- Write an executive summary, 4-5 pages in length, of existing outcome measures related to a performance issue uncovered in your gap analysis that you intend to address.
Introduction - RUBRIC
-
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: - Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
Explain key quality and safety outcomes.
Analyze the relationships between a systemic problem in an organization and specific quality and safety outcomes. - Competency 2: Determine how outcome measures promote quality and safety processes within an organization.
Determine how specific outcome measures support strategic initiatives related to a quality and safety culture.
- Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliability and high-performing organizations.
Determine the strategic value to an organization of specific outcome measures.
- Competency 4: Synthesize the various aspects of the nurse leader’s role in developing, promoting, and sustaining a culture of quality and safety.
Determine how a leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes.
- Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Write clearly and concisely, using correct grammar and mechanics.
Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Running Head: MEDICATION ERRORS 1
Executive Summary- Medication Errors
Kathryn Forsyth
Capella University
HealthCare Quality Safety Management
July, 2020
Proprietary
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 2
Executive Summary- Medication Errors
Medication administration continues to be an issue, from start to finish, errors can occur.
The bedside nurse if responsible for about a quarter of medicine errors as they happen during the
administration phase (Armstrong et al, 2017). Medication administration is a multistep process
that requires clinical judgements, professional care, and analytical thinking. Medication
administration often happen is a busy environment, nurses must be able to manage multitasking
while upholding patient safety and clinical skill (Armstrong et al, 2017). Currently medication
errors are under reported, researched, and recognized and this needs to be addressed.
A Quality Interagency Coordination Task Force was created by the Department of Health
and Human Services and other federal agencies has advised using teamwork is an important way
to improve patient safety (Buljac-Samardzic, Dekker-van Doorn, & Maynard, 2018). Factors to
address when developing a plan to reduce medication errors include increasing reporting without
punishment, when and where did the error occur, and how many changes did the staff have to
prevent the error. Creating quality initiatives, improvement strategies, new policies and
procedures are ways to decrease medication errors. Administration and leadership should use
each near miss and adverse event as a teaching opportunity with the staff and determine how the
error can be prevented in the future.
Many healthcare organizations have banded together to research ways to decrease
medication errors. Nurse education is an ongoing process as there are new medications with look
alike, sound alike names. Understanding the cause of medication errors will improve the nurse’s
knowledge and provide nurses the ability to learn from mistakes. About 5% of medication
adverse events are related to a lack of nurse knowledge related to the medication (Patient Safety
Network, 2019). Nurses should always look up information on any drug they are unfamiliar with
and be encouraged to ask questions to try to reduce these events. Use of technology has also
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 3
decrease medication errors by using the barcode to scan the patient arm band and the medication
to prevent errors by verifying the right patient is getting the right medication at the correct time
(Alotaibi & Federico, 2017). Adding healthcare technology has reduced the near miss and
adverse events however all healthcare staff must not rely in the technology and continue to use
their knowledge, double check system, and allow the computer to be the verification of the
information we have already verified.
Analyzing the Issue
Medication adverse events and near misses are costly to the facility and insurance
companies. Approximately 400,000 hospitalized patients per year experience some type of
preventable harm, with a result in approximately 100,000 people dying as a result each year.
These errors cost about $20 billion dollars per year which creates a financial burden, some errors
that cause death or cause long term effects can lead to legal risk that will only increase the
financial burden (Rodziewicz & Hipskind, 2020). Many agencies are blaming the system for
medication errors as the staff are required to work long hours, often interrupted with
administering medication, and having to multitask. By not blaming the person, more events can
be reported without fear of retaliation and policies and procedures can be updated as we always
learn from the mistakes we make.
The systemic issues is with drug packaging, “The American Food and Drug
Administration (FDA) estimated that 20% of medication errors may be attributed to confusing
packaging and poor labeling; others suggested even higher rates” (Larmené-Beld, Alting, &
Taxis, 2018, page 1). Many drugs have look alike labels, names, and packaging. The primary
labels on the medication containers is very important as administering the incorrect drug can
have serious consequences for the patient. There have been many measures suggested to enhance
the improvement of being able to read the of labels and reduce errors related to look-alike labels.
