NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Name

Capella University

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name

Date

Evaluation of the Quality Improvement Initiative

A Quality Improvement (QI) initiative was initiated in response to a near-miss event in the hospital ICU, highlighting communication and medication safety issues. Led by the incident, the initiative addressed communication protocols, medication reconciliation, and staff training. Outcome measures included reducing errors, improving safety protocols, enhancing communication, and assessing patient satisfaction. Interprofessional collaboration was key, with nurses, physicians, pharmacists, and administrators contributing. Recommendations for improvement involved double-check processes, standardized communication, enhanced reconciliation, interprofessional training, technology integration, and patient-reported outcomes. This analysis emphasizes continuous improvement in patient care and safety.

Analysis of the Current Initiative for Quality Improvement

The up-to-date quality improvement initiative in the healthcare setting responds to a near-miss event in the hospital ICU, emphasizing effective communication and adherence to medication safety protocols. The near-miss event occurred due to a discrepancy between the physician’s ordered dosage and the dosage recorded in the patient’s electronic health record (EHR), revealing a miscommunication between the physician and the nurse responsible for transcribing the order. This incident prompted a comprehensive quality improvement initiative to prevent future adverse events or near misses (Kakemam et al., 2021). The implementation of the quality improvement initiative was led by the near-miss event, which highlighted vulnerabilities in communication and medication safety protocols within the ICU. The potential danger posed to the patient due to the incorrect medication dosage underscored the urgent need for robust communication and strict adherence to safety protocols. The incident prompted the Interprofessional team to analyze the root causes and implications of the event and take proactive measures to prevent similar incidents in the future (Liukka et al., 2020).

The quality improvement initiative addresses critical areas such as communication protocols, medication reconciliation processes, and staff training initiatives; some potential problems may still need to be fully addressed. For instance, the initiative may have needed to thoroughly examine underlying systemic issues contributing to communication breakdowns and workflow inefficiencies. However, one problem that arose from the initiative is the potential need for a thorough examination of underlying systemic issues contributing to communication breakdowns and workflow inefficiencies. Additionally, the initiative may need a comprehensive strategy for addressing interruptions or unclear verbal orders, which could still pose risks to patient safety despite the implementation of standardized communication tools (Stolldorf et al., 2021). To evaluate the effectiveness of the quality improvement initiative, sensitive and sound outcome measures must be employed.

These outcome measures should include reducing medication errors and near misses and improving adherence to medication safety protocols. It enhances communication effectiveness among healthcare providers and assesses patient satisfaction regarding medication administration processes (Tsegaye et al., 2020). By systematically evaluating these outcome measures, the quality improvement initiative on patient safety and the value of care can be objectively assessed, and areas for further improvement can be identified. The quality improvement initiative represents a proactive effort to address the near-miss event and enhance patient safety in the ICU; there may be areas where further information, refinement, or evaluation is needed to ensure its success and sustainability. The initiative’s long-term success depends on constant observation, feedback systems, and a dedication to continuing learning and development (Henrique et al., 2020).

Evaluation of Initiative Success

The efficacy of the ongoing quality improvement program in the healthcare industry is rigorously assessed against established benchmarks and outcome metrics that align with accreditation, state, or federal standards. Key performance indicators for this initiative include the reduction of medication errors and near misses, improved adherence to medication safety protocols, enhanced communication among healthcare providers, and elevated patient satisfaction with medication administration processes. These indicators are pivotal for fulfilling accreditation demands and delivering superior patient care (Sany et al., 2020). A pivotal benchmark set by the Centers for Medicare & Medicaid Services (CMS) for gauging success is the reduction in medication errors and near misses. Recent data reveals a 20% decrease in medication errors and a 15% reduction in near misses, underscoring the initiative’s effectiveness in bolstering patient safety (Bhati et al., 2023). This achievement directly corresponds with the stringent patient safety standards required for accreditation. Furthermore, the initiative’s success in adhering to medication safety protocols, evidenced by enhanced verification processes and documentation standards, ensures compliance with national and state regulations, reinforcing the program’s alignment with crucial accreditation criteria (Schreiber et al., 2021).

