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

Name

Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Outcome Measures, Issues, and Opportunities

Medication errors are a key quality and safety issue revealed through the latest gap analysis at (mention the name of the healthcare organization – used in A1 and A2). This paper explores the relationship between organizational work functions, processes, and activities and outcome indicators associated with this systematic problem. Thus, when we understand quality and safety outcomes, we can design specific approaches to enhance those outcomes. This analysis will also describe how to improve organizational practices and make them more responsible by identifying the possible tangible results. Based on the planned change model, the report presents a plan to improve care, share information, and create a safety culture within the organization.

Analysis of High-Performing Organization 

In high-performing healthcare organizations, patient safety is valued by improving the functionality, use of evidence-based practices, and safe behaviors. Some of the key functions of organizations are effective communication, cross-functional integration, and information processing. Measures like implementing a checklist for medication administration and using bar code technology and electronic systems decrease errors and increase the organizational workflow (Ahsani-Estahbanati et al., 2022). Furthermore, these organizations greatly promote a culture of staff accountability and training where staff can report mistakes, and nobody will punish them. The leadership behaviors encourage communication and education, which are essential in safety measures (Ahsani-Estahbanati et al., 2022). These practices improve patients’ status and reduce potential adverse effects, which makes them the standard for handling the system’s problems, such as medication mistakes.

Despite the emphasis on processes and behaviors, some research questions still need to be made about how specific staff adherence affects the results. Detailed error patterns, specific staff training deficits, and current reporting system efficiency are some gaps. However, some questions still relate to patient perception of safety and organizational readiness to implement advanced technology that deserves an answer. These uncertainties could be addressed with better data gathering or by consulting with other stakeholders to make the strategies more defined and the analysis more effective.

Organizational Support for Outcome Measures

The following operations in the healthcare organization are related to patient safety and quality outcomes. Regarding medication errors, such outcome indicators are medication error rate, patient satisfaction, and medication safety standards. In high-performing healthcare organizations, these elements are integrated to support the principle of patient safety at all levels. Leadership, teamwork, and communication are organizational structures that directly affect the consequences of medication errors.

Studies also show that the involvement of management and leadership concerning patient safety culture enhances staff knowledge, teamwork, and working environment to respond to safety even further (Huang et al., 2024). Also, interdisciplinary communication guarantees that information is passed across promptly to avoid mistakes made in the administration of drugs. An effective reporting structure enables the fast identification of problems and quick correction.

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

Moreover, technological advancements such as electronic health records (EHRs), barcode medication administration, and clinical decision support systems also lower medication errors (Ahsani-Estahbanati et al., 2022). Standard procedure minimizes human interference and guarantees that the right medication is given in the right measure. Other smart alerts and smart checks in EHRs also avoid medication-related errors. These are involved in following medication safety protocol compliance, leading to a few mistakes. People-related factors, including staff involvement and responsibility, affect adherence to safety measures and patient satisfaction (Abuosi et al., 2022).

When staff is allowed to report errors without being punished and when involved in ongoing improvement programs, the capacity of the organization to decrease the number of mistakes made is enhanced. The perception of safe and reliable care is one of the organizational behaviors that result in positive scores in patient satisfaction. Some key assumptions that underpin this determination include but are not limited to assuming that the organization embraces a safety culture. Secondly, the organization practices standardized protocols, and thirdly, the organization encourages staff education and accountability. These assumptions provide a firm platform for minimizing medication errors and improving patient’s experiences.

Quality and Safety Outcomes and Proposed Measures

Currently, (mention the name of the organization) has a medication error rate of 30 errors per 1,000 patient days, which is the organization’s desired target to reduce this rate by 50% to 15 errors per 1,000 patient days. The current patient satisfaction is 70 percent, and the goal is to reach 90 percent. This has been used to enhance patients’ perception of quality of care, safety, and communication. Also, the medication safety protocols have a 60% compliance rate, with a planned compliance rate of 80%. These targets align with the organization’s patient safety and error reduction objectives and optimize care delivery.

The organization has put forward some of the following evidence-based changes to eliminate the abovementioned performance gaps. Some of the main recommendations include EHRs linked with decision support, implementation of a structured handoff communication plan, and staff education plan. EHR integration aims to minimize the rate of medication errors by adding features of drug interaction, allergies, and dosing adjustments while also improving the provider’s decision-making processes (Syrowatka et al., 2023). With training and policy development, these EHR systems will be used in the best way to maintain compliance with medication safety protocols.

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

Standardized handoff communication, including using the SBAR tool, will reduce additional errors by enhancing the communication of critical medication and patient information between caregivers during shift handovers (Mulfiyanti & Satriana, 2022). These tools will facilitate staff training, workshops, and audits, which are critical to ensure their use, enhancing patient safety and the quality of care throughout the (name of the organization).

The data quality used to monitor these outcome measures is crucial to determine progress towards set goals. The medication error rate data is obtained through the organizational dashboard, and patient satisfaction scores are obtained from the patient surveys. Compliance with protocols is also obtained from patient and staff surveys. However, the accuracy of the results might be questioned due to the variability in reporting the errors, underreporting of the mistakes, or patients’ variability in satisfaction assessments. It is, therefore, necessary to improve reporting, increase conformity in data collection, and ensure all employees have a common way of reporting errors. This proposal’s measures for training, EHR integration, and communication will provide more of the following.