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 4
Use of technology is one option that most hospitals have already implemented which is the a
closed-loop system with barcode technology. Another suggestion is the use of Tall Man lettering
and color-coding which aims to highlight the difference between two similar drugs by
capitalizing part of the drug names. Many organizations have endorsed Tall Man lettering
including the Joint Commission and the Institute for Safe Medication Practices (ISMP)
(Larmené-Beld, Alting, & Taxis, 2018). Administration and leadership at our local hospitals are
encouraging nurses to report look alike, sound alike drugs to aid in the fight to get labels and
names changed to make it easier to differentiate between drugs.
The current unit we are evaluating is a 50 bed burn unit, statistics show in the past six
months there has been an increase in administering the wrong drug by 40%, right timeframe by
35%, and the wrong route by 16%. Nurses have attributed these errors to a few issues that
include distractions, lack of drug knowledge, and not enough information provided by the
prescriber. Medication errors is trending upwards on this unit and the plan is to address the need
for new interventions, education, and improving use of technology to reduce errors. This unit has
also had an influx of new graduate nurses which could be another reason for the increase in
errors.
Effects of ongoing medication errors include increase cost of healthcare, increased length
of stay related to adverse medication events, legal issues from events that lead to long term
complications or death. This causes a huge financial burden and reportedly costs up to $20
billion dollars per year (Rodziewicz & Hipskind, 2020).Most medication errors are preventable
and that is what this plan is addressing, ways to decrease harm to patients, improve patient
outcomes, decrease healthcare costs and try to prevent legal issues which increase overall cost to
the facility.
Safety Culture
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 5
By creating a safe environment for reporting of medication errors, adverse events, and
near misses we are improving communication between everyone. As previously stated in this
paper, we can all learn from mistakes that we make or others make. A safe cultural is comprised
of several elements to include a just culture, engaged leadership, and complexity and improving
the of environment of care. Just culture understands that even the best, smartest individuals make
mistakes however there is no tolerance for behaviors that are repeated or violates policies and
procedures. People are not punished for making errors or voicing concerns but there is a clear
accountability principle. Engaged leadership as the force behind a safe culture. Leaders should
make safety part of the daily dialog and be addressed at each meeting. Leaders should encourage
staff to share concerns to allow a flow of information from staff to leaders and back. Leaders
should have clear expectations, support reporting of adverse events to patient and family and by
having a non-disciplinary response for those who self report or share concerns related to patient
safety. Understanding that healthcare is complex with many interdependent parts that can
continue to run even when someone goes to lunch, calls out, or the unit is short staffed. The unit
adapts to changes however sometimes a gap is left, which then causes nurses to alternate their
normal delivery of care, this increasing the risk for errors. An organization willing to discuss and
face problems is one way to identify emerging issues that could cause harm (Hemphill, 2015).
Best practice uses patient-centered quality initiatives focus on the analysis of the issues
and how best to become a High Reliability organization and obtain a Triple Aim framework.
Both address quality improvement initiatives to reduce possible patient injury and improve
patient safety. By using High Reliability and Triple Aim framework, we are seeing quality
interventions that improve patient outcomes, satisfaction, decrease mortality rates and
medication errors
(Bodenheimer & Sinsky, 2014).
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 6
Currently, the facility is using the bar code system which helps reduce medication errors
when used correctly, additional education is needed on correct use the scanner. The unit has
implemented the double check system with allowing the computer to be the triple check. We can
never replace nurse knowledge with computer as there are many things to take into consideration
when administering medications. Also, by increasing nursing education on pharmacology,
encouraging asking questions, self reporting without fear of punishment we learn the core reason
for the error to better create an initiative to prevent the error in the future. Currently the
multidisciplinary group is working on a standard way of reporting using the SBAR system
specifically for the burn unit however this could be modified to fit another unit needs as well.
