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Capella 4020 Assessment 4

Capella 4020 Assessment 4 Improvement Plan Tool Kit

Student Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan Tool Kit

The safety improvement plan developed in assessment two, disseminated to the concerned audience (nurses, head nurses, nurse informaticists, physicians, and IT and logistics personnel) through the in-service presentation, is developed using evidence-based research information gathered through various professional and scholarly resources. This improvement plan resource kit highlights all the major categories in which the information is sub-divided for the audience to understand the implementation and sustainability of the plan related to medication administration errors (MAEs).

The databases used for the research are; Google Scholar, CINAHL, PubMed and BioMed, ScienceDirect, and other professional websites. This resource tool kit will assist nurses and other stakeholders in understanding their roles in successfully implementing the safety improvement plan to reduce MAEs and improve the quality of healthcare services. 

Resource Tool Kit for Implementation and Sustainability 

To make it easier for our audience to understand the importance and development of a safety improvement plan, this resource kit is divided into four sub-categories; an overview and presence of medication administration errors, risk factors for MAEs, strategies to minimize errors, and technological integration to reduce errors. 

An Overview and Presence of MAEs

Assunção-Costa, L., Sousa, I. C. de, Oliveira, M. R. A. de, Pinto, C. R., Machado, J. F. F., Valli, C. G., & Souza, L. E. P. F. de. (2022). Drug administration errors in Latin America: A systematic review. PLOS ONE17(8), e0272123. https://doi.org/10.1371/journal.pone.0272123 

This article is based on the literature review of various studies which analyze the types and prevalence of medication administration errors in Latin American Hospitals. This systematic review concluded that the MAE rate is significantly higher in the concerned hospitals, with a median rate of 32%, which included time and dose errors, omission errors, and wrong route errors. Most drugs involved in these errors were used to treat chronic health conditions. This resource is beneficial for nurses and other role groups to understand the importance of MAEs within the country by analyzing their prevalence.

Moreover, the information on various types of MAEs assists nurses in identifying the common ones in their healthcare setting, for example, omission errors are common in our specific healthcare setting. Such an identification helps in instigating targeted interventions within the workplace. The data presented in the study advocates the need to implement the safety improvement plan devised specifically for the concerned stakeholders. 

Capella 4020 Assessment 4

Hodkinson, A., Tyler, N., Ashcroft, D. M., Keers, R. N., Khan, K., Phipps, D., Abuzour, A., Bower, P., Avery, A., Campbell, S., & Panagioti, M. (2020). Preventable medication harm across health care settings: A systematic review and meta-analysis. BMC Medicine18(1), 313. https://doi.org/10.1186/s12916-020-01774-9 

According to Hodkinson et al. (2020), drug-related errors are the third most common cause of mortality in the U.S. The study concludes that frequent preventable medication errors may lead to life-threatening situations for patients, especially in the elderly population. Other settings like primary care and psychiatric health are at high risk for such errors as most healthcare services are delivered in these areas.

Capella 4020 Assessment 4

This resource is helpful for the nurses working in geriatric, primary care, and psychiatric services within healthcare organizations to gather information regarding the risk factors and identify those factors within their healthcare settings to mitigate the threats and preserve patient safety. This study also presents the types of preventable medication errors, which eventually help nurses upgrade their knowledge and apply it to determine high-risk patients within their workplace. Preventing harm by improving nursing practices will ensure high-quality care, patient safety, and patient satisfaction. 

Jessurun, J. G., Hunfeld, N. G. M., de Roo, M., van Onzenoort, H. A. W., van Rosmalen, J., van Dijk, M., & van den Bemt, P. M. L. A. (2023). Prevalence and determinants of medication administration errors in clinical wards: A two‐centre prospective observational study. Journal of Clinical Nursing32(1–2), 208–220. https://doi.org/10.1111/jocn.16215 

Capella 4020 Assessment 4

This study investigated the presence and determinants of MAEs in Dutch hospitals using an observational design. The study results in 13.7% of MAEs, while the most common types of errors were omission, inappropriate handling, and incorrect dosage. Several determinants of MAEs were observed, including the form of the medication, the time of day, and the level of education and knowledge of the nurses. This study provides valuable insights for nurses to better understand the associated risks, develop targeted interventions to mitigate patient safety risks related to medication administration and develop targeted interventions to reduce these risks.

For example, the particular situations where the study’s findings would help nurses are while handling medications with complicated pharmaceutical forms and when there is extensive workload and busy shifts. Moreover, this study advocates for continuous professional education for nurses to reduce the likelihood of MAEs. Additionally, nurses can benefit from the study’s findings while assessing their practices and determining areas of improvement to provide quality care without harming patient safety. 

Risk Factors for MAEs

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 Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0

According to this study, MAEs are common in the healthcare settings of Ethiopia. This study found that 68.1% of nurses commit at least one type of MAE annually, among which the most prevalent are wrong time, incorrect documentation, and wrong dose errors. Along with the prevalence, this study’s focus remained to identify some of the factors associated with these errors, which include poor training, lack of standardized guidelines about drug administration, insufficient work experience, night duty hours and lack of sleep, and distractions during medication administration.