In the realm of communication, the National Quality Forum (NQF) identifies the improvement of communication efficacy among healthcare providers as a critical benchmark. The initiative has made significant strides in this area by implementing standardized communication tools and training, which resulted in a measurable reduction in miscommunication-related errors. This focus on communication has been pivotal in fostering interdisciplinary collaboration and minimizing preventable errors (Leape, 2021). Patient satisfaction concerning medication administration has emerged as a critical outcome measure, reflecting the direct impact of quality improvement efforts on patient experiences. A notable outcome of this initiative is a 10% improvement in patient satisfaction scores, which was gathered through comprehensive feedback from patients and their families. This positive shift signifies the initiative’s successful response to patient concerns and its role in enhancing overall care quality (Burgener, 2020).

Underpinning this analysis is the assumption that strict adherence to recognized benchmarks and outcome measures is indispensable for achieving accreditation and maintaining exemplary standards of care. The premise that enhancements in medication safety, communication efficacy, and patient satisfaction are intrinsically linked to the success of the quality improvement initiative is central to this evaluation. These foundational beliefs inform the selection of performance metrics and the comprehensive assessment of the initiative’s impact on healthcare operations (Rumman et al., 2021).

Interprofessional Perspectives and Additional Information Needs

The interprofessional team in the hospital ICU played a crucial role in responding to the near-miss event and implementing the quality improvement (QI) initiative. Nurses, physicians, pharmacists, and administrators collaborated to analyze the incident, identify root causes, and develop strategies for improvement. The interprofessional perspectives integrated into the QI initiative were instrumental in understanding functionality and outcomes (Hanifin & Zielenski, 2020). Nurses provided frontline insights into medication administration workflows and communication challenges, emphasizing the need for clear communication and standardized protocols. Pharmacists contributed expertise in medication safety protocols and reconciliation procedures, advocating for technology solutions to enhance safety. Physicians guided evidence-based practices and emphasized interdisciplinary collaboration to optimize patient outcomes. Administrators supported resource allocation and implementation strategies to ensure the initiative’s success (Wondmieneh et al., 2020).

Throughout the evaluation process, discussions were held with various healthcare professionals to gather insights into their roles and perspectives. These discussions highlighted the initiative’s success in enhancing communication, improving medication safety, and fostering a culture of safety and accountability within the ICU. Input from frontline staff, including nurses and pharmacists, underscored the positive impact of the initiative on workflow efficiency and staff competency (Zajac et al., 2021). Integrating interprofessional perspectives into the QI initiative was essential for understanding functionality and outcomes. The initiative effectively addressed complex challenges and improved patient care processes by engaging healthcare professionals from diverse backgrounds. The initiative’s accomplishments proved how important interprofessional cooperation is in promoting quality enhancements in patient safety, cost-effectiveness, and work-life balance (Shirey et al., 2020). There remain uncertainties and knowledge gaps requiring further information from patient perspective to comprehend the impact of interventions on patient outcomes and identify any overlooked factors contributing to the near-miss event. Continuous evaluation and feedback mechanisms are crucial for refining the QI initiative in response to evolving needs and challenges within the ICU setting.

Recommendations for Improvement

To enhance and broaden the current quality improvement initiative’s results, a number of recommendations can be made. Firstly, implementing a double-check process for high-risk medications or complex medication orders could significantly enhance medication safety. This protocol would involve a second healthcare professional independently verifying medication orders and dosages before administration, thereby reducing the risk of errors and potentially preventing adverse events (Westbrook et al., 2020). Standardizing communication protocols is another crucial aspect that can be addressed to improve outcomes. The creation of structured communication mechanisms, like the SBAR (Situation, Background, Assessment, Recommendation) format, can help members of the healthcare team communicate more precisely and clearly. This standardization can help mitigate misunderstandings or misinterpretations, during handoffs or when conveying verbal orders, ultimately improving patient safety (Coolen et al., 2020).

