NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Identification of Systemic Problems and Knowledge Gaps

Based on my experience working at Lakeland Clinic, I have identified a critical systemic issue with medication errors that highlighted a troubling 3.2% medication error rate, notably surpassing the national average of 1.3%. These errors, spanning prescribing inaccuracies, transcription discrepancies, dispensing errors, and lapses in administration, pose significant risks to patient safety. Adverse drug reactions resulting from these errors have accounted for 22% of reported incidents at the clinic over the past year, leading to prolonged hospitalizations and increased healthcare expenses. For instance, a recent incident involved a hypertensive crisis due to a dosage error, underscoring the critical need for immediate intervention to mitigate these risks and enhance care outcomes (Rasool et al., 2020).

Continuing this systemic issue results in substantial consequences, including a $250,000 financial burden from managing medication complications, damaging clinic reputation, eroding patient trust, and potentially reducing clinic utilization and satisfaction scores. Addressing it requires a strategic approach beyond quick fixes, involving analyzing current practices and identifying factors contributing to medication errors. (Love & Ika, 2021).  Key knowledge gaps include understanding communication breakdowns among healthcare providers, enhancing patient education on medication use, and implementing robust systems for medication reconciliation across care transitions. To position Lakeland Clinic as a leader in patient safety and quality care, proactive steps are essential.

This involves using technology to reduce errors, implementing evidence-based medication safety protocols, and fostering a culture of continuous improvement and accountability among healthcare teams (Love, 2022). Engaging patients through enhanced education and communication strategies empowers them to manage medications actively, reducing errors and improving health outcomes. By tackling these challenges directly and prioritizing medication safety, Lakeland Clinic can mitigate risks and uphold excellence in patient care, ensuring safety, sustainability, and trustworthiness. 

Proposing Specific Practice Changes

At Lakeland Clinic, a performance gap in medication errors significantly affects quality and safety outcomes, highlighting a critical need for improvement. This gap heightens patient safety risks, leading to incidents due to dosage errors, which strain healthcare resources and increase costs. To bridge this performance gap and enhance quality and safety outcomes, several targeted practice changes are proposed. Firstly, implementing a barcode scanning system for medication administration can reduce errors by verifying medication labels and patient identities at the point of care. Studies have shown that barcode systems can significantly decrease medication administration errors by up to 80%, thereby improving patient safety (Mulac, 2021). Additionally, enhancing interdisciplinary communication through regular team huddles and electronic health record (EHR) updates can mitigate transcription errors and ensure accurate medication orders across healthcare providers (Yuan et al., 2022).

Comprehensive staff training on medication safety protocols and the use of evidence-based guidelines for prescribing and dispensing medications are essential. This includes regular competency assessments and continuing education to reinforce best practices and update staff on new medications and safety protocols (Alrabadi et al., 2021). Patient education also plays a pivotal role in improving outcomes. Implementing tailored medication counseling sessions for patients, particularly those with complex medication regimens, can enhance medication adherence and reduce the likelihood of medication errors due to misunderstandings or confusion (Lively et al., 2020). These changes assume that upgrading technology, improving communication, educating staff, and engaging patients will enhance quality and safety outcomes. Addressing the root causes of medication errors and promoting safety and accountability can lower error rates, positioning Lakeland Clinic as a community leader in patient-centered care and bolstering its reputation and operational efficiency.

Prioritizing Proposed Practice Changes

Prioritizing practice changes at Lakeland Clinic involves implementing a barcode scanning system for medication administration, which is crucial for verifying medications and patient identities at the point of care, cutting errors by 80%, and aligning with national patient safety goals (Mulac, 2021). Improving interdisciplinary communication through team huddles and EHR updates is crucial. Effective communication ensures accurate medication orders, reduces errors, and fosters a collaborative environment for addressing systemic issues and enhancing care coordination at the clinic (Yuan et al., 2022). Prioritizing staff training on medication safety protocols and evidence-based guidelines ensures consistent, competent medication management.