Nurses can use this information to understand better the risks associated with medication administration within their organization, for example, the risk as mentioned earlier factors are common in most healthcare settings. Identification of particular risk factors will enable nurses to prevent such harm. Moreover, this resource is relevant for nurse leaders (head nurses) to understand the importance of professional training and making standardized guidelines available for practitioners to improve the quality of healthcare services and reduce these risks. 

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

Capella 4020 Assessment 4

This study examines nurses’ perception of the contributing factors to medication administration errors, which concluded that extensive workload, shortage of nurses, distractions during the administration phase, inadequate training, stress/fatigue, and lack of experience are some risk factors related to systematic and personal issues. Moreover, medication-related factors such as multiple drug regimens, inappropriate packaging, and look-alike and sound-alike (LASA) drugs may lead to several errors in healthcare settings.

This study is helpful for nurses to undertake specific actions by determining the particular risk factors in their healthcare settings. Particularly, this resource is valuable for nursing leaders to initiate specific mitigation strategies to avoid such risks and prevent medication harm. These practices may include nurse education, appropriate training on medication management, recruiting and retaining staff, and preventing interruptions during the drug administration. 

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine13, 1621–1632. https://doi.org/10.2147/IJGM.S289452 

Capella 4020 Assessment 4

Similar to other studies, Tsegaye and colleagues (2020) worked on identifying several factors that may lead to MAEs. According to the study’s results, 57.7% of nurses had made such errors, of which 30.4% committed it more than three times. Lack of training, unavailable guidelines, poor communication, interruptions, and failure to abide by medication administration rights were some of the factors identified in this study. Hence, this study is useful for nurses and other stakeholders to identify particular issues within the care setting, develop standardized guidelines, bring strictness to follow drug administration rights, enhance nurses’ training, and develop strategies to minimize distractions.

In particular, when nurses undergo such difficult times, such as when errors are committed or near-miss events, nurses can utilize this resource to improve their communication with other interdisciplinary team members to ensure patient safety remains a priority. This resource is helpful for stakeholders to understand the importance of a safety improvement plan and its implementation within the workplace. 

Strategies to Minimize Errors 

Abdulmutalib, I., & Safwat, A. (2020). Nursing strategies for reducing medication errors. Egyptian Journal of Nursing and Health Sciences1(1), 26–41. https://doi.org/10.21608/ejnhs.2020.80266 

This article emphasizes the role of nurses in medication management. Being the last line of defense, nurses are responsible for preventing medication harm, monitoring the effectiveness of the drugs and determining adverse events that may harm patient safety.  Several strategies are described in this article to minimize errors at the nursing level. These are; effective management of workload, increasing knowledge regarding drugs, drug interactions, and its management, improving nurse-patient ratio, reporting medication errors to prevent future events, improving the quality of care, and maintaining patient safety.

Capella 4020 Assessment 4

Since our safety improvement plan focuses on similar aspects; minimizing workload, improving communication, and integrating technologies, this resource will be beneficial for nurses to thoroughly understand and implement the safety improvement plan to improve nursing practices and prevent patient safety. Specific areas with high-risk patients such as pediatric settings, intensive care units, geriatric settings where nurses are dealing with complex and multiple drug regimens, this resource can be helpful for nurses and nurse leaders to take targeted actions for preventing medication errors. 

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences13, 100235. https://doi.org/10.1016/j.ijans.2020.100235 

Capella 4020 Assessment 4

Salar and colleagues (2020) presented a study to identify ways to prevent medication errors among nurses. The two primary ways determined are; professionalism and integrating technical strategies. Acting professionally or following professionalism means carefully performing medication administration procedures by being fully attentive to specific details, and communicating effectively with other team members. Moreover, nurses should know their limitations and ask for help when required. On the other hand, technical strategies like using the barcoded system to verify medications and using a double-checking system are recommended in this study.

Moreover, hospital accreditation programs are essential for setting standards related to medication safety. This study provides nurses with a valuable understanding of the factors that contribute to medication errors and the strategies that can be used to prevent them. Since technical integration and improving communication is an integral part of our safety improvement plan, this resource is relevant and useful for stakeholders to understand the implementation of the plan and make it sustainable to improve patient safety. 

Çınar, F., & Şahin, S. (2022). Nursing practices towards prevention of medication errors: A systematic review and meta-analysis. Letters in Applied NanoBioScience12(4), 124. https://doi.org/10.33263/LIANBS124.124 

Capella 4020 Assessment 4

This systematic review and meta-analysis reveals several strategies that should be implemented to improve nursing practices related to medication administration, including; continuous education through online and simulative training, technological integration such as barcoded medication administration applications and computerized order entry system, and other methods like fewer distractions, guidelines, and policies and procedures.

This resource provides nurses with a comprehensive understanding of the evidence related to the importance of nursing practices in preventing MAEs. This information can help nurses to identify and implement the most effective practices in their clinical setting. Using a safety improvement plan. For example, the study’s findings recommend that nurses should receive ongoing education and training on medication administration and double-checking medications using a barcoded system can help to reduce the risk of MAEs.

