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Capella 4020 Assessment 3

Capella 4020 Assessment 3 Improvement Plan In-Service Presentation

Student Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Safety Improvement Plan – Introduction

Good Afternoon, my name is Chalonda. I would like to welcome you all to this in-service training session. This session is designed for nurses and nurse leaders. The topic for today’s presentation is medication administration errors (MAEs) and their improvement. This in-service training is developed for nurses to observe medication errors within their unit and identify loopholes in nursing practices. Moreover, the safety improvement strategies shared will enable you to incorporate them into your practices to improve patients’ safety and provide quality care. 

Objectives of this Presentation

Let me first share the learning objectives of today’s presentation so that you are aware of the flow of the session. By the end of the session:

  • You will be aware of medication administration errors. 
  • You will recognize the need for addressing these errors within your organization. 
  • I will share with you a safety improvement plan in terms of addressing the situation. 
  • I will share the responsibilities of stakeholders in addressing these errors. 

In the end, we will do a group activity as well which will be a summary of the overall presentation. These objectives of the presentation will enable you all to achieve quality improvement in your practices and nurse leaders will benefit by recognizing safety errors and bringing reforms in their workplace.  

Medication Administration Errors 

Medication administration errors (MAEs) are defined as inaccuracies at the time of administration of drugs. The administration is the last process of medication management before the final documentation takes place. Most of these errors are committed by nurses as they are the major group of healthcare professionals who administer drugs to patients (Wondmieneh et al., 2020). These errors can occur due to the provision of the wrong drug, wrong dose, wrong path/route, at the wrong time, and/or administered to a wrong patient. Along with health risks, medication errors can lead to patient dissatisfaction and a lack of trust in the hospital (Tariq et al., 2022). Thus, it is essential to address these challenges with evidence-based strategies to ensure patients’ safety and quality of care.

Why a Safety Improvement Plan is Needed? 

So, now as you all are aware of medication administration errors and where can be the loopholes (five wrongs), it’s time to understand the need for a safety improvement plan. The safety improvement plan is devised for sustainable and considerable changes in any healthcare setting. This plan provides a blueprint for the implementation of effective strategies to bring positive reforms (Hernan et al., 2020). Similarly, it is essential to develop a safety improvement plan for medication administration errors.

Research identifies that MAEs are a universal problem in healthcare settings. The National Patient Safety Agency (NPSA), UK revealed that 50% of patients admitted in all healthcare settings experience MAEs during their hospital stay. One of the most prevailing errors which cause serious consequences is incorrect timing error. Other nations like the UK, USA, Middle East, and East Africa reported these errors to fall between the 9.4- 80% range (Raja & Badil, 2022).

Another study that reflected on the prevalence of medication errors showed that around 30.5% of errors in Malaysian hospitals occur during the administration phase (Shitu et al., 2020). Drug-related adverse events are the reason behind approximately 5-6% of hospitals annually which exceeds hospital costs by $42 billion (Assiri et al., 2018). 

Some of the poor consequences of medication errors are severe morbidities like systemic infection, pain, and worsening of the disease process. It also causes mortality in some patients with serious illnesses. Other than the physical health risks, these adverse events can lead to increased hospital expenses, prolonged stay at the hospital, and causing psychological impacts on patients, their families, and healthcare providers (Tansuwannarat et al., 2022). These literature statistics advocate that there is a need to establish a safety improvement plan within all healthcare organizations as well as in our healthcare organization.

Safety Improvement Plan

In our safety improvement plan for preventing and eliminating medication administration errors, various evidence-based strategies are included. Some of these strategies are; the establishment of an Incidence Reporting System (IRS), training and development, double-checking of medication, elimination of interruptions, and medication reconciliation. 

Incidence Reporting System (IRS)

The purpose of this system is to report drug-related medical errors so that nurses and nurse leaders can identify the prevalence and effectively take action against this. Improvement in reporting system will help in reducing these errors by continuous tracking and recording of the incidences of MAEs within the organization. A medication error reporting system acts as a tool to reduce risks associated with medication errors. However, it is essential that by building these systems, nurse leaders should create a supportive environment (without punishments and a blame culture) for nurses. The support from leaders will enhance nurses’ ability to report errors without feeling hesitant and afraid of poor consequences (Afaya et al., 2021). 

Training and Development

Nurses and other healthcare professionals must receive training related to various aspects of medication safety like safe prescribing, correct preparation and dispensing, and most importantly safe administration of medication. Since this training is prepared for nurses, safe medication practices are part of this session. The five “R” (rights) framework of medication administration safety is established for nurses to incorporate into their nursing practices. These five rights are; the right patient, right drug, right dose, right time, and right route (Jones & Treiber, 2018).

Nurses need to follow these steps during the administration of drugs so that patient is provided with medicines through standardized practices and with effective methods. Moreover, nurse instructors should encourage their employees (nurses) to use these standards during their practices. Policymakers within the hospital can assist by developing a zero-tolerance policy against the negligence of these standards thus nurses are obliged to perform effective and safe medication administration. 

Double-checking Medicines

Double-checking the medicine to be administered can also prevent medication errors from taking place. It is defined as two individuals checking and verifying the drugs using the standards of the five rights framework. The potential benefits of double-checking depend on two factors; one is two individuals nurses check the medications, as well as these medications, are checked separately by both nurses. This process prevents errors if one individual misses or skips anything, another one can identify the gap and immediate action can be taken to prevent patient harm (Koyama et al., 2020). 

Eliminating Interruptions 

A study reveals that 75% of medication errors occur due to external interruptions. These interruptions are due to environmental and personal factors (Tariq et al., 2022). It is estimated that these disruptions can enhance administration time, and reduces nurses’ efficiency which ultimately inclines the chances of medication errors.  

