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NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Student Name

Capella University

NURS4020 Improving Quality of Care and Patient Safety

Prof. Name


Enhancing Quality and Safety

The primary purpose of the healthcare system is to provide improved quality of care that enhances patient safety and satisfaction. This paper explains the factors involved in patient safety risks due to Medication Administration Errors (MAEs) that lead to adverse events or sometimes cost a patient’s life. MAEs occur due to violating the five medication administration rights, including incorrect drug, patient, dose, frequency, and time. Further in the paper, evidence-based practices and solutions are provided to improve patient safety by reducing MA errors. Moreover, the nurse’s role and collaboration with different stakeholders are also explained, which reduces the cost and enhances the quality of care within the healthcare system.  

Factors Leading to Specific Patient Safety Risks 

The patient, Jiliana, is a 60-year-old woman with anaphylactic symptoms who came to the emergency room in the community hospital. The patient’s medical history revealed hypertension and obesity. Upon the examination, the doctor prescribed a handwritten prescription which mentioned to “administer Epinephrine 1mg” only. The duty nurse without further probing into the correct route, administered her Epinephrine to aid with allergic symptoms through an intravenous route, which immediately caused an intense, crushing pain that made her lose consciousness. The resuscitation team in the hospital was called. Through supplemental oxygen and other resuscitation methods, the patient was reverted.

However, this incident was a life-threatening situation for the patient. Hence, a comprehensive case investigation was performed. The case investigation revealed several factors involved in this incident that led to the mild but reversible condition. One of the factors is the negligence of healthcare professionals while prescribing and administering medications. While the physician neglected to consider the patient’s hypertensive history before ordering a drug and did not mention the route in the prescription, the nurse neglected to double-check with the doctor and the pharmacist before administering the drug.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Another factor is the communication gap among the healthcare professionals as there was a lack of collaboration among the physician, pharmacist, and nurses which led to the adverse drug event, eventually causing complications for the patients. According to the literature, most MAEs occur due to negligent behaviour and lack of communication among healthcare professionals. This negligence and communication gap leads to several preventable adverse events which are harmful to patient safety (Tariq & Scherbak, 2023). Health literacy is another important factor. Like in the given scenario the doctor did not check the patient’s medical history as she has hypertension, and prescribed medication that could be harmful to the patient.

Health literacy of healthcare providers related to medication and risk factors associated with medication administration is an essential component of preventing patients’ safety (Mueller et al., 2019). Lastly, the lack of technological involvement in the medication management process led to a significant issue in Jiliana’s case. If the hospital had the Electronic Health Records (EHR) and Electronic Medication Administration Records (EMAR) system, there would be minimal chances of medication errors as a shared portal would have improved communication and alerted every healthcare professional for potential errors.

Evidence-Based and Best Practice Solutions 

Incidences like the one described above may bring various challenges related to patient safety which can be addressed using several evidence-based and best practices. 

Standardized Guidelines:

The Joint Commission International Accreditation (JCIA) body has helped healthcare organizations and healthcare professionals to create a safer evidence-based practice and environment for patients and healthcare providers to enhance patient safety by providing standardized patient safety goals (patient identification and medication management). These goals are related to medication administration as, which will help in preventing errors if followed adequately in the healthcare settings (ElLithy et al., 2023). 

Effective Communication:

The communication between healthcare professionals, such as physicians, pharmacists, and nurses, helps to improve patient safety in the healthcare setting. Effective Communication of the healthcare providers is enhanced when the experienced professional provide training and session to the novice nurse about medication administration. Effective communication during novice nurse training reduces the hospital’s cost to hire experienced or registered nurses for patient safety. Moreover, double-checking of prescriptions will also save the cost of medication patient and hospital. This will enable the nurses to give the right medication to the right patient with a correct route (Rodziewicz et al., 2023). 

Technological Integration:

Technical integration such as Barcode Medication Administration (BCMA) and Electronic Health Records (EHR) improve patient safety and is practical to adopt. BCMA helps to fulfil the five rights of medication administration, which enhances hospital efficacy and prevents MAEs. It enables the pharmacist to avoid mistakes in look-alike-sound-alike medication. BCMA reduces the rates of MAEs, ultimately reducing the cost of the patient’s stay at the hospital. Moreover, it also saves the patient’s cost of transportation due to the correct administration of the medicine (Shermock et al., 2023).

