NURS FPX 4020 Assessment 4
Name: Capella University
NURS FPX 4020
May 2023
Improvement Plan Tool Kit
Drug management and medication mistakes are regarded as bad disparities in patient’s well-being and healthcare organizations. It has been studied that immense time and financial resources are spent to resolve the medication mistakes. In the United States, all hospitals spend about 15% of their resources which make $42 billion of revenue on resolving medication mistakes (Mohiuddin, 2019). All healthcare workers particularly nurses have a significant role in avoiding these medication mistakes. By strengthened collaboration between nurses and pharmacists, disparities in medication mistakes can be reduced (Dilles et al., 2021). The goal of this report is to present an ordered information on avoiding medication mistakes. The updated data and information regarding avoidance of medication mistakes is presented by annotated bibliography which will assist in developing a successful improvement plan tool kit.
NURS FPX 4020 Assessment 4
Annotated Bibliography
Elements of Successful Quality Initiative
McDerby, N., Kosari, S., Bail, K., Shield, A., Peterson, G., & Naunton, M. (2019). The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial. Journal of Clinical Pharmacy and Therapeutics, 44(4), 595–602. https://doi.org/10.1111/jcpt.12822
This paper targets on assessing the effect of on-site pharmacists on medication management applications and data recording in Residential Aged Care Homes (RACH). The results of the research study infer that presence of pharmacists at RACH reduced medication errors, enhanced documentation, improved the medication management and decreased the overall time spent on medication management.
This research study took place in two RACH centers for six months in which one Residential Care Pharmacists (RCP) was employed in one center. All documentation regarding medication administration, allergies and adverse medication incidents was done before and and after the employment of a pharmacist.
The results of this study show that there is a notable reduction in rate of inappropriate medication dosage from 24% to 0%. The total time for medication administration per patient also reduced to 3.2 minutes from 4.8 minutes. The documentation about allergies and adverse drug reactions (ADRs) was enhanced from 77% to 100%. Moreover, the average medication incident report on monthly basis was increased to 25.7 from 13.3. Whereas, the control site i.e. one RACH center did not show any changes or outcomes. This research study shows enhanced medication management and data recording after employing pharmacists at RACH centers. It has decreased the overall staff time spent on each round and also improved the documentation of allergies and adverse drug reactions.
Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2020). A Systems Approach to Analyzing and Preventing Hospital Adverse Events. Journal of Patient Safety, 1. https://doi.org/10.1097/pts.0000000000000263
This research study highlights the importance of patient safety in healthcare system. 1999’s report of Institute of Medicine tells that though there are many efforts made to improve the patient safety but still the enhancements made for decreasing the adverse medication events are limited.
This study recommends the implementation of systems approaches like aviation and submarine industries for reducing adverse medication incidents in healthcare settings. The adverse incidents and bad events in a healthcare setting are because of shortcomings and flaws in overall system structure rather than individualistic errors. For prevention of medication errors and improving patient’s safety, this study suggests alteration in healthcare design and system. It also highlights the significance of learning from past adverse incidents and determines the gaps and system flaws through an in-depth investigation. It denounces the heterogeneity in present root-cause evaluation of the healthcare system and recommends a systematic-theoretic accident evaluation that will target at investigating the system’s functions and determine the shortcomings of the system control design. Causal Analysis based on System Theory (CAST) method is a systematic theoretic casual evaluation which interrogates the adverse medication incidents occurring in healthcare organizations. In this study, the CAST method is applied to identify adverse medication mistakes in cardiac surgeries. It has analyzed design flaws, individual behavior, and role of strong communication in safety control systems. It shows that there is a need for a system approach, identification of design flaws and process alterations to enhance patient’s safety in healthcare settings.