Regular competency assessments and education sessions foster a culture of safety and accountability, supporting the clinic’s goal of continuous learning and professional development (Alrabadi et al., 2021). Prioritizing patient education on medication use and safety empowers patients to participate actively in their care and reduces errors. Educating patients on dosage, side effects, and adherence aligns with Lakeland Clinic’s commitment to patient-centered care, enhancing satisfaction, and improving outcomes (Lively et al., 2020). In determining priority, Lakeland Clinic evaluates each change’s potential impact on quality and safety, alignment with strategic goals, and feasibility. This systematic approach addresses medication safety concerns, enhances care delivery, and supports the clinic’s goal of providing safe, effective, and patient-centered healthcare services.

Fostering a Culture of Quality and Safety

Implementing a barcode scanning system at Lakeland Clinic promotes a culture of quality and safety among providers by requiring scanning before medication administration. This enhances accountability, vigilance, and adherence to protocols, fostering a culture where patient safety and accuracy are prioritized. Enhancing interdisciplinary communication at Lakeland Clinic through regular team huddles and EHR updates fosters a collaborative culture. These improvements ensure teams are aligned in patient care, promoting teamwork, mutual respect, and open dialogue. This support enhances job satisfaction and a shared dedication to delivering high-quality care among healthcare providers (Yuan et al., 2022). Staff training on medication safety protocols and adherence to guidelines fosters continuous learning at Lakeland Clinic.

Investing in education and competency assessments shows commitment to equipping staff with skills for safe care, empowering providers to improve patient outcomes and organizational resilience through updated practices (Alrabadi et al., 2021). Initiating changes at Lakeland Clinic faces complexity due to resistance, ingrained habits, and varying technological proficiency among staff. Integrating new processes into workflows demands planning, clear communication, and stakeholder buy-in. Overcoming these challenges requires transparent leadership, effective change strategies, and ongoing feedback to address concerns and track progress. To evaluate culture-building efforts, Lakeland Clinic uses metrics like protocol adherence, teamwork effectiveness, staff surveys, patient safety indicators, and incident reporting rates. These metrics offer insights into embedding a culture of quality and safety (Janes et al., 2021). These criteria help assess initiative impacts and inform adjustments for ongoing improvement in the clinic.

Influence of Organizational Culture and Hierarchy

The organizational culture, hierarchy, and leadership at Lakeland Clinic significantly influence quality and safety outcomes. Characterized by a commitment to patient-centered care and continuous improvement, the clinic fosters a collaborative environment among healthcare providers. Leadership emphasizes transparency, accountability, and patient safety, encouraging open communication, teamwork, and shared decision-making to promote collective concern for patient care. The hierarchical structure poses challenges, with rigid reporting lines and decision making processes that hinder communication and collaboration. This leads to delays in errors and miscommunication, potentially compromising patient safety (Zajac et al., 2021).

Junior staff feel reluctant to voice concerns to senior colleagues, missing opportunities for error prevention and process progress. This analysis assumes that organizational culture and hierarchy significantly influence provider interactions, communication, and decision-making, impacting quality and safety outcomes. A positive culture valuing teamwork and learning enhances patient care and safety by encouraging best practices and collective vigilance.  A hierarchical culture that stifles communication and innovation can contribute to adverse outcomes by discouraging proactive risk mitigation. To mitigate negative impacts, Lakeland Clinic promotes psychological safety, empowering staff to voice concerns or suggest improvements without fear of retribution (Martin & Wu, 2023). Regular team debriefs, cross-functional collaboration, and leadership training on communication and patient safety can enhance the clinic’s culture while addressing hierarchical constraints.

Justification of Changes to Organizational Functions and Processes

Implementing changes at Lakeland Clinic is crucial to mitigate adverse quality and safety outcomes. Leadership practices, communication, and collaboration need refinement to enhance patient safety and care quality. Prioritizing transparency, accountability, and transformational leadership can foster a proactive environment where staff feel empowered to address safety issues and innovate. Improving communication at Lakeland Clinic is vital to prevent errors. Standardized handoff protocols like SBAR (Situation, Background, Assessment, Recommendation) enhance clarity and consistency in information exchange. Clear protocols of communication are necessary to ensure that all team members have information that is accurate and timely to reduce the risk of errors (Sechrest, 2023). Implementing regular team huddles and using EHR to update all relevant information can promote effective communication and coordination among healthcare providers (Yuan et al., 2022).

