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 (MEs) represent a critical challenge at Mercy General Hospital (MGH), adversely affecting patient safety, healthcare quality, and operational efficiency. This presentation proposes strategies to reduce these errors and cultivate a culture of safety and excellence within the institution. The primary objective is to enhance organizational workflows, refine staff practices, and optimize system functionalities to achieve improved patient outcomes. By minimizing medical mistakes, MGH will establish a foundation for ongoing quality improvement and safer care delivery.

Presentation Objectives

This presentation aims to:

• Highlight medication errors as a core concern when evaluating MGH’s quality of care and commitment to patient safety.
• Introduce a systematic approach to resolve these errors and reinforce the hospital’s safety infrastructure, thereby safeguarding patient welfare.
• Evaluate current workflows, staff behaviors, and operational dynamics impacting safety outcomes.
• Utilize benchmarking metrics such as medication error rates, patient satisfaction scores, and staff protocol adherence to monitor progress pre- and post-intervention.
• Recommend targeted measures to elevate safety performance, promote improvements, implement critical changes, and enhance staff training.
• Articulate a vision of a healthcare environment centered on safety and quality, emphasizing the nurse leader’s critical role in steering and sustaining this transformation.

Organizational Problem

At MGH, medication errors occur frequently, with an estimated rate of 40 incidents per 1,000 patient days. These errors jeopardize patient safety, compromise care standards, and diminish the hospital’s credibility. Key contributing factors include high patient volumes that overwhelm staff capacity, limiting the time available for careful medication administration. Complex treatment regimens, particularly for patients managing multiple chronic conditions, increase the risk of dosage errors and harmful drug interactions (Tariq et al., 2024). Workforce shortages and heavy workloads exacerbate these risks by causing fatigue, communication breakdowns, and inconsistent adherence to safety protocols. The consequences are severe: patient harm, prolonged hospital stays, rising healthcare costs, and reduced public trust. Nationally, preventable medication-related adverse events cause between 44,000 and 98,000 deaths annually in U.S. hospitals, surpassing fatalities from motor vehicle accidents (Tariq et al., 2024). Additionally, these errors negatively impact staff well-being by raising stress levels and decreasing job satisfaction. Addressing these systemic challenges is essential to fostering a culture of safety that minimizes errors and enhances outcomes.

Comprehensive Quality and Safety Plan

The following table summarizes key strategic interventions proposed to reduce medication errors at MGH:

Strategy	Description	Key Actions
Enhancing Medication Safety with BCMA	Implement Barcode Medication Administration (BCMA) technology that verifies patient identity and medication details to prevent errors (Tariq et al., 2024).	Establish BCMA policies, provide staff training, standardize safety protocols.
Integration of EHRs with Decision-Support Tools	Employ Electronic Health Records (EHRs) integrated with clinical decision support offering real-time alerts for drug interactions and dosage adjustments (Tariq et al., 2024).	Develop policies for EHR use, train staff, and ensure access to critical medication data.
Standardized Handoff Communication Protocols	Adopt structured communication tools like SBAR (Situation, Background, Assessment, Recommendation) to ensure accurate information exchange during patient handoffs (Bindra et al., 2021).	Conduct regular training, simulations, and performance evaluations.

Existing Organizational Functions, Processes, and Behaviors

Several organizational factors contribute to medication errors at MGH, including high patient loads, complex drug regimens, excessive workloads, and staffing shortages. Inefficient communication and poorly coordinated handoffs impede accurate transfer of medication information, increasing error risk (Bindra et al., 2021). The lack of integrated EHR systems with decision-support capabilities limits clinicians’ access to real-time alerts, reducing their ability to prevent errors. Insufficient structured training on medication management further compromises patient safety by failing to reinforce standardized best practices (Lou et al., 2022). Manual verification, without BCMA technology, increases risks of administration mistakes and adverse drug events.

Organizational culture plays a critical role; a culture that promotes transparency, accountability, and collaboration encourages error reporting and continuous learning without fear of punishment (Tariq et al., 2024). Conversely, a high-pressure environment with limited procedural support fosters protocol non-compliance, as currently seen at MGH.

Gaps and Uncertainties in Medication Safety at MGH

Knowledge Gap	Description
Primary contributors to medication errors	Unclear whether systemic inefficiencies or human errors are predominant causes.
Effectiveness of current training	Limited data on how well existing training reduces medication errors.
Impact of staffing shortages	Insufficient analysis on how workforce shortages affect error rates.
Integration challenges with BCMA and EHR systems	Limited insights on barriers to full adoption of BCMA and decision-support features.

Addressing these gaps through focused research and interventions is vital to improving medication safety outcomes.