Factors Leading to Patient Safety Risks with Specific Examples
Rangachari, P., & L. Woods, J. (2020). Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers. International Journal of Environmental Research and Public Health, 17(12), 4267. https://doi.org/10.3390/ijerph17124267
COVID-19 was a stressful time for all healthcare workers in which besides dealing with the patients, they had to deal with shortages of PPEs and resources. It has increased the anxiety and exhaustion among the healthcare providers. The increased work-burden and shortages of healthcare workers had put an immense stress on ICU staff. ICU staff reported increased medication mistakes and risks to the patient’s safety due to weak communication and stress. For providing worker’s support, many healthcare organizations have opted for a stoic approach. In a stoic approach, there was no supplementary assistance other than the state and federal policy legislatures for the liability of healthcare providers.
It is important for the healthcare organizations (HCO) to consider the workers’ psychological safety. Without considering the stress during pandemic on healthcare workers, organizational safety, patient protection and staff resilience can be affected even after the pandemic. There is a need to develop strong communication systems to learn from individual solving approaches for avoiding issue recurrence, decrease intervention differences, guarantee patient’s safety and ensure enhancements.
Garcia, C., Abreu, L., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicina, 55(9), 553. https://doi.org/10.3390/medicina55090553
This research article discusses the relationship between healthcare workers’ burnout and patient safety. In a healthcare setting, medication mistakes and adverse medical events are notable issues which cause many patient’s deaths each year. This study has evaluated the relationship between burnout syndrome and patient’s well-being protection. Using the PRISMA standard, the research study conducted meta-analyses and systematic study. The data for this study was extracted from research repositories like PubMed, GoogleScholar and Web of Science. These were cross-sectional studies which aimed at physicians and nurses in Europe and the US.
The meta-analysis results show that there exists a significant association between patients’ safety and healthcare workers. The results show that there exists a negative correlation between increased burnout rate among healthcare workers and patient’s safety. By reducing patient’s safety, the probability of medication and clinical errors increase. Other associated factors to reduce patient safety are work burden, decreased organizational support and poor working environment.
Burgener, A. M. (2020). Enhancing Communication to Improve Patient Safety and to Increase Patient Satisfaction. The Health Care Manager, 39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298
This research article elaborates the significance of strong healthcare communication and its effect on patient’s safety and contentedness. The article discusses different communication guidelines and approaches for enhanced communication in healthcare organizations.
Situation-Background-Assessment-Recommendation (SBAR) is a framework which tells communication guidelines for healthcare workers to communicate during shift hours and interprofessional rounds.It standardizes the communication, improves stability in the shift hours and decreases patient examination time.
In nurse handover, it is important to transfer the patient’s healthcare information to the nurses to maintain continuous care provision. Communication can be enhanced and risk to the patient’s care can be reduced significantly by providing sufficient training and handovers.
Acknowledge-Introduce-Duration-Explain-Thank (AIDET) is a framework which ensures strong communication among healthcare workers, patients and their families. It assists in strengthening the relationship, reducing anxiety and increasing the patient’s contentedness.
Online Virtual Clinical Simulations assist in improving and teaching communication skills to the nursing students through different interactive activities and simulations.
Interdisciplinary Communication Training Simulation aids in enhancing the interprofessional communication through different training designs i.e., 3P model enhances communication among nursing and medical students. These interdisciplinary communication models focus on teamwork, performance and patient’s safety.
NURS FPX 4020 Assessment 4
Organizational Interventions to Promote Patient Safety
Gray, P., Senabe, S., Naicker, N., Kgalamono, S., Yassi, A., & Spiegel, J. M. (2019). Workplace-Based Organizational Interventions Promoting Mental Health and Happiness among Healthcare Workers: A Realist Review. International Journal of Environmental Research and Public Health, 16(22), 4396. https://doi.org/10.3390/ijerph16224396
Mental illness seriously affects the workability of the healthcare workers at a workplace. Healthcare workers face extreme mental illness and stress due to workload, stress, burnout and violence which negatively impacts the patient’s safety and provision of healthcare services. This research study focuses on exploring the workplace-focused treatments to enhance mental health and psychological well-being of the healthcare workers at organizational level. It focuses on development of organizational, leadership and management skills. It suggests that limited attention is given to the mental health and psychological well-being which immensely impacts the work-productivity of healthcare workers. Patient’s safety is at high risk when healthcare workers’ mental health is suffering.
