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

Quality and Safety Gap Analysis 

Medication errors represent a significant quality and safety concern within healthcare settings, often resulting in adverse patient outcomes, increased hospital stays, and escalated healthcare costs (Justinia et al., 2021). This paper conducts a gap analysis within (organization name) to identify the systemic issues contributing to medication errors. By identifying these gaps, the analysis will offer evidence-based recommendations to enhance medication safety and improve overall patient care quality.

Systemic Problem and Knowledge Gaps/Areas of Uncertainty

Medication errors refer to mistakes that occur at any point in the medication management process, from prescription to administration. These errors account for 28% of preventable adverse drug events within hospitals in the United States, where 770,000 cases are reported for medication-related morbidity and mortality (Justinia et al., 2021). Commonly, miscommunication among healthcare providers, inadequate medication reconciliation, illegible handwriting, confusing packaging, and the complexity of medication regimens lead to such adverse events.

According to Wondmieneh et al. (2020), these errors contribute to increased healthcare costs, prolonged hospital stays, and loss of trust in the healthcare system. In (organization name), medication errors significantly affect patient safety and care quality, manifesting in increased incidences of adverse drug events and hospital readmissions. The high volume of patients, complex medication regimens, staff workload, and staffing shortages are common contributors to medication errors in our organization (Tariq & Scherbak, 2024). A recent internal audit identified inadequate use of the Electronic Health Record (EHR) system for medication safety and inconsistent handoff communication among staff as deficiencies contributing to medication errors. 

However, significant knowledge gaps remain, particularly regarding the most effective interventions to reduce errors across different stages of medication management. Moreover, leadership commitment and support towards medication error prevention remain a knowledge gap. Furthermore, there is uncertainty around the optimal integration of technology in preventing errors and whether current staff training programs adequately address the root causes of errors. Finally, unanswered questions remain about how organizational culture and interprofessional communication impact medication safety and what further steps are necessary to close these gaps.

Practice Changes within the Organization 

Evidence-based practice changes to address the performance gaps within (organization name) include effective integration of EHRs, the establishment of standardized handoff communication protocols, and staff training for effective use of both. These changes aim to enhance the consistent use of the EHR system with integrated decision-support tools and promote standardized communication within the organization, improving the overall quality of care by ensuring precise information exchange among healthcare providers. 

Implementing effective use of EHRs through robust policy development and enhanced training can significantly reduce medication errors. The proposal involves integrating decision-support tools, such as automated alerts for potential drug interactions, allergies, and dose adjustments, within the EHRs to enhance medication safety, prevent errors, and ensure accurate, timely information for healthcare providers (Syrowatka et al., 2023). Additionally, the proposal aims to train staff on the effective use of these systems, ensuring consistent application of safety protocols, accurate medication management, and improved communication across care teams. 

Another crucial practice change includes standardized handoff communication and staff training on these tools, such as SBAR (Situation, Background, Assessment, Recommendation). This communication tool helps prevent medical errors by providing a structured, clear communication framework, ensuring accurate and concise information transfer during handoffs (Mulfiyanti & Satriana, 2022). The proposal also includes a staff training program through regular workshops, simulations, and audits, emphasizing the use of structured communication tools for the seamless transfer of critical medication information and minimizing the risk of errors. 

Assumptions of the Proposal 

This proposal is based on several key assumptions, such as the willingness of the healthcare staff to engage in training programs and adapt to new protocols, the current EHR system is capable of integrating decision-support tools to enhance medication safety, there is sufficient administrative support and resources to implement these changes, and leadership supports the culture of safety and open communication to enable sustained adherence to new practices and protocols. 

Prioritization of the Practice Changes 

Decision-support tools within the EHRs should be prioritized due to their broad impact on medication safety across the entire healthcare system. By incorporating automated alerts, this technology provides real-time assistance to healthcare providers to guarantee that critical information is readily available and there are fewer chances of oversight (Syrowatka et al., 2023). Additionally, robust training on EHR systems will help staff utilize these tools effectively, ensuring that safety protocols are consistently applied and communication is improved across care teams.

On the other hand, standardizing handoff communication using SBAR communication tools is also crucial, but it should be secondary to the EHR integration. Although effective handoff communication is essential to prevent communication errors, it is specific to patient care transitions, such as shift changes or patient transfers (Toren et al., 2022). Thus, it has an indirect relationship with preventing medication errors. However, training staff through workshops, simulations, and audits on this communication tool will reinforce its use and improve overall communication, which can be helpful in preventing medication errors as well. Therefore, while essential, standardized handoff communication is prioritized after addressing the broader EHR integration.

Quality and Safety Culture and its Evaluation 

The proposal of integrating decision-support tools in EHR and standardized communication promotes a culture of quality and safety within the (organization name). Firstly, the automatic alerts within the system promote a culture of safety where safety measures are directly incorporated into the workflow. Moreover, staff training on EHR usage reinforces this culture by equipping staff with the skills needed to utilize these tools effectively, thus encouraging adherence to safety protocols, improving competencies, and enhancing staff satisfaction (Musa et al., 2023). Ultimately, consistent application of these tools across the organization demonstrates a commitment to patient safety and supports a culture that values precision and reliability.