Medication Reconciliation

Medication reconciliation is defined as a process whereby the medication lists are reviewed at both the prescription side and administration side of the process. This step helps nurses in only administering drugs that are currently active in the list to avoid mishappenings (Ciapponi et al., 2021). This process not only reduces errors but also supports cost reduction related to adverse drug events.

Roles of Interprofessional Team Members

In this presentation, until now we have covered all about medication administration errors and how we can bring safety improvements to our organization. However, improvements are only possible if an interprofessional team works together collaboratively to achieve the desired outcomes. For this safety improvement plan, we need a team of nurses, nurse leaders, policymakers, and of course our quality improvement auditors. Let’s discuss the roles of each professional team in this plan. 

As discussed earlier, nurses are a pivotal group of people because of their jobs’ frontline nature. They are the ones who are responsible for these errors and only they can improve their practices to ensure quality and safe care is provided. Nurses can do this by following organizational and international guidelines, remaining up-to-date with the healthcare trends, being involved in training and development programs, and ensuring effective reporting of these errors if identified.

Capella 4020 Assessment 3

Nurse leaders are responsible to conduct training for their staff, constantly encouraging safe medication practices within the workplace, and ensuring that every individual practicing medication is credentialed for this healthcare practice. Moreover, they should create a supportive and kind environment for their staff to appropriately report errors and improve their practices without any being troubled. Policymakers should develop specific organizational policies against medication negligence for example zero-tolerance policy and should reprimand the staff if found committing errors. Moreover, they must develop an incidence reporting system together with the hospital’s administration to ensure effective reporting takes place.

QI auditors play an important part related to reporting where they should be checking and monitoring the record every week to ensure the effectiveness of the reporting system by taking appropriate measures. They should also audit staff about the safe medication practices knowledge to have an idea of more training required. Moreover, they must obtain data from patients about their satisfaction levels related to medication safety practices.  This interprofessional team’s participation and the development of an improvement plan enables nurses and other healthcare professionals to perform their healthcare practices effectively thus creating a safe, reliable, and trustworthy environment for patients and their families. 

Activity and Educational Resources

We are at the end of our in-service training session. You can ask questions now before we do a small activity to ensure that whatever we have learned today, we will incorporate 

into our practices. 

In the end, participants of the session will develop some educational resources (pamphlets, worksheets, puzzles, charts, etc.) to demonstrate their learnings. These educational resources will be utilized for future sessions and for spreading awareness among other colleagues to ensure safe medication practices are followed by all healthcare professionals. 

Conclusion

I would like to conclude my presentation by reviewing the objectives that we achieved today. We discussed medication administration errors, their prevalence, and the poor consequences which are resulted from these errors. We identified the need for a safety improvement plan and suggested some evidence-based strategies to overcome these challenges. These strategies are the development of a reporting system, training, and education, medication reconciliation, elimination of disruptions, and double-checking practices.

Moreover, we discussed the roles of various stakeholders in forming an interprofessional team. In the end, some of the resources were developed by you all and some were provided by me which can be used for the future session and to spread knowledge among other co-workers

References

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 

Assiri, G. A., Shebl, N. A., Mahmoud, M. A., Aloudah, N., Grant, E., Aljadhey, H., & Sheikh, A. (2018). What is the epidemiology of medication errors, error-related adverse events, and risk factors for errors in adults managed in community care contexts? A systematic review of the International Literature. BMJ Open8(5). https://doi.org/10.1136/bmjopen-2017-019101  

Ciapponi, A., Fernandez Nievas, S. E., Seijo, M., Rodríguez, M. B., Vietto, V., García-Perdomo, H. A., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Garcia-Elorrio, E. (2021). Reducing medication errors for adults in hospital settings. The Cochrane Database of Systematic Reviews11(11), CD009985. https://doi.org/10.1002/14651858.CD009985.pub2

Hernan, A. L., Giles, S. J., Beks, H., McNamara, K., Kloot, K., Binder, M. J., & Versace, V. (2020). Patient feedback for safety improvement in primary care: Results from a feasibility study. BMJ Open10(6). https://doi.org/10.1136/bmjopen-2020-037887 

Jones, J. H., & Treiber, L. A. (2018). Nurses’ rights of medication administration: Including authority with accountability and responsibility. Nursing Forum53(3), 299–303. https://doi.org/10.1111/nuf.12252  

Koyama, A. K., Maddox, C. S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ quality & safety29(7), 595-603. https://qualitysafety.bmj.com/content/qhc/29/7/595.full.pdf 

Capella 4020 Assessment 3

Raja, P. K., & Badil, S. A. (2022). The magnitude of medication administration errors and their types. Rawal Medical Journal47(1). https://www.rmj.org.pk/fulltext/27-1576130201.pdf 

Shitu, Z., Aung, M. M., Tuan Kamauzaman, T. H., & Ab Rahman, A. F. (2020). Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia. BMC Health Services Research20(1). https://doi.org/10.1186/s12913-020-4921-4 

Tansuwannarat, P., Vichiensanth, P., Sivarak, O., Tongpoo, A., Promrungsri, P., Sriapha, C., Wananukul, W., & Trakulsrichai, S. (2022). Characteristics and consequences of medication errors in pediatric patients reported to Ramathibodi Poison Center: A 10-year retrospective study. Therapeutics and Clinical Risk ManagementVolume 18, 669–681. https://doi.org/10.2147/tcrm.s363638 

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication dispensing errors and prevention. StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519065/

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), 1-9. https://doi.org/10.1186/s12912-020-0397-0 

Capella 4020 Assessment 3