Grossman, L. V., Masterson Creber, R. M., Benda, N. C., Wright, D., Vawdrey, D. K., & Ancker, J. S. (2019). Interventions to increase patient portal use in vulnerable populations: a systematic review. Journal of the American Medical Informatics Association, 26(8-9), 855–870. https://doi.org/10.1093/jamia/ocz023
This systematic review aims to evaluate the effect of interventions on decreasing the discripencies in use of patient portals among vulnerable communities. Use of patient portals can notably reduce the probability of medication mistakes, enhance decision making skills and improve patient’s health results. For increasing the portal use among patients; training and technical assistance programs are extremely important. However discrepencies in use of patient’s portal can increase healthcare inequalities and prevent population from taking benefits.
DeChant, P. F., Acs, A., Rhee, K. B., Boulanger, T. S., Snowdon, J. L., Tutty, M. A., Sinsky, C. A., & Thomas Craig, K. J. (2019). Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(4), 384–408. https://doi.org/10.1016/j.mayocpiqo.2019.07.006
Healthcare workers face extreme burnout rates and exhaustion due to immense workload and pressure. In such a situation, organizational interventions play a significant role to reduce the burnout rate and increase patient’s safety. The past decade has been marked with studying the organizational-centric interventions for improving teamwork to enhance patient’s care, strengthen professional development and reduce workloads. Use of technological tools i.e., telehealth and EHR can reduce workload, improve scheduling and reporting in a healthcare organization. Leadership support, aligning the workflow and reduction of management load by EHR can improve burnout rates which can enhance patient’s safety.
Role of Nurses in Care
Brooks Carthon, J. M., Hatfield, L., Plover, C., Dierkes, A., Davis, L., Hedgeland, T., Sanders, A. M., Visco, F., Holland, S., Ballinghoff, J., Del Guidice, M., & Aiken, L. H. (2019). Association of Nurse Engagement and Nurse Staffing on Patient Safety. Journal of Nursing Care Quality, 34(1), 40–46. https://doi.org/10.1097/NCQ.0000000000000334
The research study focuses on assessing the relationship among staffing, nurses’ involvement and patient’s safety. 26,960 feedback survey forms were collected by nurses of 599 hospitals. The data was evaluated by Logistic Regression Model. The results show that almost 23% of the nurses gave a poor grade to the patient’s safety in their hospital. Healthcare organizations where nurses’ engagement rate was higher showed lesser probability of medication mistakes and increased patient’s safety. Appropriate nursing staffing and engagement ensure patient’s safety.
Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15. https://doi.org/10.3390/ijerph17062028
This research study shows that there are several individualistic and systemic factors which affect the nurses’ care interventions and their commitment to the patient’s safety guidelines. The parameters which improve the nurses’ role in a healthcare organization are improved nurses’ knowledge, strong communication, decreased work burden and implementation of standardized care protocols.
Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse-patient communication and patient satisfaction from nursing care. Nursing Open, 6(3), 1189–1196. https://doi.org/10.1002/nop2.316
Effective and professional communition between nurses and patients is important for patient’s safety and patient satisfaction. The results of the research study shows that there is a strong correlation between nurse-patient communication and patient’s satisfaction. Strenghtened communication between patients and nurses reduce medication errors. There is a need of proper nurses’ training and acquitance of communication skills for increasing patient’s care and satisfaction.
Di Muzio, M., Dionisi, S., Di Simone, E., Cianfrocca, C., Di Muzio, F., Fabbian, F., Barbiero, G., Tartaglini, D., & Giannetta, N. (2019). Can nurses’ shift work jeopardize the patient safety? A systematic review. European Review for Medical and Pharmacological Sciences, 23(10), 4507–4519. https://doi.org/10.26355/eurrev_201905_17963
Nurses are key players in providing patient’s care and ensuring patient’s safety. Almost 40% of the nurses work responsibility is comprised of medication management. The factors which can cause medication mistakes by nurses are fatigue, exhaustion, workload, night shifts and workflow disruptions. It is important to decrease the workload on nurses for decreasing their stress and burnout particularly during night shifts. This will decrease the probability of medication errors and increase patient’s safety.