Similarly, standardized communication protocols guarantee a culture of safety by ensuring that critical information is communicated clearly and consistently during transitions in care (Toren et al., 2022). By implementing structured communication practices, the organization reduces the risk of miscommunication. This practice promotes accountability and encourages staff to focus on clear and effective communication, fostering an environment where quality and safety are central to workflow. Training and regular reinforcement help maintain this focus, emphasizing the importance of thorough and precise information transfer, which supports a culture of transparency and continuous improvement.

Criteria for Evaluating Culture of Quality and Safety

The criteria to evaluate this culture include monitoring the frequency of medication errors and communication-related incidents to gain insights into the effectiveness of the implemented changes. Moreover, it is crucial to assess staff adherence to new protocols and communication practices through regular audits and feedback, examining the level of engagement and satisfaction with the safety initiatives (Musa et al., 2023). Finally, evaluating the impact of training programs on staff knowledge and application of EHR tools and communication practices can help determine their effectiveness, ensuring continuous improvement and commitment to high standards of patient care.

Culture Affecting Quality and Safety Outcomes 

Organizational culture and hierarchy play critical roles in shaping quality and safety outcomes within the organization. According to the literature, culture refers to shared beliefs and practices, whereas hierarchy deals with power relationships and the structure of decision-making (Chalmers & Brannan, 2023). In (organization name), hierarchical culture, which is characterized by clear top-down communication and decision-making authority, is inadvertently contributing to safety issues as lower-level staff feel reluctant to voice concerns or report errors. This reluctance results in underreported incidents, missed opportunities for improvement, and a lack of frontline input into safety protocols. Additionally, the culture within the organization prioritizes speed and efficiency over thoroughness, leading to incomplete medication administration and documentation increasing the risk of errors. 

According to the literature, a culture that emphasizes openness, continuous learning, and teamwork fosters a safer environment. In such a culture, the staff is encouraged to report errors, share concerns, and be involved in decision-making, eventually influencing staff readiness to change (Ellis et al., 2023).  If (organization name) fosters a culture of safety and supports open communication across all levels, it can enhance the effectiveness of implemented practice changes, such as improved EHR utilization and standardized communication practices. This analysis assumes that organizational culture and hierarchy significantly influence staff behavior and reporting practices. It also presumes that a hierarchical culture can create barriers to effective communication and problem-solving. Furthermore, it is based on the assumption that fostering a culture of openness and shared responsibility positively impacts quality and safety outcomes.

Justification of Necessary Changes in an Organization

Several organizational changes are essential to successfully implement the proposal and reduce adverse quality and safety outcomes. These include changes in leadership practices, adequate resource allocation, and improving quality monitoring practices. Firstly, leadership must prioritize commitment to safety and quality. This involves actively supporting the implementation of the proposal. Moreover, leaders should create an environment where staff feel empowered to report errors without fear of retribution (Wawersik et al., 2023). Through this approach, leadership can drive the successful adoption of these practices and foster a more proactive approach to quality and safety.

Another crucial change is effective resource allocation, which includes investing in advanced technological systems and allocating time and funds for comprehensive staff training. Resources should also be directed toward developing and maintaining standardized communication practices and providing ongoing support for their use. Finally, the organization should expand quality monitoring practices to evaluate the effectiveness of the proposed changes. This includes establishing regular audits to ensure adherence to new protocols (Musa et al., 2023). Monitoring should involve tracking medication error rates, incident reports, and feedback from staff regarding the latest practices. Regular review of these metrics will help identify areas for improvement, ensuring that safety initiatives are meeting their objectives and driving continuous enhancement of care quality.

References 

Chalmers, R., & Brannan, G. D. (2023). Organizational culture. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560543/ 

Ellis, L. A., Tran, Y., Pomare, C., Long, J. C., Churruca, K., Saba, M., & Braithwaite, J. (2023). Hospital organizational change: The importance of teamwork culture, communication, and change readiness. Frontiers in Public Health, 11(11). https://doi.org/10.3389/fpubh.2023.1089252 

Justinia, T., Qattan, W., Almenhali, A., Khatwa, A., Alharbi, O., & Alharbi, T. (2021). Medication errors and patient safety: Evaluation of physicians’ responses to medication-related alert overrides in clinical decision support systems. Acta Informatica Medica, 29(4), 248. https://doi.org/10.5455/aim.2021.29.248-252 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275 

Musa, S., Dergaa, I., Shekh, A., & Singh, R. (2023). The impact of training on electronic health records related knowledge, practical competencies, and staff satisfaction: A pre-post intervention study among wellness center providers in a primary health-care facility. Journal of Multidisciplinary Healthcare, 16, 1551–1563. https://doi.org/10.2147/jmdh.s414200 

Syrowatka, A., Motala, A., Lawson, E., & Shekelle, P. (2023). Computerized clinical decision support to prevent medication errors and adverse drug events: Rapid review. PubMed; Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK600580/ 

Tariq, R. A., & Scherbak, Y. (2024). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/ 

Toren, O., Lipschuetz, M., Lehmann, A., Regev, G., & Arad, D. (2022). Improving patient safety in general hospitals using structured handoffs: Outcomes from a national project. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.777678

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Wawersik, D. M., Boutin, E. R., Gore, T., & Palaganas, J. C. (2023). Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: A systematic review. Journal of Healthcare Leadership, 15, 59–70. https://doi.org/10.2147/jhl.s369242 

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 Nursing, 19(4), 1–9. https://doi.org/10.1186/s12912-020-0397-0