Leadership has stepped up to provide support, an environment that encourages nurses to ask
questions, self-report errors, and voice any concerns. By working as a team, we will improve our
knowledge, procedures and decrease errors.
Leadership in a pivotal role in implementing quality improvement and keeping the team
engaged on the goal. Transformational leadership is a leader with a vision for the team who can
stimulate others in a clear and concise but also appreciative of the individual team members.
Transactional leaders influence their followers based on providing rewards for a job well done
and in response to their achieved defined goals (Saravo, Netzel, & Kiesewetter, J. 2017). Lack of
leadership can result in failure of implementing the initiatives, reaching objective, and not
meeting goals. Barriers may limit the nurse ability to provide quality patient care, these barriers
could be placed by leadership, management, administration, and other healthcare personnel
(Bodenheimer & Sinsky, 2014).
Outcomes measures will support the ongoing use of technology, triple check, increased
communication skills, standardized reporting by having a decrease in medication errors by ten
percent within the first month. This will be an ongoing process, so leaders will have to keep the
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 7
staff motivated to incorporate the changes into their daily routines. Once habits are formed, we
expected medication errors to drop significantly withing 90 days.
Conclusion
Medication administration remains an area that constant quality improvements are needed
to decrease harm and improve patient outcomes. By using technology to create a system to verify
the right patient, right time and right dose medication errors have decreased. Creating a culture
of safety for staff to self report and express themselves, we are improving communication and
allowing others to learn from mistakes. This allows gives an opportunity to research why the
error occurred and create a plan to prevent the error in the future. Having strong leadership will
increase staff participation in interventions and will improve patient care and satisfaction.
Quality and safety of healthcare is a result of interventions, objectives, and goals to work
towards decreasing medication errors by all staff members. This will have a direct positive
impact on all stakeholders.
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 8
References:
Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient
safety. Saudi medical journal, 38(12), 1173–1180.
https://doi.org/10.15537/smj.2017.12.20631
Armstrong, G., Dietrich, M., Norman, L., Barnsteiner, J. & Mion, L. (2017). Nurses’ Perceived
Skills and Attitudes About Updated Safety Concepts. Journal of Nursing Care Quality,
32(3), 226–233. doi: 10.1097/NCQ.0000000000000226.
Bodenheimer, T and Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient
Requires Care of the Provider. The Annals of Family Medicine, 12 (6) 573-576; DOI:
https://doi.org/10.1370/afm.1713
Buljac-Samardzic, M., Dekker-van Doorn, C., & Maynard, M. T. (2018). Teamwork and
teamwork training in health care: An integration and a path forward. Group &
Organization Management, 43(3), 351-356. doi:10.1177/1059601118774669
Hemphill R. R. (2015). Medications and the Culture of Safety : Conference Title: At the
Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and
Medication Safety Venue ACMT Pre-Meeting Symposium, 2014 North American
Congress of Clinical Toxicology, New Orleans, LA. Journal of medical toxicology :
official journal of the American College of Medical Toxicology, 11(2), 253–256.
https://doi.org/10.1007/s13181-015-0474-z
Larmené-Beld, K.H.M., Alting, E.K. & Taxis, K. (2018). A systematic literature review on
strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol 74, 985–993.
https://doi.org/10.1007/s00228-018-2471-z
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
MEDICATION ERRORS 9
Patient Safety Network (PSA). (2019). Medication Errors and Adverse Drug Events. Retrieved
from https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
Rodziewicz L., Hipskind J. (2020). Medical Error Prevention. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK499956/
Saravo, B., Netzel, J., & Kiesewetter, J. (2017). The need for strong clinical leaders –
transformational and transactional leadership as a framework for resident leadership
training. PLoS One, 12(8)
doi:http://dx.doi.org.library.capella.edu/10.1371/journal.pone.0183019
This study source was downloaded by 100000855641916 from CourseHero.com on 01-03-2023 20:37:26 GMT -06:00
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
Powered by TCPDF (www.tcpdf.org)
https://www.coursehero.com/file/66014757/MSN-FP6212-ForsythKathy-Assessmen2-2docx/
http://www.tcpdf.org
· Write an executive summary, 4-5 pages in length, of existing outcome measures related to a performance issue uncovered in your gap analysis that you intend to address.
