NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Name

Capella University

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Enhancing Quality and Safety

Medication errors in Massachusetts General Hospital (MGH) stem from various factors, including human elements like fatigue among healthcare professionals and communication breakdowns during hand-offs. Additionally, chaotic work environments with frequent interruptions pose significant challenges to medication safety. However, evidence-based solutions such as implementing Computerized Physician Order Entry (CPOE) with Clinical Decision Support (CDS), medication reconciliation processes, Barcode Medication Administration (BCMA) systems, and comprehensive education and training programs for healthcare professionals have demonstrated effectiveness in reducing these risks. Nurses, pivotal care coordinators, are instrumental in implementing these solutions and collaborating with stakeholders such as physicians, pharmacists, and health information technology specialists to enhance patient safety through streamlined medication management protocols and interdisciplinary teamwork.

Factors Leading to a Patient-Safety Risk

Medication errors pose a noteworthy patient safety risk in MGH. These errors occur at different stages of the medication use process. Below, each factor leading to medication errors is discussed along with relevant data, evidence, and standards.

Human Factors

Fatigue among healthcare professionals, particularly nurses and doctors, significantly contributes to medication errors. Extended work hours, especially night shifts, exacerbate this issue. Data indicates that the rate of medication errors is 3.5 times higher during the night shift compared to the day shift. Research found that extended shifts of more than 12 hours are associated with a substantial increase in errors, highlighting the detrimental impact of fatigue on clinical performance. To address this, the Accreditation Council for Graduate Medical Education (ACGME) has established standards limiting resident work hours to 80 hours per week, aiming to reduce fatigue-related errors and improve patient safety (Caruso et al., 2022).

Communication Breakdowns: Hand-off Errors

Inadequate communication between shifts or departments during patient hand-offs is a critical factor leading to medication errors. According to The Joint Commission, poor communication occurs during care transitions in 80% of primary medical errors. Implementing standardized hand-off protocols can reduce errors by 23%. To mitigate this risk, the Joint Commission mandates using a consistent approach to hand-off communications like the SBAR (Situation-Background-Assessment-Recommendation) technique. This ensures that vital information is accurately conveyed during transitions, enhancing patient safety (Chernyak & Posten, 2022).

Environmental Factors

Busy and chaotic healthcare environments with frequent interruptions pose a significant risk to medication safety. A study found that nurses are interrupted up to 11 times per hour while administering medications. These disruptions are linked to a rise in clinical errors of 12.1% and a rise in procedural failures of 12.7%. To address this issue, the Institute for Safe Medication Practices (ISMP) recommends creating “no interruption” zones or periods to minimize distractions during critical tasks. Implementing such measures helps maintain focus and reduces the likelihood of errors, thereby improving patient safety (Alshammari et al., 2022).

Evidence-Based and Best Practice Solutions

Medication errors are a major concern in MGH, affecting risks to increasing costs and patient safety. Addressing this requires implementing evidence-based and best-practice solutions. Below are effective strategies to improve safety and reduce costs by mitigating medication errors. Implementing CPOE with CDS significantly reduces medication errors. CPOE minimizes transcription errors, while CDS provides real-time alerts for potential issues. Meta-analyses consistently show substantial reductions in errors with CPOE. Leadership support and adequate resources are crucial for implementation. Multidisciplinary collaboration ensures effective integration into workflows. Continuous monitoring and evaluation identify areas for improvement (Qureshi et al., 2021). Medication Reconciliation ensures that reviewing medication lists at care transitions ensures accuracy and reduces discrepancies, significantly decreasing errors and improving safety. Strong leadership establishes reconciliation as standard practice. Multidisciplinary collaboration ensures effective communication and coordination. Continuous evaluation enhances accuracy and adherence (Konrad, 2020).

BCMA systems ensure correct medication administration by allowing electronic verification. Studies show a substantial decrease in errors with BCMA adoption. Leadership support is critical for overcoming implementation challenges. Collaboration among IT specialists, nurses, and pharmacists ensures successful integration. Continuous evaluation and staff training ensure sustained accuracy and efficiency (Heikkinen, 2022). Education and Training Programs for healthcare professionals on safe medication practices significantly decrease errors and increase staff confidence. Continuous education ensures adherence to best practices. Studies demonstrate effectiveness in reducing errors and improving safety protocols. Leadership support is essential for resource allocation and promoting a culture of continuous learning. Multidisciplinary collaboration ensures programs meet specific needs. Continuous evaluation enables refinement to meet evolving safety needs (Ciapponi et al., 2021). Implementing these evidence-based solutions and best practices can significantly improve patient safety, reduce medication errors, and lower costs in MGH.

Nurses’ Role in Coordinating Care

Nurses are essential in coordinating care to reduce costs and increase patient safety, especially concerning medication errors in MGH. One way nurses contribute is through medication reconciliation. Nurses meticulously review medication lists during transitions to ensure accuracy, preventing discrepancies and errors. For instance, nurses compare medications with records during admission, addressing discrepancies and ensuring alignment with patient history, minimizing errors, and reducing expenses (Konrad, 2020). Additionally, nurses are crucial in medication administration, following protocols to ensure accuracy. Through BCMA, nurses verify medications electronically before administration, reducing errors such as wrong dosage or medication. When using BCMA, nurses scan barcodes to confirm patient, medication, dosage, and route, enhancing safety and minimizing complications, optimizing resource utilization (Heikkinen, 2022). Nurses facilitate interdisciplinary collaboration, serving as effective communicators and advocates for safety. They communicate with team members to relay critical information, discuss concerns, and implement coordinated care plans. For example, nurses collaborate with pharmacists to conduct medication reviews, identify interactions, and recommend interventions, fostering teamwork and accountability, reducing errors, and improving care quality (Kozel et al., 2020).

