NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

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Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Outcome Measures, Issues, and Opportunities

Medication errors (MEs) have emerged as a substantial quality and safety concern at Mercy General Hospital (MGH), as identified in the latest gap analysis. This report explores how organizational structures, workflows and operational practices contribute to this issue and influence patient outcomes. Understanding these quality and safety metrics allows for developing interventions to mitigate risks and enhance care delivery. The analysis outlines strategies to refine institutional processes. It ensures accountability through measurable improvements. Guided by the planned change model, this report proposes initiatives to strengthen patient care. It optimizes information-sharing and cultivates a safety culture within the organization.

Analysis of High-Performing Organization 

In high-achieving healthcare institutions, patient safety is prioritized through enhanced operational efficiency, adherence to evidence-based protocols and promotion of safe practices. Principal organizational functions include clear communication, well-trained personnel, seamless interdisciplinary coordination and efficient data management. Implementing medication administration checklists, utilizing Barcode Medication Administration (BCMA) systems, and standardizing medication reconciliation help minimize MEs. It optimizes workflow efficiency (Grailey et al., 2023).

These organizations foster a culture of accountability, teamwork and continuous education, where staff can openly report errors without fear of retribution. Leadership is crucial in reinforcing communication and knowledge-sharing. It is fundamental to safety initiatives (Grailey et al., 2023). These measures enhance patient outcomes and mitigate potential complications. It establishes them as best practices for addressing systemic challenges like MEs.

Despite the focus on procedural standards and staff behavior, several research gaps remain regarding the direct impact of staff compliance on patient outcomes. Areas requiring further investigation include the frequency of reported adverse drug reactions, communication breakdowns, training deficiencies, and the efficiency of current reporting systems. Uncertainties persist regarding patient perceptions of safety and the organization’s preparedness to integrate advanced technologies. Addressing these gaps through enhanced data collection and collaboration with key stakeholders could refine strategic approaches and improve the depth and accuracy of the analysis.

Organizational Support for Outcome Measures

At MGH, several operational aspects influence patient safety and quality outcomes. In MEs, key performance indicators include error rates, patient satisfaction, and adherence to medication safety protocols. Leading healthcare organizations integrate these factors to uphold patient safety across all levels. Organizational elements such as leadership, collaboration, and communication are vital in shaping MEs impact. Research indicates that strong managerial and leadership engagement in fostering a safety-oriented culture enhances staff expertise, teamwork, and the work setting. It strengthens safety initiatives (Nurmeksela et al., 2021). Effective interdisciplinary communication ensures timely data exchange. It reduces the risk of medication administration errors. A well-structured reporting system facilitates rapid issue detection and swift corrective actions.

Innovative technologies such as BCMA and electronic health records (EHRs) significantly reduce MEs. Standardized procedures limit human error. It ensures accurate dosing and proper medication administration. Additionally, built-in safety features like smart alerts and automated checks within EHRs help prevent medication-related mistakes by supporting adherence to safety protocols. BCMA enhances patient safety by verifying medications at the point of care. Standardized medication reconciliation ensures accurate tracking of prescriptions across transitions of care (Grailey et al., 2023).

It reduces discrepancies and adverse events. Human factors, including staff engagement and accountability, are crucial in maintaining compliance with safety measures and enhancing patient satisfaction (Elliott et al., 2021). When employees can report errors without fear of punishment and actively participate in quality improvement initiatives, the organization strengthens its ability to minimize mistakes. A culture prioritizing safe, dependable care improves patient satisfaction ratings. This approach is based on key assumptions. First, the organization fosters a safety-oriented culture. Secondly, standardized protocols are consistently followed, and third, staff education and liability are encouraged. These principles establish a strong basis for reducing MEs and enhancing patient experience.

Quality and Safety Outcomes and Proposed Measures

MGH reports an MEs rate of 40 per 1,000 patient days. The organization aims to decrease this number by 60%, reducing it to 20 errors per 1,000 patient days. Patient satisfaction is 80%, and increasing it to 90% will strengthen perceptions of care quality, safety, and communication. Adherence to medication safety protocols is at 60%, with a targeted improvement to 80% compliance. These objectives align with MGH’s commitment to patient safety, error reduction, and improving care delivery.

The organization has proposed several evidence-based initiatives to address the identified performance gaps. Key recommendations include the implementation of BCMA, EHRs, standardized medication reconciliation, and a structured handoff communication plan. Integrating EHRs is designed to reduce MEs by incorporating features such as drug interaction alerts, allergy warnings, and dosing adjustments. It supports providers in making informed decisions (Taft et al., 2023). BCMA ensures the right medication is administered to the patient by scanning barcodes. It enhances accuracy in medication delivery, while standardized medication reconciliation minimizes discrepancies during patient transitions.

These EHR systems will be utilized through targeted training and policy updates to ensure adherence to medication safety protocols (Grailey et al., 2023). Standardized handoff communication, particularly through the Situation, Background, Assessment, and Recommendation (SBAR) tool, will mitigate errors by improving the transfer of essential medication and data during shift changes (Taft et al., 2023). These initiatives will support ongoing staff development through training sessions, workshops, and audits. It is crucial for optimizing patient safety and elevating the quality of care at MGH.

The quality of data used to track these outcome measures is vital for assessing progress toward the established goals. The MEs rate, frequency of reported incidents and adverse drug reaction data are collected through the organizational dashboard. Patient satisfaction scores are derived from surveys. Compliance with safety protocols is evaluated through surveys targeting patients and staff.

However, the reliability of these results may be compromised due to inconsistent error reporting, underreporting of incidents, and variations in patient satisfaction ratings. To address these concerns, enhancing reporting mechanisms and standardizing data collection processes is essential. It ensures all staff are aligned in reporting errors. The proposed measures, including BCMA implementation, staff training, EHR integration, and improved communication, will help refine data accuracy and support more consistent monitoring.

