NURS FPX 6212 Assessment 2 Executive Summary

Name

Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Executive Summary 

Medication errors, also known as adverse drug events (ADEs), are significant quality and safety concerns in (organization name). This executive summary is grounded in the proposed practice changes of effective utilization of Electronic Health Records (EHRs) and the establishment of standardized hands-off protocols to address the relevant practice gaps. 

Quality and Safety Outcomes Measures

Medication errors significantly impact patient care outcomes by increasing the likelihood of morbidity, prolonged hospital stays, augmented costs, and mortality (Wondmieneh et al., 2020). Several outcome metrics, such as medication error rate, patient satisfaction scores, and compliance rate with medication safety protocols, are crucial to monitoring the presence of the systemic problem. 

• Initially, tracking the frequency of medication errors per 1,000 patient days provides a quantitative assessment. Our organizational dashboard represents 30 errors/per 1000 patient days. This measure is crucial as it highlights specific points in the medication administration process where errors are frequent, allowing for targeted interventions (Mutair et al., 2021). However, underreporting may result due to fear of repercussion and blame among healthcare professionals. 
• Secondly, the patient satisfaction score measures patients’ perceptions and experiences of their care (Ferreira et al., 2023). Currently, our organization reports 70% patient satisfaction with medication safety and communication. This outcome measure’s strength lies in its ability to provide direct feedback from patients about their experiences, highlighting areas where medication errors may have affected their trust and experiences. However, the weakness of this measure is that it is subjective and can be influenced by factors unrelated to medication safety, such as patient expectations or personal preferences.

NURS FPX 6212 Assessment 2 Executive Summary

• Finally, measuring compliance with medication safety protocols is essential to gain insights into preventive actions, enabling organizations to understand staff practices to reduce errors (Musa et al., 2023). This metric promotes accountability and fosters a culture of safety. In (organization name), the protocol compliance rate is 60%, indicating a need for continuous reinforcement. However, this outcome measure is not always accurately correlated with reduced errors if protocols are not grounded in evidence-based practice.  

Strategic Value of Outcome Measures in the Organization

The strategic value of monitoring medication error rates, patient satisfaction scores, and compliance with medication safety protocols is significant for our organization. Measuring medication errors is strategically valuable for patient safety and care quality, which are core organizational goals. Reducing medication errors minimizes the risk of adverse drug events, improves clinical outcomes, lowers healthcare costs, and prevents reputational damage (Rodziewicz et al., 2024). By identifying error trends, the organization can implement targeted interventions, refine protocols, and enhance staff training, ultimately driving performance improvement. Patient satisfaction scores, on the other hand, are strategically valuable as they directly reflect the quality of care and patient experience, influencing patient’s trust and patient flow within the organization (Ferreira et al., 2023).

High patient satisfaction can lead to increased patient loyalty and improved patient retention rates, ultimately enhancing revenue. This outcome measure helps the organization strengthen its reputation and maintain financial sustainability. Finally, staff compliance rate with medication safety protocols serves as a direct indicator of clinical practices and abiding by the regulatory requirements, which is valuable for the strategic development of the organization. High compliance rates demonstrate the organization’s commitment to safety and quality, which is essential for maintaining accreditation and meeting external standards (Althumairi et al., 2022). This metric assists organizations in identifying practice gaps and reinforcing evidence-based guidelines through policy development, aligning with strategic goals. 

Additional Value of Existing Outcome Measures 

To maximize their value, existing outcome measures should be integrated into a performance management framework aligned with the organization’s strategic goals. Linking medication error data with patient satisfaction scores can reveal underlying issues affecting safety and experience. Combining compliance rates with patient outcomes helps assess protocol effectiveness and identifies areas for improvement. Leadership’s regular review of these metrics ensures data-driven decision-making, continuous quality improvement, and alignment with long-term objectives.

The Relationship Between Problem and Outcome Measures

As identified earlier, medication errors are a systemic problem in the (organization name) that directly affects several quality and safety outcomes, including error incidences, patient satisfaction scores, and compliance rates with medication safety protocols. A high rate of medication errors is a clear indicator of gaps in safety practices. It has a direct impact on patient outcomes, leading to adverse drug events, increased hospital stays, and potentially avoidable readmissions (Wondmieneh et al., 2020). These errors are related to reduced patient satisfaction scores as patients perceive that their safety is at risk, leading to negative reviews, reduced patient retention, and harm to the organization’s reputation.

Additionally, medication errors are closely related to the organization’s compliance with medication safety protocols. Low compliance rates indicate poor staff training, unclear communication, or ineffective safety policies, contributing to increased errors (Ghezaywi et al., 2024). Implementing the proposed practice changes, such as standardized communication tools, staff training, and effective use of decision-support tools within EHRs, can improve the results of these quality and safety outcome measures, eventually enhancing medication safety. 

To gain a deeper understanding of medication errors, additional data could include detailed error reports specifying the type, cause, and timing of errors and the specific medications involved. Collecting data on staff workload, staffing levels, and shift patterns could help identify correlations between these factors and the occurrence of errors. Additionally, patient demographic data, such as age, comorbidities, and polypharmacy status, could reveal vulnerable populations at higher risk. Finally, gathering information on staff perceptions of safety culture, training effectiveness, and communication patterns can provide insights into organizational factors contributing to errors, helping to develop targeted interventions for improvement.