Enhancing interprofessional collaboration improves teamwork and patient outcomes. Regular interdisciplinary meetings and collaborative care planning sessions reduce errors and improve the quality of care.  Addressing knowledge gaps involves investigating barriers to communication and collaboration. Surveys and focus groups can uncover insights for targeted interventions alongside assessing and training staff in technological proficiency for new tools and protocols (Bengtsson et al., 2021). Reviewing financial management at Lakeland Clinic is essential to support changes. Allocating resources for training, technology upgrades, and process improvements is critical, as investing in safety initiatives can yield long-term cost savings through reduced adverse events.

Conclusion

Addressing the systemic issue of medication errors at Lakeland Clinic is imperative for enhancing patient safety and quality care. Implementing a barcode scanning system, improving interdisciplinary communication, and prioritizing staff training on medication safety protocols are crucial steps. Engaging patients through education and fostering a culture of accountability will further support these efforts. By integrating these changes, Lakeland Clinic can mitigate risks, uphold excellence in care, and strengthen its reputation as a leader in patient-centered healthcare.

References

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: A focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025 

Bengtsson, M., Ekedahl, A.-B. I., & Sjöström, K. (2021). Errors linked to medication management in nursing homes: An interview study. BMC Nursing, 20(1), 69. https://doi.org/10.1186/s12912-021-00587-2 

Janes, G., Mills, T., Budworth, L., Johnson, J., & Lawton, R. (2021). The association between health care staff engagement and patient safety outcomes. Journal of Patient Safety, Publish Ahead of Print(3). https://doi.org/10.1097/pts.0000000000000807 

Lively, A., Minard, L. V., Scott, S., Deal, H., Lambourne, T., & Giffin, J. (2020). Exploring the perspectives of healthcare professionals in delivering optimal oncology medication education. PLOS ONE, 15(2), e0228571. https://doi.org/10.1371/journal.pone.0228571 

Love, J. S. (2022). Reducing near miss medication events using an evidence-based approach. Journal of Nursing Care Quality, 37(4), 327–333. https://doi.org/10.1097/ncq.0000000000000630 

Love, P. E. D., & Ika, L. A. (2021). Making sense of hospital project (Mis)performance: Over budget, late, time and time again—why? and what can be done about it? Engineering, 12. https://doi.org/10.1016/j.eng.2021.10.012 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Martin, G., & Wu, F. (2023). Openness in healthcare leadership. Www.elgaronline.com; Edward Elgar Publishing. https://www.elgaronline.com/edcollchap/book/9781800886254/book-part-9781800886254-24.xml 

Mulac, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 

Rasool, M. F., Rehman, A. ur, Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Hassali, M. A. A., & Hayat, K. (2020). Risk factors associated with medication errors among patients suffering from chronic disorders. Frontiers in Public Health, 8(1). https://doi.org/10.3389/fpubh.2020.531038 

Sechrest, J. L. J. (2023). Standardized situation, background, assessment, recommendations-based bedside nursing handoff. Archive.hshsl.umaryland.edu. https://archive.hshsl.umaryland.edu/handle/10713/20867 

Yuan, C. T., Dy, S. M., Lai, A. Y., Oberlander, T., Hannum, S. M., Lasser, E. C., Heughan, J.-A., Dukhanin, V., Kharrazi, H., Kim, J. M., Gurses, A. P., Bittle, M., Scholle, S. H., & Marsteller, J. A. (2022). Challenges and strategies for patient safety in primary care: A qualitative study. American Journal of Medical Quality, 37(5), 379–387. https://doi.org/10.1097/jmq.0000000000000054 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

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 Communication, 6(1). https://doi.org/10.3389/fcomm.2021.606445