NURS 4020 Assessment 1 & 2 Sample Papers

NURS 4020 Assessment 1 & 2 Sample Papers

NURS 4020 Assessment 1 & 2 Sample Papers

Enhancing Quality and Safety

Introduction

People seek medical attention in hospitals and other healthcare facilities as they know that they are safe there and cannot experience any harm. Hospitals and healthcare professionals have the mandate of ensuring the safety of the patients at all costs. According to the World Health Organization (2017), patient safety is a fundamental aspect of healthcare. Any event that impacts the quality of care and safety of the patients can have very serious and costly consequences for both healthcare facilities and patients. Medication errors are among the most preventable cause of death in the US. According to Cloete (2015), they are also one of the most common causes of unintended harm to patients in healthcare facilities. There are various causes of medication errors and they all contribute towards making a healthcare facility an unsafe environment for patients. Therefore, it is imperative that healthcare institutions identify the probable causes of medication errors and implement an effective quality improvement plan. NURS 4020 Assessment 1 & 2 Sample Papers

Causes of Medication Errors

There are various causes of medication errors in a healthcare facility. They include things like exhaustion on the part if the healthcare professionals. According to Majeed (2017), there is a shortage of healthcare professionals in the US and that number is set to grow over the coming years. Shortage of healthcare workers have various impacts on healthcare delivery and the quality of care within a healthcare facility. For instance, such a shortage would result in a large number of patient that very few healthcare workers would have to attend to at any given time. This would overburden and exhaust the workers as they would have to work multiple shifts or long hours. As a result, they would be prone to making mistakes during the administration of medication as they might read the wrong things, fail to examine the medical history of the patients, and might also fail to assess the effect that the medication might have on the patients and the reaction. Administering medication is a very sensitive process that requires the utmost competence and concentration as any mistake can have dire consequences and can even cost the life of the patient.

Medication errors can also occur when the healthcare professionals do not observe the various safety protocols and systems in place to ensure that they do the right thing. One safety protocol in place is the five rights of medication administration. According to Blignaut et al. (2017), these five rights includes administering the right medication, in the right dose, to the right patient, at the right time through the right route. Many of the medication errors that occur usually involve the administration of the wrong dosage among other things.

As earlier stated, system level failures like shortages in healthcare workers and even things like poor management, and poor equipment design can also result in medication errors. Communication plays a major role in healthcare facilities as it allows various healthcare professionals to assist in the management of a patient. Any gaps in the system of communication can result in medication errors.

Evidence-Based and Best Practice Solutions

There are various strategies that can improve patient safety and help reduce medication errors. These strategies include things like having adequate healthcare staffs in the healthcare facilities. Adequate staffing will help achieve economic and clinical improvement when it comes to patient care as it would enhance patient satisfaction and serve to decrease and even prevent medication errors. Marznaki et al. (2020) lists understaffing as one of the various causes of medication errors. Sufficient staffing can improve workflows, reduce burnout, workload, and turnover rates.

Another strategy is to implement the use of information technology systems that will serve to reduce medication errors. These technology systems include the use of Computerized Physician Order Entry Systems and Automated Medication Dispensing Systems among other things. According to Risor et al. (2016), automated technologies are an effective strategy of reducing medication error rates. These technologies have various capabilities such as packing medication in multidose or unit dose bags for various individual patients among other things.

Effective medication reconciliation in healthcare settings during transfer and discharge of patients, admission can help reduce medication errors. Errors can occur during these processes and failure to reconcile the processes can lead to miscommunication and increased risks. According to Rose et al. (2017), medication reconciliation is a significant focus of quality measurement activities. The Joint Commission has provisions that require healthcare professionals to reconcile the medication of the patients at each visit.

Stakeholders

Patient safety is paramount when it comes to healthcare delivery in healthcare facilities. Each healthcare professional has a vital role to play in ensuring the overall safety of the patients while in healthcare facilities. The nurse is the primary person when it comes to the delivery of healthcare. They are with the patients at every process and stage of healthcare and thus play an important role in driving quality improvement initiatives. The nurses collaborate with other healthcare professionals in the delivery of quality and patient centered care. Nursing educators, healthcare administrators, and other professional associations work together with nurses to provide the nurses with the various resources that they require to ensure patient safety and quality of care. The stakeholders involved in patient safety therefore include society in general, patients, healthcare professionals, healthcare administrators, nurse educators, and professional associations.