Performance Issues and Opportunities in Healthcare Setting 

At MGH, several factors have been identified as contributing to performance issues that result in MEs. These include an increased frequency of reported incidents, adverse drug reactions, communication breakdowns, inadequate staff training, and workflow inefficiencies. High patient volumes place pressure on staff to ensure accurate medication administration while considering potential interactions with other prescribed drugs.

The complexity of managing multiple chronic conditions and polypharmacy increases the likelihood of errors (Kassaw et al., 2022). It requires precise dose measurements and constant monitoring of drug interactions. Staffing shortages exacerbate these challenges. It reduces the workforce available to meet patient needs. Staff become overburdened, leading to lapses in attention to detail. Healthcare employee fatigue, driven by heavy workloads, heightens the risk of mistakes (Elliott et al., 2021).

Several areas within MGH require improvement. Appropriate staffing levels and better task organization based on insights gained from efficient management practices can alleviate the strain on individual employees. This will ensure sufficient time is allocated to medication administration and patient care. Key goals for enhancing medication process accuracy include reducing medication order variability and integrating BCMA with the electronic medication process (Grailey et al., 2023). It strengthens communication during handoffs.

By prioritizing standardized protocols for interdepartmental communication and refining training programs can reduce errors linked to knowledge gaps and inconsistent practices (Taft et al., 2023). This study presents several research questions for future exploration, such as the specific causes of MEs in high-volume units, the impact of staffing shortages on MEs rates, and the efficacy of current training programs for managing complex medication regimens. The degree to which staff awareness and adherence to safety protocols have been developed and the role of patient involvement in medication safety remains unclear. Addressing these gaps is essential for creating strategies to reduce errors and improve safety.

Change Model for Outcome Measurement and Knowledge Sharing

The recommended change model for addressing MEs and patient care outcomes is the Plan-Do-Study-Act (PDSA) framework. This approach provides a systematic method for continuous improvement. It enables the measurement of various aspects of patient care (Chen et al., 2020). It ensures that the knowledge gained is shared effectively across the team. This iterative cycle will support MGH in evaluating the efficiency of implemented changes, reviewing the outcomes, and fostering ongoing enhancements.

1. Plan: The first step is to set precise targets, such as reducing the MEs rate by 60%, improving patient satisfaction by 80%, and increasing compliance by 90%. In this phase, the suitability of the targets, which include staffing, medication management, and communication, is clear.
2. Do: The following step is to test the pinpointed changes in the school, controlled units, or departments before beginning the changes as organizational standards. This includes incorporating the BCMA, new EHR tools, standard handoff setup, and training sessions.
3. Study: Information will be collected after the intervention to assess the success of the categorized goals. This includes the frequency of MEs, patient satisfaction, and protocol adherence. The changes will also be evaluated by receiving feedback from the staff and patients.
4. Act: Based on the results, changes will be made to improve the organization’s processes, training, or resources. This stage includes enhancing the method and spreading its use across the MGH.

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Effective knowledge sharing with staff can be achieved through structured training sessions, workshops, and clear communication channels. At MGH, staff will receive training on updated practices for medication administration, integrating BCMA and EHR in medication management, and communication protocols like SBAR. Information will be distributed via team meetings, intranet updates, and printed materials to ensure accessibility.

Feedback loops will encourage staff to share their ideas and concerns about patient care processes. This will be supported by interdisciplinary collaboration with a multidisciplinary team of nurses, pharmacists, physicians, and IT professionals. It ensures that all perspectives are considered when implementing safety measures. This approach will enhance knowledge transfer across the team. It promotes error reduction, boosting efficiency and improving patient care during the project lifecycle.

Conclusion

Implementing targeted strategies at MGH will be crucial in addressing MEs and improving patient safety. By adopting evidence-based practices such as BCMA, EHR, and standardized communication protocols, MGH aims to reduce errors and optimize care delivery. The PDSA framework will guide continuous improvement efforts. It fosters a safety-oriented culture and promotes effective knowledge-sharing across teams. Through these initiatives, MGH will strengthen its commitment to enhancing patient outcomes, improve operational efficiency, and elevate overall care quality.

References

Chen, Y., VanderLaan, P. A., & Heher, Y. K. (2020). Using the model for improvement and Plan-Do-Study-Act to effect SMART change and advance quality. Cancer Cytopathology, 129(1), 9–14. https://doi.org/10.1002/cncy.22319

Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30(2), 96–105. https://doi.org/10.1136/bmjqs-2019-010206

Grailey, K., Hussain, R., Wylleman, E., Ezzat, A., Huf, S., & Franklin, B. D. (2023). Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. a mixed methods study. Bio Med Central Nursing, 22(1). https://doi.org/10.1186/s12912-023-01382-x

Kassaw, A. T., Sendekie, A. K., Minyihun, A., & Gebresillassie, B. M. (2024). Medication regimen complexity and its impact on medication adherence in patients with multimorbidity at a comprehensive specialized hospital in Ethiopia. Frontiers in Medicine, 11, 1369569. https://doi.org/10.3389/fmed.2024.1369569 

Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. Bio Med Central Health Services Research, 21(1), 296. https://doi.org/10.1186/s12913-021-06288-5

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Taft, T., Rudd, Thraen, I., Kazi, S., Pruitt, Z. M., Bonk, C., Busog, Franklin, E., Hettinger, A. Z., Ratwani, R. M., & Weir, C. R. (2023). “Are we there yet?” Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses. Journal of the American Medical Informatics Association, 30(5), 809–818. https://doi.org/10.1093/jamia/ocad031