NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Name

Capella university

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name

Date

Quality Improvement Initiative Evaluation

Quality improvement (QI) initiatives are systematic efforts to enhance healthcare processes and outcomes. They are crucial in addressing medical errors, including medication safety risks, by identifying root causes, implementing targeted interventions, and fostering a culture of safety to mitigate these risks and improve patient care (Bhati et al., 2023). In this assessment, we evaluate a current QI initiative in a bustling hospital in New York related to medication administration errors. 

Analysis of the Current Quality Improvement Initiative

In the New York-based hospital, the implementation of a quality improvement initiative was prompted by a critical medication error involving Nurse Jane, who administered an incorrect insulin dosage to Mr. Smith, a diabetic patient. This incident resulted in short-term complications for the patient, such as hypoglycemia and distress, which the physician immediately intervened to stabilize the patient. However, the incident underscored systemic vulnerabilities in the medication administration process, including interruptions, lack of verification, and inadequate use of technology, necessitating robust medication safety protocols. This particular case, along with similar past incidents, catalyzed the hospital’s leadership to adopt a structured approach to minimize medication errors and improve overall care quality.

The QI initiative introduced strategies to address critical areas such as double-checking procedures, minimizing interruptions, and implementing Barcoding Medication Administration (BCMA) technology. Nevertheless, several areas remain unaddressed. For instance, the initiative overlooked the broader context of nurse workload and staffing levels, which significantly contribute to errors. Additionally, the need for a comprehensive cultural shift toward prioritizing patient safety was inadequately addressed. Finally, the initiative disregarded the existing communication breakdowns within the healthcare team, which resulted in inaccurate dose administration. 

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Furthermore, the implementation of the QI initiative brought about some unintended challenges. Resistance to change emerged among staff accustomed to existing practices, leading to initial compliance issues with new protocols (Cheraghi et al., 2023). The introduction of BCMA technology required substantial training and adjustment, resulting in temporary workflow disruptions. Furthermore, the focus on minimizing interruptions, while beneficial, occasionally led to delays in other patient care activities, highlighting the need for balanced and flexible approaches (Abdelhadi et al., 2021).

Several knowledge gaps and areas of uncertainty persist in this analysis. These include information about staff training needs, leadership’s commitment to fostering a patient safety culture, and the availability of human and financial resources to upgrade the existing QI initiative with new strategies. Addressing these gaps through detailed studies and continuous feedback from healthcare professionals could significantly enhance the initiative’s effectiveness and patient safety outcomes.

Evaluation of the Success of the Quality Improvement Initiative

This QI initiative for medication administration was evaluated using national and state benchmarks, as well as accreditation standards from organizations like The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS). The critical outcome metrics employed were the rate of medication errors per 10,000 prescriptions and compliance rates with double-checking protocols and BCMA usage. According to the set benchmarks, the number of medication errors should be less than 100/10,000 processed orders (ElLithy et al., 2023).

Additionally, double-checking compliance should be within the range of 52-97% (Koyama et al., 2020), and the utilization rate of BCMA technological protocols should remain at 95% (Kirit, 2023). The evaluation was performed by collecting the hospital’s dashboard data, highlighting the most successful aspect of the initiative. The implementation of BCMA technology led to a notable decrease in medication administration errors, where the medication error rates dropped by 45%, a successful aspect of the QI initiative. 

Conversely, the BCMA usage compliance remained at 60%, below the average benchmark. Additionally, staff adherence to double-checking procedures requires attention, as due to busy schedules and excessive workload, this compliance rate was 42%, which is significantly lower than the conventional benchmark. These low compliance rates underscore the need for constant staff training and engagement in the new protocols to improve performance and patient outcomes. The assumptions of the analysis include the utilization of accurate data collection methods, adequate measures taken to train staff related to technology use, the organization ensuring the user-friendliness of the BCMA system, and the hospital environment, which allowed for effective implementation of the QI measures. 

Interprofessional Perspectives and Actions

The interprofessional team played a critical role in the success of the QI initiative by bringing diverse expertise and perspectives within the organization. Nurses, pharmacists, physicians, and IT specialists collaborated to implement the QI initiative. Nurses were at the forefront, directly involved in administering medications and adhering to the new protocols (Coelho et al., 2023). They played a pivotal role in implementing double-checking procedures, minimizing interruptions during medication rounds, and using BCMA technology. Their compliance and diligence in following the new protocols were instrumental in reducing medication errors.

Similarly, pharmacists contributed their expertise in medication management and safety to the QI initiative. They reviewed and revised the medication dispensing processes, ensuring that all steps were free of errors. Pharmacists were integral in developing and implementing the double-checking system, providing essential checks before medications reached the nursing staff (Tariq & Scherbak, 2023). Their role also included educating nurses and other healthcare providers on the importance of medication verification and the correct use of BCMA technology. 