Conclusion

Hospitals and healthcare professionals have the mandate of ensuring the safety of the patients at all costs. Patient safety is a fundamental aspect of healthcare. Medication errors are among the most preventable cause of death in the US. There are various causes of medication errors in a healthcare facility. There are various strategies that can improve patient safety and help reduce medication errors. There are various strategies that can improve patient safety and help reduce medication errors. These strategies include things like having adequate healthcare staffs in the healthcare facilities. Each healthcare professional has a vital role to play in ensuring the overall safety of the patients while in healthcare facilities. The stakeholders involved in patient safety therefore include society in general, patients, healthcare professionals, healthcare administrators, nurse educators, and professional associations. NURS 4020 Assessment 1 & 2 Sample Papers

References

Blignaut, A. J., Coetzee, S. K., Klopper, H. C., & Ellis, S. M. (2017). Medication administration errors and related deviations from safe practice: an observational study. Journal of clinical nursing, 26(21-22), 3610-3623.

Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1).

Majeed, A. (2017). Shortage of general practitioners in the NHS.

Marznaki, Z. H., Pouy, S., Salisu, W. J., & Zeydi, A. E. (2020). Medication errors among Iranian emergency nurses: A systematic review. Epidemiology and Health, 42.

Risør, B. W., Lisby, M., & Sørensen, J. (2016). An automated medication system reduces errors in the medication administration process: results from a Danish hospital study. European Journal of Hospital Pharmacy, 23(4), 189-196.

Rose, A. J., Fischer, S. H., & Paasche-Orlow, M. K. (2017). Beyond medication reconciliation: the correct medication list. Jama, 317(20), 2057-2058.

World Health Organization. (2017). Patient safety: making health care safer (No. WHO/HIS/SDS/2017.11). World Health Organization. NURS 4020 Assessment 1 & 2 Sample Papers

Root-Cause Analysis

Healthcare and medicine are some of the most vital aspects and components of human life. People get sick and they seek treatment from the various healthcare facilities within their area of residence. Some might need specialized care. However, there are some instances where the healthcare facilities and the various healthcare professionals can experience errors that affect the patients. In the recent past, Clarion Court Nursing Facility has experienced an increase I n the number of medication errors that occur within the facility. Some cases are serious in that they result in the overdosing of the patients which has the potential to become fatal. Completing a root cause analysis can help in identifying the causes behind the medication errors and also help in devising and implementing an improvement plan to improve the safety of the patients in the facility. A root cause analysis serves to identify areas that need improvement in terms of patient safety (Haxby & Shuldham, 2018).

Analysis of the Root Cause

The nursing professionals at the healthcare facility comprise of CNAs, LPNs, and RNs. There are specific nursing professionals who have the obligation or mandate of delivering the medication to the patients. In the last year, there has been a significant rise in the number of medication errors in the care facility. One case saw a patient overdose that can have devastating effects for all the parties involved. Such incidences have warranted the application of a root cause analysis to improve patient safety in the care institution.

According to the World Health Organization (2016), medication errors refer to any avoidable and preventable event that has the potential to result to inappropriate medication that might cause patient harm while the medication is in the control of the consumer, patient, or healthcare professional. The organization further explains that the events can relate to the method of medication prescription, the healthcare products, professional practice among other things. The healthcare professionals working in the healthcare facility discovered the near overdose during a bedside shift change. The nurse that took over the shift discovered that the patient was unresponsive to the attempts of the nurse to arouse him. After extensive investigation into the issue, the discovery was that the patient had received an extra dose of oxycodone. The interim nurse had administered pain medication after the patient requested for it as he was in pain.

Unfortunately, the interim nurse did not did not document the administered medication. The primary nurse assigned to the patient on the other hand was on a lunchbreak and upon returning to the patient, administered another dose at the request of the patient who has dementia. The request was not less than an hour later after the first administration. According to Makary and Daniel (2016), it is not possible to completely eliminate human error, however, the relevant people and authorities can study the problem and develop a safer system of doing things.

The root cause analysis conducted in the institution sought to identify the recent increase in medication errors. The main objective of the analysis was to understand why the medication errors have been on the rise and identify the issues that cause the medication errors.

