Patient Safety Risk MAEs can cause severe health hazards to patients. Many factors contribute to patient safety hazards during pharmaceutical delivery. Poor teamwork and inadequate communication and interaction among doctors and nurses are some of the contributing factors to MAEs. Lack of collaboration among medical personnel can result in medication errors (Tiwary et al., 2019). Mr. John’s medication was administered incorrectly due to a misunderstanding and lack of communication among nurses and specialists. Misunderstanding and a lack of multidisciplinary cooperation result in insufficient information exchange among physicians, nurse practitioners, and pharmacy professionals, which can harm patients and increase medical expenditures. To prevent such events, efficient interaction is vital (Tiwary et al., 2019). Other recognized reasons for MAEs include errors in written correspondence, such as prescription drugs and record-keeping, drug delivery and inventory problems, such as pharmacy errors in dispensing, and facility management of stock. According to various studies, excessive job stress of nurses contributes to MAEs (Ayorinde & Alabi, 2019).  However, the majority of MAEs impacting patients in hospitals happen at the bedside and arise when a drug dose is provided inappropriately (Ayorinde & Alabi, 2019). MAEs are more likely in patients who have complicated drug regimes. Many research investigations have found a link between pharmaceutical regimen complexity and an increased likelihood of mishaps (Jessurun et al., 2023). Mr. John’s history of cardiac myopathy most likely demanded an elaborate drug prescription. Using standardized verifying techniques can help reduce the chance of misunderstanding and mistakes. Medical professionals can minimize the chance of MAEs in people like Mr. John by highlighting the significance of verification of prescriptions (Jessurun et al., 2023). Solutions Based on Evidence-Based Best Practices  Increased incidents of MAE results in a financial burden on patient and the healthcare system. Evidence-Based Practice (EBP) educates medical professionals on the most effective drugs or medications for particular diseases (Patel et al., 2019). EBP allows clinicians to select medicines with fewer adverse drug reactions. EBP enables physicians to administer Mr. John’s drug regimen effectively. EBP can significantly reduce MAEs, such as duplicate and incorrect dosages, and save medical expenses (Ahsani et al., 2022). Here are several EBPs that can assist in reducing MAEs: Medication Error Reporting System Introducing the Medication Error Reporting System (MERS) aids in identifying potential sources or risk factors of drug mistakes. Medication error reporting provides valuable information highlighting areas that require improvement to enhance patient safety (Mutair et al., 2021). Additionally, MERS is essential for assisting in easily avoiding errors and their typical serious consequences. Through MERS, healthcare professionals can evaluate contributing and risk variables in MAEs and the frequency of prescription mistakes. This system is critical to avoiding medication adverse events (Mutair et al., 2021). Barcoding Medication Administration (BCMA) BCMA functions as a beneficial Clinical Decision Support System (CDSS) to reduce medication errors. The BCMA technique can improve medicine delivery precision and effectiveness (Shitu et al., 2019). The scanning of barcodes verifies the drug information, guaranteeing the relevant patient, the right medicine, dosage, and mechanism is used. The BCMA system assists nurses in appropriately diagnosing patients and preventing MAEs. This approach enables hospitals and clinics to meet patient safety objectives (Mulac et al., 2021). Computerized Physicians’ Order Entry System (CPOE) The CPOE system helps nurses deliver medications currently functioning in the system. Using CPOE systems has been estimated to prevent around half of all medication errors (Jungreithmayr et al., 2021). A drug prescription should meet requirements such as legibility and accuracy to avoid MAEs. CPOE systems can significantly minimize unclear prescriptions and data exclusion, typical contributors to medication errors (Jungreithmayr et al., 2021). Medication Reconciliation (MR) MR is crucial to eliminate exclusion and replication errors, improper dosages or schedules, and harmful or adverse drug interactions. Adverse events can be reduced to improve patient safety by efficient MR, reducing the unwanted hospital stay of patients and mitigating healthcare costs (Chiewchantanakit et al., 2020). The MR strategy for Mr. John can help guarantee that his prescription information is updated during his hospitalization. This procedure involves contrasting his medicines with the drug prescription (Elbeddini et al., 2021). The Role of Nurses in Coordinate Care for Patient Safety Medication errors adversely affect patient safety. MAEs can result in extended hospital stays, incurring significant costs for medical facilities and individuals.  Nurses can avoid these additional expenditures by playing their role in coordinating care (Mileski et al., 2020). Nurses can follow evidence-based drug safety procedures such as the five rights of drug management, including the right patient, prescription drugs, dosage, met hod of administration, and timing. Nurses regularly give the right medicine

Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan Name Capella university NURS-FPX 4020 Improving Quality of Care and Patient Safety Prof. Name Date Root-Cause Analysis and Improvement Plan Root-cause analysis (RCA) is an approach that evolved in the medical field and is used to explore the direct and indirect contributing variables for a preventable adverse event and develop a prevention strategy (Kwok et al., 2020). The most common application of RCA in healthcare is in the analysis of Medication Administration Errors (MAEs), which contribute to Adverse Drug Events (ADE). ADE has adverse patient implications, ranging from insignificant negative outcomes to potentially fatal situations (Singh et al., 2023). MAEs resulted in a patient safety issue at the Vila Health Hospital. This study will investigate the root cause of the MAE incident, taking into account the factors that contributed to the problem. Furthermore, an evidence-based safety improvement plan will be developed based on the organization’s available resources to avoid such problems.  Root-cause analysis of medication administration errors One of the biggest causes of preventable patient damage in healthcare systems is inappropriate drug practices. The majority of these errors occur during the process of administration of drugs. Nurses are mainly accountable for MAEs (Wondmieneh et al., 2020). Lack of collaboration and records, a lack of medication interaction understanding, and inadequate instruction for patients result in MAEs that cause ADE (Guncag et al., 2021). By completing a comprehensive RCA, organizations can determine the sources of mistakes and design focused measures to avoid adverse events. A 52-year-old, Mr. Joseph, experienced adverse events due to MAEs. He was the patient of cardiac myopathy. During his hospital stay, the nurse misunderstood his handwritten medication prescription and gave him the wrong medicine, resulting in severe ADE, including increased cardiac rate and shortness of breath. It happens due to the injurious reaction of the wrong medicine with other drugs. The medication administration mistake committed by the nurse was an underlying concern. Poor standard of care and uncertain practices can result in significant death and disability in patients (Vaismoradi et al., 2020). To prevent repeated occurrences of severe drug reactions due to MAEs, it is critical to develop compatible guidelines for medication dispensing and highlight the importance of administering drug education (Vaismoradi et al., 2020). As a result, it is critical to recognize the elements contributing to the issue and develop an immediate safety improvement plan to address them. Elements Contributed to Safety Issues Assessing the primary cause of the patient protection concern, mainly Ms. Joseph’s MAE incident indicates various contributing variables relating to drug administration in the healthcare system. Inappropriate Medication Reconciliation (MR) and evaluation methods, such as the absence of complete drug records and accurate prescription histories, result in MAEs and harm the well-being of patients (Millichamp & Johnston, 2020). During nursing training, nurses acquire the five rights of administering medicines, which include the proper patient, prescription medicines, dosage, mode of delivery, and time. However, there are instances where nurses fail to adhere to this standard guideline, resulting in MAEs (Martyn et al., 2019). According to research, 38.6% of pharmaceutical mistakes were attributed to incorrect time management, while 27.5% were attributed to incorrect evaluation and prescription to the incorrect patient (Tsegaye et al., 2020). Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan The absence of defined standards for pharmaceutical prescribing, as well as clear recommendations and decision support systems, leads to dependence on human knowledge, which increases the risk of MAEs and adverse events (Alshahrani et al., 2021). Continuing professional education (CPD) is critical for nurses to promote and upgrade their expertise and abilities based on recent developments (Hakvoort et al., 2022). It is reported that improper or lack of training of nurses leads to the MAEs. According to research, 78.7% of MAEs are caused by inadequate education (Tsegaye et al., 2020). This evidence demonstrates that nurses with a limited understanding of medications can make mistakes during medication administration without identifying side effects that can compromise patient safety (Hakvoort et al., 2022). Application of Evidence-Based Strategies Evidence-based and standard interventions can tackle the incidents due to MAEs and the fundamental reasons indicated for these issues. The MR process is critical in encouraging an appropriate approach to drug administration. Hazardous occurrences can be decreased to promote patient safety through effective MR, minimizing unnecessary hospitalizations and lowering medical costs (Milanez-Azevedo et al., 2022). Integrating Electronic Health Records (EHR) systems with MR allows for the accessibility of correct and updated medication records. It assists in lowering healthcare administrative expenses by eliminating duplicate drug prescriptions or problems with duplication and related issues (Adane et al., 2019). Introducing the Medication Error Reporting System (MERS) assists with recognizing possible contributors or indicators for medication mistakes. MERS provides beneficial data by revealing issues that need improvement to increase patient safety (Karande et al., 2021). Moreover, this system is critical for readily minimizing mistakes and their associated ADR. MERS allows doctors and nurses to assess causative variables in the incidence of prescription mistakes. This framework prevents medication-related adverse reactions (Afaya et al., 2021). Capella 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan Barcoding scanning or Barcoding Medication Administration (BCMA) system can aid in reducing ADE by improving medication administration. The BCMA approach promotes the accuracy and efficacy of drug distribution and administration. Scanning barcodes confirms the details of the medication, ensuring that the appropriate drug, dose, and procedure is employed. The BCMA program helps caregivers accurately assess patients to avoid MAEs. This method allows healthcare facilities to accomplish goals related to patient safety (Owens et al., 2020). Collaboration and coordination with pharmacists and health personnel can also assist patients with complex health issues in analyzing pharmaceutical prescriptions. Raising drug interaction awareness and instruction is essential in reducing MAEs (Jaam et al., 2021). To reduce MAEs and their impact on patient safety, comprehensive training sessions for medical professionals concentrating on drug interactions and medication administration are required (Vifladt et al., 2023). How Strategies Address Adverse Events Related to Medication Administration Error Evidence-based techniques will deal with the ADE associated with MAEs. Medical personnel can obtain detailed drug details by integrating EHR and BCMA (Owens et al., 2020). MERS assists in the identification of potential causes