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Additionally, physicians played a crucial role in supporting the QI initiative by fostering a culture of safety and open communication. They ensured that medication orders were clear, accurate, and updated in the electronic health records. Physicians also provided critical oversight and guidance, collaborating with nurses and pharmacists to resolve any issues that arose during the implementation of the new protocols (Tariq & Scherbak, 2023). Their leadership and endorsement of the QI measures were vital in encouraging team-wide compliance and commitment to reducing medication errors. Finally, IT specialists were responsible for the technical aspects of the QI initiative, particularly the implementation and integration of BCMA technology. They ensured that the barcode scanning system was seamlessly integrated with the hospital’s existing electronic health records and that it was user-friendly for the clinical staff. 

Input from these interprofessional team members impacted this analysis. While nurses highlighted the necessity of workflow adjustments to accommodate new safety protocols without increasing workload (Tariq & Scherbak, 2023), pharmacists’ insights led to improved verification processes and prevented errors at the grassroots level. Moroever, physicians’ feedback emphasized the importance of interdisciplinary communication, and IT specialists’ contributions ensured the BCMA system was tailored to clinical needs and user-friendly. This comprehensive input enriched the analysis by identifying practical challenges and ensuring that solutions were realistic and sustainable. Despite the comprehensive approach, areas of uncertainty remain, such as the long-term sustainability of the new protocols and the impact of nurse workload on compliance. Further information on the effectiveness of ongoing training programs and staff feedback on the latest processes is needed to refine and sustain the initiative. 

Recommended Additional Indicators and Protocols

To further enhance the effectiveness of the QI initiative and expand patient outcomes, it is recommended to implement a standardized medication reconciliation process at all transition points of care (admission, transfer, discharge). Elbeddini et al. (2021) emphasize the importance of medication reconciliation in ensuring accuracy in patients’ medication lists and preventing errors due to outdated information. Moroever, it enhances patient safety and continuity of care by fostering better communication among healthcare providers across different settings. While this process reduces discrepancies and potential adverse drug events (Elbeddini et al., 2021), a negative aspect of this recommendation is it is resource and time-intensive, potentially increasing workload. 

Additionally, it is suggested that smart infusion pumps be implemented to enhance medication administration safety. These devices ensure accurate medication delivery rates and volumes, with built-in safety checks that prevent dosing errors. They can alert healthcare providers to potential errors before they reach the patient, reducing adverse events (Alamer & Alanazi, 2023). However, high upfront costs and the need for regular maintenance and updates can be a challenging task for the organization. Missing outcome measures es that must be evaluated include patient satisfaction scores related to medication management and staff adherence rates to the new protocols over time. Additionally, tracking the frequency and types of near misses can provide valuable insights into areas needing further improvement.

Conclusion

In conclusion, this thorough evaluation of the QI initiative for medication administration errors analyzed the effectiveness of strategies like double-checking, minimizing interruption, and BCMA technology. However, several challenges were faced, such as staff resistance and overlooked workload issues. Furthermore, the QI initiative reduced medication errors through BCMA implementation. However, compliance rates for BCMA usage and double-checking procedures were below average, highlighting the need for ongoing staff training and engagement. The success was driven by interprofessional collaboration. Yet, several recommendations are made to enhance QI initiatives. Implementing standardized medication reconciliation and smart infusion pumps, along with evaluating patient satisfaction and tracking near misses, will ensure sustained improvements in medication safety and patient care quality. 

References

Abdelhadi, N., Drach‐Zahavy, A., & Srulovici, E. (2021). Work interruptions and missed nursing care: A necessary evil or an opportunity? The role of nurses’ sense of controllability. Nursing Open, 9(1). https://doi.org/10.1002/nop2.1064

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Alamer, F., & Alanazi, A. T. (2023). The impact of smart pump technology in the healthcare system: A scope review. Cureus, 15(3). https://doi.org/10.7759/cureus.36007 

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10). https://doi.org/10.7759/cureus.47731

Cheraghi, R., Ebrahimi, H., Kheibar, N., & Sahebihagh, M. H. (2023). Reasons for resistance to change in nursing: An integrative review. BMC Nursing, 22(1), 1–9. https://doi.org/10.1186/s12912-023-01460-0

Coelho, F., Furtado, L., Mendonça, N., Soares, H., Duarte, H., Costeira, C., Santos, C., & Sousa, J. P. (2023). Interventions to minimize medication error by nurses in intensive care: A scoping review protocol. Nursing Reports, 13(3), 1040-1050. https://doi.org/10.3390%2Fnursrep13030091

Elbeddini, A., Almasalkhi, S., Prabaharan, T., Tran, C., Gazarin, M., & Elshahawi, A. (2021). Avoiding a med-wreck: A structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources. Journal of Pharmaceutical Policy and Practice, 14(1). https://doi.org/10.1186/s40545-021-00296-w 

ElLithy, M. H., Salah, H., Lamyaa Samir Abdelghani, 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), 101726–101726. https://doi.org/10.1016/j.jsps.2023.101726

Kirit, I. (2023). Improving patient safety and emergency department staff efficiency in barcode medication administration by using the RoverTM mobile application. DNP Scholarly Projects. https://scholars.unh.edu/scholarly_projects/94 

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Koyama, A. K., Maddox, C.-S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552

Tariq, R. A., & Scherbak, Y. (2023, May 2). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/