NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Name

Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Planning for Change: A Leader’s Vision 

Medication errors are one of the major issues for (mention your organization), influencing patient safety, care quality, and organizational performance. This presentation proposes ways to correct these errors and create a culture of quality and safety. In this case, we seek to optimize organizational processes, behaviors, and functions to achieve better patient outcomes, decrease medical errors, and establish the basis for ongoing quality enhancement.

Presentation Objectives 

This presentation will: 

• Emphasize medication errors as the key area of interest in examining the quality and safety of the organization.
• Detail a process to address the problem and improve the organization’s safety culture to prevent errors affecting patient care.
• Determine the current state of processes, behaviors, and functions that impact safety results.
• Pre- and post-combined target goals like medication error rate, patient satisfaction, and staff compliance rate are used to identify the measure of progress.
• Include specific recommendations for improving safety outcomes, gains, changes, and training.
• Provide a vision of a culture of quality and safety, including the nurse leader as a critical component of that potential.

Organizational Problem 

Medication errors are a persistent challenge within our organization, with a current rate of 30 per 1,000 patient days. These errors pose significant risks to patient safety, care quality, and organizational reputation. In (mention your organization), contributing factors include a high volume of patients, which overwhelms staff and reduces the time available for thorough medication management. Complex medication regimens, particularly for patients with multiple chronic conditions, increase the likelihood of dosing and interaction errors (Kassaw et al., 2022). Staff workload and shortages further exacerbate the issue, leading to fatigue, communication lapses, and inconsistent adherence to safety protocols. The consequences of these errors are profound, including patient harm, extended hospital stays, increased healthcare costs, and diminished trust in the organization (Tsegaye, 2020). Medication errors also impact staff morale, leading to stress and reduced job satisfaction. Addressing these systemic issues is critical to fostering a culture of quality and safety, reducing errors, and improving overall patient outcomes.  

Comprehensive Quality and Safety Plan 

To address medication errors, we proposed a comprehensive plan as follows: 

Integration of EHRs with Decision-Support Tools

The plan is to bring enhanced Electronic Health Records (EHRs) with decision-support systems to minimize medication errors on the list of priorities. Tools like alerts for drug-drug interactions, allergies, and dosage modifications will assist clinicians in making better decisions that will not harm the patient (Syrowatka et al., 2023). As a part of the solutions above, the policies expanding effective EHR use and the staff’s adequate training on such systems are vital in this approach. Training will allow standardization of safety measures and real-time information on important aspects like medication safety and patient information for the care teams.

Standardized Handoff Communication Protocols

Our organization can further implement communication tools like SBAR (Situation, Background, Assessment, Recommendation) to reduce handoff communication errors, particularly leading to medication mistakes. This structured communication tool affords an accurate and comprehensive way of passing on important information (Mulfiyanti & Satriana, 2022). Ongoing skills sessions, role play, and audits will further promote the use of SBAR within multidisciplinary teams. Accurate and brief communication will improve the patient’s care, diminish communication breakdowns, and foster a safety culture.  

Comprehensive Staff Training Programs

A robust training program for staff development will focus on the effective use of technology, especially EHRs and communication instruments. This includes workshops, role plays, and further training about medication handling, including its safety precautions (Saada et al., 2023). This means that through regular audits and feedback, there will always be an improvement and an accountability check. The training will enable staff to use technology and some of the set communication structures to ensure that safety practices are enhanced and the overall organizational culture of quality care is transformed.  

Existing Organizational Functions, Processes, and Behaviors 

Some organizational factors that lead to medication errors in our setting include high patient volume, multiple prescriptions for patients, workload on the staff, and lack of adequate staffing. However, some organizational processes and functions can be negative, including communication processes and handoffs, especially when they are ineffective in passing important medication information (Janagama et al., 2020). In the same respect, the organization has no integrated EHRs with decision-support tools. These restrict access to real-time data and alerts concerning possible medication errors for the limited providers.

Last, absent staff education on appropriate medication handling endangers patient safety since it fails to use standardized vital practices (Saada et al., 2023). In addition, organizational culture has a central influence on quality and safety, especially medication safety. An organizational culture that supports and promotes values such as openness, responsibility, and teamwork is when staff is empowered to report mistakes and close calls for learning purposes and improvement without penalties (Fukami, 2024). On the other hand, a high-pressure organizational culture that lacks sufficient support for outlining procedures will lead to failure to follow safety measures as illustrated in (mention your organization).

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Several questions and unknowns related to medication safety persist in our organization. One gap concerns the root causes of medication errors. Whether the causes are largely system-based or stem from human error is still being determined. Moreover, there is confusion about whether the current training and practicing methods are efficient enough to reduce these mistakes. We also need a fine-grained understanding of how staffing deficits lead to increased error rates, and there is relatively little known about the factors that can hinder the complete implementation of decision-support tools within our EHR system. All of these gaps need to be researched and addressed more specifically.

Current Outcome Measures 

In (mention your organization), quality and safety related to medication practices will be measured using three established metrics: medication error rate, patient satisfaction score, and staff compliance rate with standardized medication protocols. 

• The medication error rate is an easily understood, objective measure of medication safety that offers the organization specific data about the frequency of medication errors. Theoretically, it determines where change is required and facilitates monitoring changes within a given period. However, it could not include all medication errors, including near misses and those that did not cause harm. Also, it lacks a way of indicating the cause of the mistakes, like a staff shortage or lack of communication. Thus, it cannot be used to direct the cause-effect analysis.
• Patient satisfaction scores reflect the patient’s perspective on care quality (Alibrandi et al., 2023), describing the patient’s experience with medication management and care quality from the patient’s point of view. Higher scores are usually associated with better care delivery and patient safety. However, satisfaction scores represent perception and can be influenced by factors related to the hospital setting and the time the patients wait before being prescribed medication. They also may not provide a rich picture of the particular safety concerns and may have more difficulty detecting medication-related problems.