Identifying Stakeholders

Nurses play a critical role in healthcare, collaborating with various stakeholders to drive safety enhancements regarding medication errors in MGH. Identifying these stakeholders and understanding their relevance and potential importance is crucial for effective coordination.

As primary prescribers, physicians are key collaborators for nurses in medication management. Nurses work closely with physicians to clarify medication orders, discuss concerns, and ensure appropriate prescribing practices to enhance patient safety. Pharmacists provide valuable insights into medication safety and interactions with their expertise in medication therapy. Nurses collaborate with pharmacists to verify orders, review patient profiles, and discuss medication-related issues to prevent errors (Alsaloom et al., 2022). Health Information Technology (IT) specialists support implementing and maintaining electronic health record (EHR) systems, including CPOE and BCMA systems. Nurses collaborate with IT specialists to ensure effective technology use, troubleshoot issues, and optimize functionalities to prevent errors. Quality Improvement (QI) teams focus on identifying areas for improvement in patient care and safety. Nurses collaborate with QI teams to analyze data, identify root causes, and implement interventions to prevent errors, promoting continuous improvement (Kozel et al., 2020).

Patient advocates represent patient interests and concerns. Nurses engage with advocates to gather feedback, address concerns and involve patients in treatment decisions. Hospital administrators oversee operations and resource allocation. Nurses collaborate with administrators to advocate for investments in patient safety initiatives, such as training programs and technology upgrades, to mitigate errors and enhance outcomes (Alshammari et al., 2022). Regulatory agencies, like the Food and Drug Administration (FDA) and the Joint Commission, establish standards and guidelines for medication safety in healthcare settings. Nurses collaborate with regulatory agencies to ensure compliance with medication safety standards, participate in accreditation processes, and implement best practices to meet regulatory requirements and enhance patient safety. By coordinating with these stakeholders, nurses drive safety enhancements, reduce errors, and improve patient outcomes in MGH (Stawicki & Firstenberg, 2022).

Conclusion

Medication errors pose a significant patient safety risk in MGH due to human fatigue, communication breakdowns, and chaotic work environments. Implementing evidence-based solutions such as CPOE with CDS, medication reconciliation, BCMA systems, and education programs for healthcare professionals is crucial for mitigating these risks. Nurses play a central role in coordinating care and advocating for safety measures. At the same time, collaboration with stakeholders ensures the effective implementation of strategies to enhance patient safety and reduce medication errors. Addressing these factors through comprehensive approaches is essential for substantially improving patient outcomes and healthcare quality.

References

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Alshammari , W. A., Alharbi , S. A., Aldhafeeri , A. M., Aldhafeeri , M. O., Alharbi , S. A., & Aldhafeeri , W. O. (2022). Medication administration time study (MATS): Health professionals performance of medication administration. Chelonian Research Foundation, 17(2), 1522–1530. http://www.acgpublishing.com/index.php/CCB/article/view/472

Caruso, C. C., Arbour, M. W., Berger, A. M., Hittle, B. M., Tucker, S., Patrician, P. A., Trinkoff, A. M., Rogers, A. E., Barger, L. K., Edmonson, J. C., Landrigan, C. P., Redeker, N. S., & Chasens, E. R. (2022). Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector. American Journal of Industrial Medicine. https://doi.org/10.1002/ajim.23363

Chernyak, M., & Posten, C. (2022). Quality of care improvement: a process to standardize handoff communication between anesthesia providers and post-anesthesia care unit nurses. DNP Scholarly Projects. https://digitalcommons.lasalle.edu/dnp_scholarly_projects/2/

Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., Perdomo, H. A. G., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Elorrio, E. G. (2021). Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2

Heikkinen, I. (2022). Barcode medication administration and patient safety: A narrative literature review. Www.theseus.fi. https://www.theseus.fi/handle/10024/745259

Konrad, S. (2020). Medication reconciliation: A quality improvement project, a doctoral project submitted in partial fulfillment of the requirements for the degree of doctor of nursing practice. http://sonapp.fullerton.edu/FacultyStaff/DNP/FinalProject/ProjectPDF/Sharon%20Konrad%20DNP_Final_PDF.pdf

Kozel, V. (2020). Reducing medication errors through addition of a pharmacist and standardized communication to interdisciplinary team rounding: A quality improvement project. Sigma.nursingrepository.org. https://sigma.nursingrepository.org/handle/10755/20590

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Qureshi, I., Baig, M. T., Shahid, U., Arif, J. M., Jabeen, A., Pirzada, Q. A., Mirza, A. S., Huma, A., & Toor, M. N. (2021). Computerized physician order entry system: A review on reduction of medication errors. Journal of Pharmaceutical Research International, 27–33. https://doi.org/10.9734/jpri/2020/v32i3931021

Stawicki, S. P., & Firstenberg, M. S. (2022). Contemporary topics in patient safety: Volume 1. In Google Books. BoD – Books on Demand. https://books.google.com.pk/books?hl=en&lr=&id=FtJuEAAAQBAJ&oi=fnd&pg=PA9&dq=Regulatory+agencies