Technological Integration to Reduce Errors 

Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2020). The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review. Research in Social and Administrative Pharmacy, 17(5), 832–841. https://doi.org/10.1016/j.sapharm.2020.08.001  

The systematic review by Zheng et al. (2020) investigated the impact of three technologies – automatic dispensing cabinets (ADCs), barcoded medication administration (BCMA), and closed-loop electronic medication management systems (EMMS) on improving medication safety in the healthcare settings. The study found that ADCs, BCMA, and EMMS can all have a significant impact on work processes and medication safety. However, some of the drawbacks were identified as workload, system complexity, and increased implementation costs.

Capella 4020 Assessment 4

Despite the drawbacks identified, this resource provides nurses and other stakeholders with a comprehensive overview of various technologies that can be integrated into the healthcare system to improve patient safety regarding medication management. The particular way of utilizing this resource is to carry out a root-cause and risk-benefit analysis within the healthcare setting which will help stakeholders understand the importance of such technologies and address the challenges associated with them. These informed decisions will enable subsequent changes within the healthcare system. 

Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to the implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J10, 45-46. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2019/03/Commentary-14.pdf 

The literature review presents how effective technologies like computerized order entry systems and barcoded systems are for cost reduction and preventing medication errors. The results of the study revealed that up to 72% of the errors can be prevented by using both the systems combined together. This resource is helpful for the audience of the safety improvement plan to introduce such technologies within their healthcare settings to improve the medication management process at each stage.

Capella 4020 Assessment 4

BCMA system is mainly useful for nurses, as introduced in our safety improvement plan to ensure medication administration rights are carefully followed. These technological systems are useful for the identification of errors before they are committed to prevent potential harm. Thus, the resource is a great source of information for nurses and other stakeholders to implement and make safety improvement plans sustainable.  

Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 

This mixed-methods study investigated the prevalence and causes of policy deviations in barcode medication administration (BCMA) use in hospital practice. The authors observed some deviations in nursing practices after implementing BCMA due to nurses’ workload, interruptions, knowledge and skill, and organizational factors like policies and technological glitches. Such a study gives valuable insight related to the post-implementation monitoring of technologies and nursing actions.

For this purpose, the stakeholders of our safety improvement plan can ensure multiple security and technological checks by IT professionals to ensure the software and devices are appropriately working. Nurse leaders must monitor nurses’ actions and plan continuous feedback sessions to avoid such deviations. This resource is helpful in understanding and identifying such variations to not only implement the plan but successfully sustain it for longer times. 

Conclusion 

In conclusion, this safety improvement plan tool kit is developed related to medication administration errors, which is helpful for nurses, head nurses, physicians, and IT and logistics personnel to ensure the effective implementation of the safety improvement plan and make it sustainable for a more extended period. The resource tool kit is divided into four sub-categories to make it easier to understand. This resource kit will help to enhance knowledge related to medication administration errors, eventually minimizing the errors, improving the quality of care, and preserving patient safety. 

References

Abdulmutalib, I., & Safwat, A. (2020). Nursing strategies for reducing medication errors. Egyptian Journal of Nursing and Health Sciences1(1), 26–41. https://doi.org/10.21608/ejnhs.2020.80266 

Assunção-Costa, L., Sousa, I. C. de, Oliveira, M. R. A. de, Pinto, C. R., Machado, J. F. F., Valli, C. G., & Souza, L. E. P. F. de. (2022). Drug administration errors in Latin America: A systematic review. PLOS ONE17(8), e0272123. https://doi.org/10.1371/journal.pone.0272123 

Çınar, F., & Şahin, S. (2022). Nursing practices towards prevention of medication errors: A systematic review and meta-analysis. Letters in Applied NanoBioScience12(4), 124. https://doi.org/10.33263/LIANBS124.124 

Hodkinson, A., Tyler, N., Ashcroft, D. M., Keers, R. N., Khan, K., Phipps, D., Abuzour, A., Bower, P., Avery, A., Campbell, S., & Panagioti, M. (2020). Preventable medication harm across health care settings: A systematic review and meta-analysis. BMC Medicine18(1), 313. https://doi.org/10.1186/s12916-020-01774-9 

Jessurun, J. G., Hunfeld, N. G. M., de Roo, M., van Onzenoort, H. A. W., van Rosmalen, J., van Dijk, M., & van den Bemt, P. M. L. A. (2023). Prevalence and determinants of medication administration errors in clinical wards: A two‐centre prospective observational study. Journal of Clinical Nursing32(1–2), 208–220. https://doi.org/10.1111/jocn.16215 

Capella 4020 Assessment 4

Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to the implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J10, 45-46. https://med-fom-ubcmj.sites.olt.ubc.ca/files/2019/03/Commentary-14.pdf

Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences13, 100235. https://doi.org/10.1016/j.ijans.2020.100235 

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine13, 1621–1632. https://doi.org/10.2147/IJGM.S289452 

Capella 4020 Assessment 4

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 Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0

Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2020). The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review. Research in Social and Administrative Pharmacy, 17(5), 832–841. https://doi.org/10.1016/j.sapharm.2020.08.001