References
Brooks Carthon, J. M., Hatfield, L., Plover, C., Dierkes, A., Davis, L., Hedgeland, T., Sanders, A. M., Visco, F., Holland, S., Ballinghoff, J., Del Guidice, M., & Aiken, L. H. (2019). Association of Nurse Engagement and Nurse Staffing on Patient Safety. Journal of Nursing Care Quality, 34(1), 40–46. https://doi.org/10.1097/NCQ.0000000000000334
Burgener, A. M. (2020). Enhancing Communication to Improve Patient Safety and to Increase Patient Satisfaction. The Health Care Manager, 39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298
DeChant, P. F., Acs, A., Rhee, K. B., Boulanger, T. S., Snowdon, J. L., Tutty, M. A., Sinsky, C. A., & Thomas Craig, K. J. (2019). Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(4), 384–408. https://doi.org/10.1016/j.mayocpiqo.2019.07.006
Di Muzio, M., Dionisi, S., Di Simone, E., Cianfrocca, C., Di Muzio, F., Fabbian, F., Barbiero, G., Tartaglini, D., & Giannetta, N. (2019). Can nurses’ shift work jeopardize the patient safety? A systematic review. European Review for Medical and Pharmacological Sciences, 23(10), 4507–4519. https://doi.org/10.26355/eurrev_201905_17963
Dilles, T., Heczkova, J., Tziaferi, S., Helgesen, A. K., Grøndahl, V. A., Van Rompaey, B., Sino, C. G., & Jordan, S. (2021). Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes. International Journal of Environmental Research and Public Health, 18(11), 5973. https://doi.org/10.3390/ijerph18115973
Garcia, C., Abreu, L., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicina, 55(9), 553. https://doi.org/10.3390/medicina55090553
Gray, P., Senabe, S., Naicker, N., Kgalamono, S., Yassi, A., & Spiegel, J. M. (2019). Workplace-Based Organizational Interventions Promoting Mental Health and Happiness among Healthcare Workers: A Realist Review. International Journal of Environmental Research and Public Health, 16(22), 4396. https://doi.org/10.3390/ijerph16224396
Grossman, L. V., Masterson Creber, R. M., Benda, N. C., Wright, D., Vawdrey, D. K., & Ancker, J. S. (2019). Interventions to increase patient portal use in vulnerable populations: a systematic review. Journal of the American Medical Informatics Association, 26(8-9), 855–870. https://doi.org/10.1093/jamia/ocz023
Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2020). A Systems Approach to Analyzing and Preventing Hospital Adverse Events. Journal of Patient Safety, 1. https://doi.org/10.1097/pts.0000000000000263
Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse-patient communication and patient satisfaction from nursing care. Nursing Open, 6(3), 1189–1196. https://doi.org/10.1002/nop2.316
McDerby, N., Kosari, S., Bail, K., Shield, A., Peterson, G., & Naunton, M. (2019). The effect of a residential care pharmacist on medication administration practices in aged care: A controlled trial. Journal of Clinical Pharmacy and Therapeutics, 44(4), 595–602. https://doi.org/10.1111/jcpt.12822
Mohiuddin, A. (2019). Patient Safety: A Deep Concern to Caregivers. INNOVATIONS in Pharmacy, 10(1), 7. https://doi.org/10.24926/iip.v10i1.1639
Rangachari, P., & L. Woods, J. (2020). Preserving Organizational Resilience, Patient Safety, and Staff Retention during COVID-19 Requires a Holistic Consideration of the Psychological Safety of Healthcare Workers. International Journal of Environmental Research and Public Health, 17(12), 4267. https://doi.org/10.3390/ijerph17124267
Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15. https://doi.org/10.3390/ijerph17062028
