Factors Leading to Patient-Safety Risk

For this assessment, you will develop a 3–5 page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

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Introduction

Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.

You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

References

Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academy Press.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.

Scenario

Select one of the safety quality issues presented in the Assessment 01 Supplement: Enhancing Quality and Safety [PDF] Download Assessment 01 Supplement: Enhancing Quality and Safety [PDF]resource and incorporate evidence-based strategies to support communication and ensure safe and effective care.

Instructions

For this assessment, you will analyze a safety quality issue in a health care setting and identify a quality improvement (QI) initiative.

Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.

Explain factors leading to a specific patient-safety risk in a health care setting.
Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
Explain how nurses can help coordinate care to increase patient safety and reduce costs.
Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Additional Requirements

Length of submission: 3–5 pages, plus title and reference pages.
Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: References and citations are formatted according to current APA style.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
- Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
Competency 2: Analyze factors that lead to patient safety risks.
- Explain factors leading to a specific patient-safety risk in a health care setting.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
- Explain how nurses can help coordinate care to increase patient safety and reduce costs.
- Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
- Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
- Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

Title: Enhancing Patient Safety in Medication Administration

Introduction

Patient safety is a paramount concern in healthcare settings, and healthcare professionals, particularly nurses, play a critical role in ensuring the well-being of patients. Medication errors are a significant safety quality issue in healthcare settings, with the potential to cause harm to patients. This paper will focus on factors leading to medication errors, evidence-based and best-practice solutions to improve patient safety, the role of nurses in coordinating care to increase patient safety, and the identification of stakeholders in driving safety enhancements related to medication administration.

Factors Leading to Medication Errors

Medication errors can occur due to various factors, including:

Lack of Communication: Poor communication between healthcare providers, such as physicians and nurses, can lead to medication errors. Misunderstandings regarding medication orders or patient information can result in the administration of the wrong medication or dosage.
Medication Packaging and Labeling: Confusing packaging and labeling of medications can contribute to errors. Similar-looking medications or unclear labeling can lead to medication mix-ups.
Staff Fatigue and Overwork: Overworked and fatigued healthcare providers are more likely to make mistakes. Long working hours and high patient loads can negatively impact concentration and decision-making.
Inadequate Medication Education: Patients may not receive adequate education about their medications, leading to errors in self-administration at home.
Lack of Double-Checking: Failing to double-check medication orders and patient identities before administration can result in errors.

Evidence-Based and Best-Practice Solutions

To improve patient safety and reduce costs related to medication errors, healthcare organizations should implement evidence-based and best-practice solutions, including:

Computerized Physician Order Entry (CPOE) Systems: Implementing CPOE systems can reduce errors related to illegible handwriting and enhance accuracy in medication orders.
Barcode Medication Administration (BCMA): BCMA systems require nurses to scan medication barcodes and match them to patient identification, reducing the risk of administering the wrong medication or dosage.
Medication Reconciliation: Performing thorough medication reconciliation during transitions of care ensures that patients receive the correct medications and dosages.
Standardized Medication Labels and Packaging: Ensuring standardized labeling and packaging of medications reduces confusion and errors.
Interprofessional Communication: Encouraging open and effective communication among healthcare team members is crucial in preventing medication errors.

Role of Nurses in Coordinating Care

Nurses play a pivotal role in coordinating care to enhance patient safety in medication administration. They can:

Administer Medications Safely: Nurses are responsible for administering medications accurately, following proper protocols, and double-checking patient identities and medication orders.
Educate Patients: Nurses should provide clear and comprehensive medication education to patients, ensuring they understand their medications and how to take them correctly.
Advocate for Patients: Nurses can serve as patient advocates by raising concerns about medication safety and communication issues within the healthcare team.
Report Errors: Nurses should promptly report any medication errors they witness or are involved in to facilitate a rapid response and prevent future occurrences.

Identifying Stakeholders

In driving safety enhancements related to medication administration, nurses must collaborate with various stakeholders, including:

Physicians: Physicians prescribe medications and need to communicate clearly with nurses to prevent errors.
Pharmacists: Pharmacists can provide expertise in medication management and review medication orders for accuracy.
Patients and Families: Engaging patients and their families in medication safety discussions and education is essential.
Hospital Administration: Hospital administrators should support the implementation of technology and policies that enhance medication safety.

Conclusion

Medication errors pose a significant risk to patient safety in healthcare settings. However, by implementing evidence-based solutions, involving nurses in coordinating care, and collaborating with key stakeholders, healthcare organizations can enhance patient safety and reduce the costs associated with medication errors. Nurses, as frontline caregivers, play a crucial role in promoting safe and effective medication administration, ultimately improving patient outcomes.