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

• Staff compliance measures demonstrate how closely the staff follows the set safety measures, which will influence medication safety (Saada et al., 2023). High compliance means that the organization implements all the safety measures well. The first problem of this measure is the lack of correlation with quality of care as it only measures following some protocols, not the results of these actions. Also, the measure may not capture how the protocol is implemented in a more complicated clinical practice or when there is a time constraint.

Actionable Plan to Achieve Improved Outcomes

The actions required to attain the desired outcomes for each proposed strategy are as follows: 

EHR Integration with Decision-Support Tools   

1. Ensure changes to policies that require decision-making tools in EHRs.
2. Educate healthcare workers about the application of these resources in determining interactions and allergies, as well as the right dosage.
3. Compliance checks should be conducted occasionally concerning the guidelines for using EHRs.
4. Implement real-time alerts for possible medication-related errors as a part of the EHR systems.
5. It is necessary to supplement the system with new clinical recommendations and safety measures as often as possible.

Standardized Handoff Communication Protocols (SBAR) 

1. Use SBAR (Situation, Background, Assessment, Recommendation) during all verbal and written handoffs.
2. SBAR must be included in all healthcare sector employees’ initial and continuing training.
3. Conduct role-play and simulations to increase staff’s comfort and effectiveness with SBAR.
4. Auditing and providing feedback are good ways to check compliance.
5. Continue to use SBAR in incident reporting and root cause analysis forms to maintain an improvement loop.

Staff Training on Medication Safety Protocols

1. Design and carry out an extensive medication safety staff orientation program to enhance compliance with issues related to errors.
2. Integrate medication safety cases and difficulty-solving sessions.
3. Monitor and review employee performance using tests and feedback. 
4. Provide follow-up training often to remind people of the right things to do.
5. Promote medication safety through debriefings and non-punitive reporting of medication-related errors.

Assumptions of the Plan

The plan assumes that the staff will participate in training programs and use the tools offered, along with leadership, to guarantee the policies are being implemented. It also presupposes that EHR systems are all-encompassing and will be up and running without any technical hitch. Also, using common communication techniques such as SBAR is expected from the staff, and audits and feedback will be enough to keep to them. Moreover, it is assumed that enough staff and time will be provided for these initiatives.

Future Vision and Nurse Leaders’ Role

The future vision for our organization is to create a culture of quality and safety that is patient-focused and reduces risks while focusing on improvement. Organization goals include increasing the usability of EHR, expanding health information exchange, implementing standard protocols and procedures for staff communications, and staff education regarding patient safety practices to reduce medication errors. Nurse leaders are central to this change by leading, supporting, and promoting improvement projects, patient safety, and interprofessional collaboration (Huang et al., 2024). They model appropriate behavior regarding safety and encourage others to follow safety measures; staff are encouraged to report mistakes and stay up-to-date with new information.

Nurse leaders are also pivotal in building interdisciplinary and multidisciplinary systems to work together for the common goal of safety for each member, including physicians, pharmacists, and all other allied health professionals. In their article, Dietl et al. (2023) noted that interprofessional collaboration leads to better communication, better team performance, and a direct influence on patient safety. Skills of nurse leaders embraced the notion of a professional practice environment where all healthcare professionals contribute to problem-solving and quality improvement endeavors. In the future, this patient-centered teamwork approach would enhance clinical results, patient satisfaction, and the health system’s ability to effectively respond to the identified challenges, hence the sustainability of the quality and safety culture.

Conclusion 

In conclusion, by addressing the current challenges related to medication errors through strategic, evidence-based practices, our organization can significantly improve patient safety and quality outcomes. Integrating enhanced EHR systems, standardized communication protocols, and comprehensive staff training will create a robust framework for reducing medication errors and promoting a safety culture. Nurse leaders are critical in driving this change, fostering interprofessional collaboration, and ensuring sustainable improvements. Together, we have the potential to build a high-performing, safety-focused organization that consistently delivers excellent, patient-centered care. Let us work collectively towards achieving these goals.

References 

Alibrandi, A., Gitto, L., Limosani, M., & Mustica, P. F. (2023). Patient satisfaction and quality of hospital care. Evaluation and Program Planning, 97, 102251. https://doi.org/10.1016/j.evalprogplan.2023.10225 

Dietl, J. E., Derksen, C., Keller, F. M., & Lippke, S. (2023). Interdisciplinary and interprofessional communication intervention: How psychological safety fosters communication and increases patient safety. Frontiers in Psychology, 14(14). https://doi.org/10.3389/fpsyg.2023.1164288 

Fukami, T. (2024). Enhancing healthcare accountability for administrators: Fostering transparency for patient safety and quality enhancement. Cureus, 16(8). https://doi.org/10.7759/cureus.66007 

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 

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

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 

Janagama, S. R., Strehlow, M., Gimkala, A., Rao, G. V. R., Matheson, L., Mahadevan, S., & Newberry, J. A. (2020). Critical communication: A cross-sectional study of signout at the prehospital and hospital interface. Cureus, 12(2). https://doi.org/10.7759/cureus.7114 

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 

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Saada, M., Morrissey, H., & Ball, P. (2023). Importance of healthcare professional training on medication safety, medication error prevention, and reporting ‎. Journal of Advanced Pharmacy Education and Research, 13(3), 1–7. https://doi.org/10.51847/nsvledyp4z 

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/ 

Tsegaye, D. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 13(13), 1621–1632. https://doi.org/10.2147/ijgm.s289452