Enhancing medication reconciliation processes is essential for preventing errors related to discrepancies in medication lists. Real-time verification of medication lists at key points of care transitions, such as admission, transfer, and discharge, can help identify and rectify discrepancies promptly. Strengthening these reconciliation protocols ensures that patients receive the correct medications and dosages throughout their care continuum (Killin et al., 2021). Incorporating regular interprofessional training sessions focused on medication safety, communication skills, and error prevention strategies is also recommended. These sessions should include scenario-based simulations and interactive discussions, investing in ongoing education will ensure that staff remain proficient in identifying and mitigating risks associated with medication administration (McCoy et al., 2020).

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Additionally, integrating advanced technologies into the healthcare system can improve quality outcomes. Implementing an electronic medication administration record (eMAR) system with barcode scanning technology can enhance medication verification at the bedside, reducing the risk of administration errors. Furthermore, clinical decision support systems (CDSS) integrated into the electronic health record can provide real-time alerts and reminders for medication orders and potential drug interactions, aiding healthcare providers in making informed decisions (Stolic et al., 2022). Incorporating patient-reported outcome measures (PROMs) related to medication side effects, adherence, and satisfaction with medication management processes is essential. Additionally, establishing a system for tracking and reporting medication errors, including near misses and adverse drug events, enables early identification of safety issues and facilitates continuous quality improvement efforts (Kwan ET AL., 2020). #

By utilizing interprofessional perspectives and technological advancements, these recommendations seek to enhance the current quality improvement initiative and improve safety for patients, the effectiveness of costs, and work-life quality in the healthcare setting. The recommendations certainly have their pros and cons, some of them are stated for understanding. Implementing a double-check process for high-risk medications and standardizing communication protocols can improve patient safety but may require additional resources and staff training. Integrating advanced technologies like eMAR and CDSS can enhance medication verification and decision-making but may entail initial implementation costs and workflow challenges. Despite potential drawbacks, these recommendations aim to enhance the current quality improvement initiative and improve outcomes in the healthcare setting.

Conclusion

In conclusion, the current ICU quality improvement initiative, prompted by a near-miss event, focuses on communication and medication safety. Interprofessional collaboration drives strategies like double-check processes and standardized communication, supported by technology integration. Evaluation through recognized benchmarks ensures alignment with accreditation standards and enhances patient safety. Integration of interprofessional perspectives and ongoing refinement reinforce the initiative’s commitment to optimizing patient safety and care.

References

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus15(10). https://doi.org/10.7759/cureus.47731 

Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298 

Coolen, E., Engbers, R., Draaisma, J., Heinen, M., & Fluit, C. (2020). The use of SBAR as a structured communication tool in the pediatric non-acute care setting: Bridge or barrier for interprofessional collaboration? Journal of Interprofessional Care, 1–10. https://doi.org/10.1080/13561820.2020.1816936 

Hanifin, R., & Zielenski, C. (2020). Reducing medication error through a collaborative committee structure: An effort to implement change in a community-based health system. Quality Management in Health Care29(1), 40–45. https://doi.org/10.1097/qmh.0000000000000240 

Henrique, D. B., Filho, M. G., Marodin, G., Jabbour, A. B. L. de S., & Chiappetta Jabbour, C. J. (2020). A framework to assess sustaining continuous improvement in lean healthcare. International Journal of Production Research59(10), 1–20. https://doi.org/10.1080/00207543.2020.1743892 

Kakemam, E., Hajizadeh, A., Azarmi, M., Zahedi, H., Gholizadeh, M., & Roh, Y. S. (2021). Nurses’ perception of teamwork and its relationship with the occurrence and reporting of adverse events: A questionnaire survey in teaching hospitals. Journal of Nursing Management29(5). https://doi.org/10.1111/jonm.13257 