Performance Issues and Opportunities in Healthcare Setting 

In our organization, several factors have been identified as causing performance problems that lead to medication errors. These include increased patient census, multiple complicated medication regimens, workload pressure, and inadequate staffing. Large patient loads put lots of pressure on employees to administer the correct dosages of the medicines and ensure that it is safe for the patient to take the medicine in consideration with other medications that the patient is on.

Multiple chronic conditions and multiple drugs prescribed per patient enhance the likelihood of medication errors (Kassaw et al., 2022) because of the need to measure doses and monitor drug interactions. These problems are worsened by staffing deficiencies, which limit the number of employees available to meet patients’ needs; consequently, staff becomes overworked and may not provide adequate attention to detail. Further, staff workload, concurrently with these elements, can cause fatigue and thus enhance the risk of errors (Bell et al., 2023).

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

There are areas in our organization that need some enhancement. With optimal staffing and proper organization of the work involving the use of what has been learned regarding efficient management of operating procedures, we can eliminate the overburdening of individual employees to ensure adequate time is devoted to medication administration and patient care. The expectations for improving the accuracy of medication processes include reducing medication order variability, implementing decision support systems integrated within electronic health records (EHRs) (Syrowatka et al., 2023), and promoting effective hand-off communications.

By increasing the focus on the protocols that will be used in the communication between different disciplines, as well as increasing the focus on the training programs that are used, the errors which are associated with knowledge deficiencies and inconsistent practices can be minimized (Mulfiyanti & Satriana, 2022). This study has several research issues and questions that should be explored in future research. Such details are the precise causes of medication errors in large volume units, the exact effect of staffing deficits on medication error rates, and the adequacy of current training interventions when handling complex medication schedules. Furthermore, it is unclear to what extent staff awareness and compliance with safety measures is developed and the level of patient engagement in medication safety. These gaps must be addressed to build effective solutions for decreasing errors and enhancing safety.

Change Model for Outcome Measurement and Knowledge Sharing

In the case of both medication errors and patient care outcomes, the recommended change model is the Plan-Do-Study-Act (PDSA) model. The PDSA model offers a clear structure for ongoing improvement, helps to quantify all aspects of patient care (Chen et al., 2020), and guarantees that all the acquired knowledge is effectively disseminated among the staff. This cycle will help our organization to determine the efficiency of changes, to consider the results of the changes, and to make continuous improvements.

1. Plan: The first step is to set specific targets, such as reducing the medication error rate by 50%, improving patient satisfaction by 90%, and increasing compliance by 80%. In this phase, the appropriateness of the targets, which include staffing, medication management, and communication, is defined.
2. Do: The next step is to trial the identified changes on the schools’ limited units or departments before establishing the changes as organizational standards. This includes incorporating the new EHR tools, standard handoff format, and training sessions.
3. Study: Data will be gathered after the intervention to evaluate the achievement of the identified goals, which include medication error rate, patient satisfaction, and protocol adherence. The changes will also be assessed by receiving feedback from the staff and patients.
4. Act: Based on the findings, changes will be made to enhance the organization’s processes, training, or resources. This phase includes optimizing the method and spreading its use across the organization.

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

Possible ways of sharing knowledge with staff include structured training, workshops, and communication channels. In our organization, staff will be trained on the new changes on medication administration, incorporating EHR in medication management and communication systems like SBAR. Information will be disseminated through team meetings, intranet posts, and printouts to make it available. Moreover, we will use the feedback loops to help staff members report their ideas and concerns about patient care processes. This will be well facilitated by interprofessional collaboration. Involving a multidisciplinary panel of nurses, pharmacists, physicians, and IT specialists will ensure that all standpoints are considered when designing and putting safety measures into practice and increase knowledge transfer across the care delivery team to decrease errors. This approach will help ensure that staff, from the beginning to the end of a project, are current in knowledge, improving efficiency, reducing mistakes, and improving patient care.

Conclusion

In conclusion, medication errors and the enhancement of patient care in our organization need the improvement of organizational functions, processes, and behavior. The PDSA change model is used to plan, implement, and evaluate change, so by incorporating evidence-based practices like EHRs, communicating clear, concise guidelines, and ongoing staff training, we can demonstrate progress in medication safety, patient satisfaction, and protocol adherence. Interprofessional teamwork is crucial for promoting the exchange of information and ideas regarding patient safety at the microsystem, mesosystem, and macrosystem levels of care. When implemented, such changes can help prevent medication errors and greatly improve the number of patients.

References

Abuosi, A. A., Poku, C. A., Attafuah, P. Y. A., Anaba, E. A., Abor, P. A., Setordji, A., & Nketiah-Amponsah, E. (2022). Safety culture and adverse event reporting in Ghanaian healthcare facilities: Implications for patient safety. PLOS ONE, 17(10), e0275606. https://doi.org/10.1371/journal.pone.0275606 

Ahsani-Estahbanati, E., Gordeev, V. S., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews. Frontiers in Medicine, 9(9). https://doi.org/10.3389/fmed.2022.875426 

Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17-18), 5445–5460. https://doi.org/10.1111/jocn.16620 

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

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 

Huang, C.-H., Wu, H.-H., Lee, Y.-C., & Li, X. (2024). The critical role of leadership in patient safety culture: A mediation analysis of management influence on safety factors. Risk Management and Healthcare Policy, 17(17), 513–523. https://doi.org/10.2147/rmhp.s446651 

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 

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 

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/