The person in charge of conducting the analysis interviewed the various nurses in the facility from different shifts. They obtained important information from the interviews that contributed or served to explain the rise in the medication errors. Some of the information that came up from the interviews include things such as poor listening among the nursing staff. Another thing is that there is a high rate of turnover in the facility and the new employees are not conversant with the residents in the facility. Another observation was that the charting system in use in the facility is challenging to use and causes some of the nurses that have not mastered its use to fall behind.

Communication is also an issue in the organization with the LPNs stating that there is lack of proper communication that leads to some not having all the necessary information on a patient. A response from the RNs showed that it was difficult finding a balance between meeting the needs of the patients, keeping up with their various duties and following the appropriate protocol. The interviews also indicated that the staff feel that the facility does no have the appropriate number of employees, leaving the ones that are currently there feeling overburdened, overworked, and exhausted. All these are some of the factors that can result in medication errors in healthcare facilities. According to Tawfik et al. (2018), all the identified factors are independently associated with significant medical errors.

Evidence from research indicates that there are a lot of factors that can result in medical errors. These factors include things such as medications having improper labels, poor communication on the part of the healthcare professionals working on a specific case, distractions, exhaustion, and missing patient information among others. In this case, the cause of the medication error was lack of proper communication and documentation on the part of the nurses assigned to the resident. The primary nurse was unavailable when the patient required pain medication. As a result, the interim nurse who was still getting familiar with the various processes administered the medication and failed to document it on the patient chart. The primary nurse upon arrival administered the same dose as requested by the patient who has dementia and has no recollection of receiving the medication earlier.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Understaffing, poor communication, unfamiliarity with eh residents, and large patient to nurse ratios were the main factors that contributed to the increase in medication errors and near patient overdoes in the facility. These factors all pose various patient safety concerns. Many of these errors occurred in cases involving patients with cognitive impairments.

There are various strategies that the facility can put in place to address the issue of medication errors. The improvement plan should include things such as putting in place an automated medication dispensing machine. According to Risør et al. (2018), automated medication dispensing machines have the potential to greatly reduce medication errors. It also serves to improve patient safety. Another alternative that can be combined with the automated medication dispensing machines is barcode scanning of the medication. Nurses that fail to scan the medication will be liable and face disciplinary actions as the facility will monitor the scans. The facility can also create a quality improvement program that will comprise of the various nurses in the facility, the charge nurse, and the director of nursing. These members will meet regularly and strategize on the various ways that they can improve patient safety and quality of care. Implementing an SBAR tool would help address the issue of communication as it would offer immediate access to relevant patient information. According to Stewart (2016), the tool enables all users to communicate through a common structure. Finally, the improvement plan should also include a strategy on how to increase the staff numbers to better accommodate the number of residents in the facility to reduce exhaustion and large patient to nurse ratios.

Existing Organizational Resources

Some of the resources that the organization requires include state of the art technology, more human resources within the facility among other things. However, the facility already has some resources that it can leverage to ensure that the improvement plan is a success. For instance, the facility has various nursing professional that can e a part of the quality improvement team. It can set aside a room within the facility that will serve as a meeting place for the team where they can meet and hold discussions to try and find a way forward. The facility will require additional resources such as stationery and projectors for the meetings as well as hiring additional staff among other things.

Conclusion

Medication errors are a common but a highly preventable issue in the US medical system. There are various factors that lead to medication errors and they include things like understaffing, poor communication among other things. Conducting a root cause analysis can help a healthcare facility identify the factors and develop an appropriate improvement plan.

References

Haxby, E., & Shuldham, C. (2018). How to undertake a root cause analysis investigation to improve patient safety. Nurs Stand, 32(20), 41-46. NURS 4020 Assessment 1 & 2 Sample Papers

Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. Bmj, 353.

Risør, B. W., Lisby, M., & Sørensen, J. (2018). Complex automated medication systems reduce medication administration errors in a Danish acute medical unit. International Journal for Quality in Health Care, 30(6), 457-465.

Stewart, K. R. (2016). SBAR, communication, and patient safety: an integrated literature review.

Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., … & Shanafelt, T. D. (2018, November). Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. In Mayo Clinic Proceedings (Vol. 93, No. 11, pp. 1571-1580). Elsevier.

World Health Organization. (2016). Medication errors. World Health Organization. NURS 4020 Assessment 1 & 2 Sample Papers.