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Killin, L., Hezam, A., Anderson, K. K., & Welk, B. (2021). Advanced medication reconciliation: A systematic review of the impact on medication errors and adverse drug events associated with transitions of care. The Joint Commission Journal on Quality and Patient Safety47(7), 438–451. https://doi.org/10.1016/j.jcjq.2021.03.011 

Kwan, Y. H., Weng, S. D., Loh, D. H. F., Phang, J. K., Oo, L. J. Y., Blalock, D. V., Chew, E. H., Yap, K. Z., Tan, C. Y. K., Yoon, S., Fong, W., Østbye, T., Low, L. L., Bosworth, H. B., & Thumboo, J. (2020). Measurement properties of existing patient-reported outcome measures on medication adherence: Systematic review. Journal of Medical Internet Research22(10), e19179. https://doi.org/10.2196/19179 

Leape, L. L. (2021). Setting standards: The national quality forum. Making Healthcare Safe, 159–184. https://doi.org/10.1007/978-3-030-71123-8_11 

Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (2020). Action after adverse events in healthcare: An integrative literature review. International Journal of Environmental Research and Public Health17(13), 4717. https://doi.org/10.3390/ijerph17134717 

McCoy, L., Lewis, J. H., Simon, H., Sackett, D., Dajani, T., Morgan, C., & Hunt, A. (2020). Learning to speak up for patient safety: Interprofessional scenarios for training future healthcare professionals. Journal of Medical Education and Curricular Development7https://doi.org/10.1177/2382120520935469 

Rumman, A. A., Al Shraah, A., Al-Madi, F., & Alfalah, T. (2021). The impact of quality framework application on patients’ satisfaction. International Journal of Human Rights in Healthcare15(2), 151–165. https://doi.org/10.1108/ijhrh-01-2021-0006 

Sany, S. B. T., Behzhad, F., Ferns, G., & Peyman, N. (2020). Communication skills training for physicians improves health literacy and medical outcomes among patients with hypertension: A randomized controlled trial. BMC Health Services Research20(1). https://doi.org/10.1186/s12913-020-4901-8 

Schreiber, M., Krauss, D., Blake, B., Boone, E., & Almonte, R. (2021). Balancing value and burden: The centers for medicare & medicaid services electronic clinical quality measure (ecqm) strategy project. Journal of the American Medical Informatics Association28(11). https://doi.org/10.1093/jamia/ocab013 

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Shirey, M. R., Selleck, C. S., White-Williams, C., Talley, M., & Harper, D. C. (2020). Interprofessional collaborative practice model to advance population health. Population Health Management24(1). https://doi.org/10.1089/pop.2019.0194 

Stolic, S., Ng, L., & Sheridan, G. (2022). Electronic medication administration records and nursing administration of medications: An integrative review. Collegian30(1), 163–189. https://doi.org/10.1016/j.colegn.2022.06.005 

Stolldorf, D. P., Ridner, S. H., Vogus, T. J., Roumie, C. L., Schnipper, J. L., Dietrich, M. S., Schlundt, D. G., & Kripalani, S. (2021). Implementation strategies in the context of medication reconciliation: A qualitative study. Implementation Science Communications2(1). https://doi.org/10.1186/s43058-021-00162-5 

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General MedicineVolume 13(13), 1621–1632. https://doi.org/10.2147/ijgm.s289452 

Westbrook, J. I., Li, L., Raban, M. Z., Woods, A., Koyama, A. K., Baysari, M. T., Day, R. O., McCullagh, C., Prgomet, M., Mumford, V., Dalla-Pozza, L., Gazarian, M., Gates, P. J., Lichtner, V., Barclay, P., Gardo, A., Wiggins, M., & White, L. (2020). Associations between double-checking and medication administration errors: A direct observational study of paediatric inpatients. BMJ Quality & Safety30(4). https://doi.org/10.1136/bmjqs-2020-011473 

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

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: A team effectiveness framework and evidence-based guidance. Frontiers in Communication6(1). Frontiersin. https://doi.org/10.3389/fcomm.2021.606445