Introduction
Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.
As a nurse leader, you must be able to access, identify, and describe outcome measures as they relate to safety and quality problems in your organization.
This assessment provides an opportunity to examine existing outcome measures, assess their strategic value, and present your findings to executive leaders in a manner that will help you gain their support.
Quality and safety are everyone’s responsibility as a team of interprofessional care delivery partners. Together we develop policies that support quality and safe care delivery. As part of the interprofessional team, nurses are leaders in care and thus are responsible and accountable for leading and providing safe quality care.
Health care delivery is structured around evidenced-based information. Quality is defined by exploring proven, evidenced-based information. After reviewing and defining evidenced-based information, the interprofessional team applies this knowledge to assess the organization’s or the practice setting’s ability to provide evidenced-based care delivery. When a gap in care is identified, it is important to propose an evidenced-based change and to execute a plan for improved care.
Your summary of relevant outcome measures is based on your findings from the quality and safety gap analysis you completed in the previous assessment.
Preparation
Your analysis of the gap between current and desired performance was the first step toward improving outcomes. You now have the information you need to move forward with proposed changes. Your next step is to focus on existing outcome measures and their relationship to the systemic problem you are addressing. For this assessment, you have been asked to draft a summary of existing outcome measures for your organization’s executive team to raise awareness of the problem and the strategic value of existing measures.
Note: As you revise your writing, check out the resources listed on the Writing Center’s
Writing Support
page.
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
Building stakeholder support is crucial to fostering and sustaining change. Therefore, as you approach this assessment, think about the stakeholders whose support you will need for the change you want to bring about.
· What information is most essential for both the formal and informal stakeholders to understand about the proposed change?
· How might you communicate the need for change using just a few sentences (this is often referred to as an “elevator speech”).
The following resources are required to complete the assessment.
·
APA Style Paper Tutorial [DOCX]
. Use this for your executive summary.
Requirements
Note: The requirements outlined below correspond to the grading criteria in the Executive Summary Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Executive Summary Scoring Guide and
Guiding Questions: Executive Summary [DOCX]
to better understand how each criterion will be assessed.
Composing the Executive Summary
· Explain key quality and safety outcomes.
· Determine the strategic value to an organization of specific outcome measures.
· Analyze the relationships between a systemic problem in your organization or practice setting and specific quality and safety outcomes.
· Determine how specific outcome measures support strategic initiatives related to a quality and safety culture.
· Determine how the leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes.
Writing and Supporting Evidence
· Write clearly and concisely, using correct grammar and mechanics.
· Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
Additional Requirements
Format your document using APA style.
· Use the
APA Style Paper Tutorial [DOCX]
. Be sure to include:
11. A title page and reference page. An abstract is not required.
11. A running head on all pages.
11. Appropriate section headings.
11. Properly-formatted citations and references.
· Your summary should be 4–5 pages in length, not including the title page and reference page.
Portfolio Prompt: You may choose to save your executive summary to your
ePortfolio.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
· Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.
13. Explain key quality and safety outcomes.
13. Analyze the relationships between a systemic problem in an organization and specific quality and safety outcomes.
· Competency 2: Determine how outcome measures promote quality and safety processes within an organization.
14. Determine how specific outcome measures support strategic initiatives related to a quality and safety culture.
· Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliability and high-performing organizations.
15. Determine the strategic value to an organization of specific outcome measures.
· Competency 4: Synthesize the various aspects of the nurse leader’s role in developing, promoting, and sustaining a culture of quality and safety.
16. Determine how a leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes.
· Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
17. Write clearly and concisely, using correct grammar and mechanics.
17. Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.