Nurse Role in Care Coordination and Cost Reduction 

Nurses are the frontline force that helps the healthcare system provide quality care and improve patient safety. MAEs are the leading cause of hospitalization and disability worldwide, which include multiple factors; one of them is mainly due to novice nurses and their negligence. The training of the nurses in medication administration helps them to understand the five rights of medication administration, which include the correct dose, route, patient, timing, and frequency. Training young nurses with registered nurses will improve patient safety as they discuss the patient cases during training.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Moreover, this training session enables them to communicate and collaborate with healthcare professionals such as pharmacists to get information about the new and LASA drugs (Luokkamäki et al., 2020). Care coordination involves a multidisciplinary team, which helps the patient receive an improved quality of care and enhances patient safety. The nurses will collaborate with the physician and pharmacist in a team to provide care at the right time to the right patient. The incidence reporting system within the healthcare setting will help the institution improve the quality of healthcare services by addressing previous challenges and adverse events.

To make reporting comfortable for newly registered nurses, senior nurses can play an efficient role in creating a safe, blame-free, and collaborative environment so that novice nurses actively report errors without fearing losing their jobs. This approach will optimize the care coordination process through effective collaboration and help the organization save additional costs to combat adverse events (Shermock et al., 2023).  

Identification of Stakeholders

The stakeholders involved in improving patient safety and helping coordinate medication management care include physicians, pharmacists, registered nurses, the organization’s administration, and policymakers. Nurses will coordinate and double-check with the physician about the name and dosage of the medication on the prescription of the patient. Furthermore, nurses will coordinate and communicate with the pharmacist to ensure the right patient gets the correct dose and medication.

Clinicians, pharmacists, registered nurses, organization administration, and policymakers are the critical stakeholders that help the healthcare organization to improve patient safety through reduction in the MAEs. The physician maintains and promotes the patient’s health through diagnosis and treatment. The pharmacist helps the nurse and healthcare setting to receive the right drugs for the right patient and also decides to improve the medication administration.

Policymakers help the healthcare system to plan initiatives for patient safety that will enhance the quality of care.  These stakeholders should take into consideration the implementation of the intervention that enhances patient safety. The stakeholders help implement the intervention financially and provide funding to hire experienced staff to train the nurses about MAEs (Manias et al., 2020). 


In conclusion, MAEs are the pertaining issue in the USA, as evidenced by the specific example presented in the paper. The factors involved in the patient safety risk are the healthcare professionals’ negligent behavior, reduced health literacy, communication and collaboration gap, and lack of technology. The evidence-based practices such as training of the nurses and establishing incidence reporting systems helps to reduce MAEs. Nurses play an essential role in effective coordination and reducing costs associated with adverse events. However, nurses must collaborate with various stakeholders to achieve these goals. Thus, nurses and other stakeholders within healthcare settings, patient safety, and the quality of healthcare services. 


ElLithy, M. H., Salah, H., Abdelghani, L. S., Assar, W., & Corbally, M. (2023). Benchmarking of medication incidents reporting and medication error rates in a JCI-accredited university teaching hospital at a GCC country. Saudi Pharmaceutical Journal, 31(9), 101726. 

Luokkamäki, S., Härkänen, M., Saano, S., & Vehviläinen‐Julkunen, K. (2020). Registered   nurses’ medication administration skills: A systematic review. Scandinavian Journal of Caring Sciences, 35(1). 

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1), 1–29. 

Mueller, B. U., Neuspiel, D. R..,  &Fisher, E. R. S., (2019). Principles of pediatric patient safety: Reducing harm due to medicalcare. Pediatrics, 143(2). 

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. 

Rodziewicz, T. L., Hipskind, J. E., & Houseman, B. (2023). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. 

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Shermock, S. B., Shermock, K. M., & Schepel, L. L. (2023). Closed-loop medication     management with an electronic health record system in U.S. and Finnish Hospitals. International Journal of Environmental Research and Public Health, 20(17), 6680. 

Suclupe, S., Martinez‐Zapata, M. J., Mancebo, J., Font‐Vaquer, A., Castillo‐Masa, A. M., Viñolas, I., Morán, I., & Robleda, G. (2020). Medication errors in prescription and administration in critically ill patients. Journal of Advanced Nursing, 76(5). 

Tariq, R. A., & Scherbak, Y. (2023). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. 

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15.