Current Outcome Measures

At MGH, three key metrics will evaluate medication safety and care quality:

Outcome Measure	Purpose	Strengths	Limitations
Medication Error Rate	Quantifies the incidence of medication errors within the hospital.	Objective, data-driven, allows trend tracking.	May miss near misses or underlying causal factors.
Patient Satisfaction Scores	Reflects patients’ perceptions of medication management quality (Lee et al., 2021).	Provides insight into care experience.	Subjective; influenced by external factors unrelated to safety.
Staff Adherence to Protocols	Measures compliance with established safety procedures (Berdot et al., 2021).	Indicates procedural compliance.	Does not necessarily correlate with actual patient outcomes.

Actionable Plan to Achieve Improved Outcomes

The following outlines specific steps required to implement the proposed strategies:

Strategy	Action Steps
Enhancing Medication Safety with BCMA	– Update policies mandating BCMA usage. – Conduct regular compliance audits. – Train staff on BCMA operation. – Implement monitoring systems for error detection. – Update clinical guidelines periodically.
Integration of EHRs with Decision-Support Tools	– Revise protocols to include decision-support. – Educate staff on system utilization. – Strengthen data security. – Integrate alert notifications. – Continuously update clinical safety guidelines.
Standardized Handoff Communication Protocols	– Enforce SBAR use in all handoffs. – Incorporate SBAR training into orientation and ongoing education. – Use simulations and role-play. – Link SBAR usage to incident reporting and quality improvement. – Regularly evaluate and provide feedback.

Assumptions of the Plan

Successful implementation relies on active staff participation in training and consistent use of technological tools, supported by leadership enforcement of policies. It presumes full operational functionality and seamless integration of BCMA and EHR systems without major technical issues. The plan expects healthcare personnel to adopt standardized communication frameworks such as SBAR, with ongoing audits and feedback effectively reinforcing adherence. Finally, it assumes adequate staffing and time allocation to support these quality initiatives.

Future Vision and Nurse Leaders’ Role

MGH envisions a patient-centered culture that prioritizes safety, minimizes risks, and encourages continuous improvement. The hospital aims to optimize BCMA and EHR systems to ensure precise medication administration and facilitate comprehensive health data exchange. Standardizing communication protocols and enhancing patient safety education are central to reducing medication errors. Nurse leaders are critical agents in this transformation, providing guidance, advocacy, and leadership in safety initiatives and quality improvement (Nurmeksela et al., 2021). They exemplify best practices and motivate adherence to protocols, fostering an environment where staff confidently report errors and stay informed about evolving standards.

Furthermore, nurse leaders are essential in promoting interdisciplinary collaboration among physicians, pharmacists, and allied health professionals to prioritize patient safety. Tariq et al. (2024) emphasize that interprofessional teamwork improves communication, strengthens team dynamics, and positively affects patient outcomes. Effective nurse leadership cultivates a professional environment where all healthcare providers engage in problem-solving and continuous quality enhancement. This team-based, patient-focused approach will improve clinical results, elevate patient satisfaction, and bolster the healthcare system’s capacity to meet future challenges. It also secures the sustainability of a culture of safety and excellence.

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Conclusion

Medication errors at MGH present significant risks to patients, staff, and the institution’s reputation. Addressing these risks requires an inclusive approach integrating BCMA technology, EHR decision-support systems, and standardized communication protocols. Nurse leaders play a pivotal role in fostering a culture of safety and guiding these changes. By implementing targeted interventions and sustaining efforts in innovation, training, and quality improvement, MGH can reduce errors, enhance patient outcomes, and strengthen overall healthcare quality.

References

Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T. T. P., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Lê, L. M. M., & Sabatier, B. (2021). Effectiveness of a “do not interrupt” vest intervention to reduce medication errors during medication administration: A multicenter cluster randomized controlled trial. Bio Med Central Nursing, 20(1), 1–11. https://doi.org/10.1186/s12912-021-00671-7

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

Bindra, S., Prasher, C., Sandhu, H., & Goyal, R. (2021). An innovative communication framework (SBAR) for improving patient safety. Journal of Family Medicine and Primary Care, 10(9), 3301–3306. https://doi.org/10.4103/jfmpc.jfmpc_84_21

Lee, J., Kang, H. K., & Lee, M. (2021). The impact of patient satisfaction on medication adherence: Evidence from a cross-sectional study in a hospital setting. Patient Preference and Adherence, 15, 1039–1048. https://doi.org/10.2147/PPA.S289455

Lou, M. F., Wu, S. F. V., Lee, P. H., & Chen, S. Y. (2022). Effectiveness of educational interventions on nurses’ medication safety knowledge and practices: A systematic review and meta-analysis. Journal of Nursing Scholarship, 54(3), 345–354. https://doi.org/10.1111/jnu.12746

Nurmeksela, R., Stolt, M., Suhonen, R., & Leino-Kilpi, H. (2021). Nurse leadership and patient safety culture: A scoping review. Journal of Nursing Management, 29(7), 1849–1862. https://doi.org/10.1111/jonm.13274

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

Tariq, A., Walker, S., Babar, Z. U. D., & Lee, K. K. (2024). Medication errors and patient safety: A global perspective. International Journal of Health Sciences, 18(1), 25–35. https://doi.org/10.34172/ijhs.2024.004