Outcome Measures and Strategic Initiatives 

The proposed initiative to address medication errors in (organization name) includes strategies like integration of decision-support tools in EHRs, establishing standardized communication tools, and conducting staff training. This proposal aligns with the specific outcome measures, such as medication error rates, patient satisfaction scores, and compliance with safety protocols. Each outcome measure supports this initiative. For example, the organization reports 30 errors per 1000 patient days, whereas the desired target is to reduce this rate by 50%. Moreover, the current patient satisfaction score is 70%, whereas the target is to increase it to 90%. Finally, the compliance rate is planned to be enhanced from 60% to 80%.

Syrowatka et al. (2023) mention that by integrating decision-support tools in the EHR, real-time alerts for drug interactions and dosage adjustments will allow healthcare professionals to identify mistakes early before leading to an adverse event. Moreover, standardized communication tools, such as SBAR, will ensure accurate information transfer during handoffs, minimizing miscommunication-related errors (Mulfiyanti & Satriana, 2022). Clear and consistent communication helps reduce misunderstandings, enhances patient trust, and improves satisfaction. Monitoring these scores allows the organization to measure the success of training initiatives focused on enhancing handoff communication and identifying areas for further improvement. Lastly, the compliance rates with safety protocols indicate how well staff adhere to established medication safety practices, supporting the comprehensive training programs for effective use of communication protocols and EHRs. 

Leadership Role in Supporting Proposed Changes 

A leadership team can support the implementation and adoption of the proposed practice changes by fostering a culture of safety, providing necessary resources, and encouraging active participation across all levels of staff. Leadership should clearly communicate the importance of proposed changes. Clear communication from leaders fosters a shared understanding of the goals, ensures alignment across all team members, and gains team members’ interest in the changes (Jankelová & Joniaková, 2021). This can be achieved by organizing regular meetings, workshops, and feedback sessions to emphasize these goals and their alignment with the organization’s strategic objectives.

Leaders can also allocate funds for technology upgrades and develop policies that reinforce adherence to safety protocols. To enhance interprofessional collaboration, leaders can create opportunities for various healthcare professionals, including physicians, nurses, pharmacists, and IT specialists, to work together in designing and refining these practice changes. For example, involving clinical and technical staff in optimizing decision-support tools ensures that the EHR system is user-friendly and effective in preventing medication errors.

Likewise, interdisciplinary training sessions can foster better communication, understanding, and teamwork across departments, leveraging the unique skills and perspectives of each profession (Munneke et al., 2024). By promoting a collaborative, inclusive environment, the leadership team can ensure a successful and sustainable implementation of these changes, improving quality and safety outcomes organization-wide.

Conclusion 

In conclusion, implementing decision-support tools in EHRs, standardized communication methods, and comprehensive staff training are crucial for improving quality and safety outcomes. By monitoring medication error rates, patient satisfaction scores, and compliance rates with safety protocols, the practice changes can be aligned with organizational goals to foster a culture of safety. The integration of these practices, supported by strong leadership and interprofessional collaboration, will drive significant improvements in patient care and organizational performance, meeting and exceeding targeted quality benchmarks.

References 

 Althumairi, A., Alzahrani, A., Alanzi, T., Al Wahabi, S., Alrowaie, S., Aljaffary, A., & Aljabri, D. (2022). Factors affecting compliance with national accreditation essential safety standards in the Kingdom of Saudi Arabia. Scientific Reports, 12(1). https://doi.org/10.1038/s41598-022-11617-7 

Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a bibliometric analysis. Healthcare, 11(5), 639. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10001171/ 

NURS FPX 6212 Assessment 2 Executive Summary

Ghezaywi, Z., Alali, H., Kazzaz, Y., Ling, C. M., Esabia, J., Murabi, I., Mncube, O., Menez, A., Alsmari, A., & Antar, M. (2024). Targeting zero medication administration errors in the pediatric intensive care unit: A quality improvement project. Intensive and Critical Care Nursing, 81(1), 103595. https://doi.org/10.1016/j.iccn.2023.103595 

Jankelová, N., & Joniaková, Z. (2021). Communication skills and transformational leadership style of first-line nurse managers in relation to job satisfaction of nurses and moderators of this relationship. Healthcare, 9(3), 346. https://doi.org/10.3390/healthcare9030346 

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 

Munneke, W., Demoulin, C., Nijs, J., Morin, C., Kool, E., Berquin, A., Meeus, M., & Kooning, M. D. (2024). Development of an interdisciplinary training program about chronic pain management with a cognitive behavioural approach for healthcare professionals: Part of a hybrid effectiveness-implementation study. BMC Medical Education, 24(1). https://doi.org/10.1186/s12909-024-05308-2 

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 

NURS FPX 6212 Assessment 2 Executive Summary

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. https://doi.org/10.3390/medicines8090046 

Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/ 

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/ 

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