Assignment: Improving Quality Care and Patient Safety

Assignment: Improving Quality Care and Patient Safety

Assignment: Improving Quality Care and Patient Safety

For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.

As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.

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The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel & Wright, 2018).

As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.

You are encouraged to explore the AONE Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONE Nurse Executive Competencies—especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.

Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
Explain the need and process to improve safety outcomes related to medication administration.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).
Reference
Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic & Neonatal Nursing​, 47(3), s16–s17.

Professional Context
As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group. Preparing to run an in-service may be daunting, as the facilitator must develop his or her message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove him- or herself a valuable resource to others.

Scenario
For this assessment it is suggested you take one of two approaches:

Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, or
Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.
Instructions
The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.

Be sure that your presentation addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
Explain the need for and process to improve safety outcomes related to medication administration.
Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.
There are various ways to structure an in-service session; below is just one example:

Part 1: Agenda and Outcomes.
Explain to your audience what they are going to learn or do, and what they are expected to take away.
Part 2: Safety Improvement Plan.
Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
Explain why it is important for the organization to address the current situation.
Part 3: Audience’s Role and Importance.
Discuss how the staff audience will be expected to help implement and drive the improvement plan.
Explain why they are critical to the success of the improvement plan focusing on medication administration.
Describe how their work could benefit from embracing their role in the plan.
Part 4: New Process and Skills Practice.
Explain new processes or skills.
Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
Part 5: Soliciting Feedback.
Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
Explain how you might integrate this feedback for future improvements.
Remember to account for activity and discussion time.

For tips on developing PowerPoint presentations, refer to:

Capella University Library: PowerPoint Presentations.
Guidelines for Effective PowerPoint Presentations [PPTX].
Additional Requirements
Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be at least 10 slides and no more than 15 slides (not including the title, conclusion, or references slides).
Speaker notes: Speaker notes (located under each slide) should reflect what you would actually say if you were delivering the presentation to an audience. This presentation does NOT require audio or a transcript. Another presenter would be able to use the presentation by following the speaker’s notes.
APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.
Number of references: Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.

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NURS-FPX4020: Improving Quality Care and Patient Safety

Root-Cause Analysis and Safety Improvement Plan

Root-cause analysis (RCA) refers to measures, tools, and approaches used to reveal the causes of problems. It entails unearthing the root causes of problems to establish appropriate solutions. An RCA of medication errors was conducted in a care home. The purpose of this paper is to examine the RCA in medication errors, discuss evidence-based and best practice interventions to address the issue, and outline a safety improvement plan.

Analysis of the Root Cause

Medication errors were the identified patient safety problem in the care home facility. Elderly patients encounter unique issues associated with medication errors. Besides, patients in care homes are usually frail with multiple illnesses and are often on multiple medications. Medication administration in this setting is usually different from that in the patients’ homes since it is provided by nurses or other healthcare providers. “This raises various issues around drug dispensing, administration and monitoring” (Manias et al., 2020). The RCA has been driven after various reports of medication errors in the care home caused by nurses failing to uphold the five rights of drug administration: right patient, right medication, right dose, right time, and right route. The unit supervisors detected the problem after noting an increased incidence of adverse drug reactions related to patients being administered the wrong drug, dose, and through the wrong routes.

The medication errors in the care home have affected the elderly patients in the care home as they have led to undesirable health outcomes like adverse drug reactions, drug-drug interactions, and allergic reactions, which led to prolonged patient stays. In addition, “the errors have lowered patients’ quality of life due to adverse outcomes and have led to a negative patient experience” (Manias et al., 2020). Medication errors have had considerable economic consequences on patients since they lead to increased healthcare costs caused by prolonged hospitalization, increased utilization of health services, and preventable medication error-related hospital admissions.

Medication errors caused by wrongful administration were not supposed to occur if the nurses followed the five rights of drug administration. However, the issue is likely more pronounced in the elderly because of multiple risk factors, especially polypharmacy. Environmental factors that influence medication errors include high nursing workload and time pressures. “Nurses in the care home reported being understaffed, overworked, and having insufficient time to adequately attend to a single patient during medication administration” (Manias et al., 2020). Besides, nurses reported various distractions and interruptions from colleagues and patients, which creates room for medication errors since nurses do not fully concentrate during the drug administration process. Poor physical work environments, especially with lighting and temperature, were reported in some units.

Human factors contributing to medication errors include inadequate therapeutic training and drug knowledge and experience, especially among new graduate nurses. This has contributed to dose miscalculations resulting in wrong dosages that cause adverse drug effects. Nurses reported being overworked and experiencing fatigue and burnout, which led to physical and emotional health problems and reduced quality of patient care. In addition, poor communication between health care providers and patients may have contributed to medication errors. Low literacy levels and language barriers in patients contribute to communication barriers resulting in medication errors.

Application of Evidence-Based Strategies

Evidence-based strategies that have been effective in reducing medication errors include the adoption of CPOE, an Automated drug distribution system, pharmacist partnership, prescriber education, and medication reconciliation. “One evidence-based strategy for reducing medication administration errors is strengthening electronic prescribing and alert systems” (Mutair et al., 2021). Computerized provider order entry (CPOE) with decision support may be remarkably effective since it potentially helps prevent inappropriate medication prescribing. It is designed to decrease the alert burden by focusing on clinically-relevant warnings. Manias et al. (2020) found that CPOE and adopting an automated drug distribution system reduced medication administration errors as single measures. CPOE with a clinical decision support system helps to reduce prescribing errors like prescribing contraindicated medications.

Pharmacist partnership with prescribing clinicians also reduces medication errors and length of hospitalization. This is because pharmacists are well-positioned to work collaboratively with the medical team to evaluate medication therapy during patient admission. Manias et al. (2020) also established that combined approaches that included CPOE, prescriber education and interdisciplinary collaboration effectively reduced prescribing errors. In addition, combined interventions that comprised automated drug distribution and utilizing the electronic medical record or pharmacist-led medication reconciliation and prescriber education effectively alleviated drug administration errors. Prescriber education involves educating primary care providers on the common causes of medication errors. Besides, “they should be provided with simple tools to help them in safe drug prescribing and use” (Mutair et al., 2021). Providers are also encouraged to consider how patients can actively participate in medicine management to reduce medication errors in the home setting.

 Medication reconciliation is vital in the care of hospitalized patients and those in care homes and promotes a safe transition to other care settings. Kreckman et al. (2018) found that medication reconciliation using a transition of care team reduced the number of medications with errors during hospital admission, discharge, and follow-up visit. Medication reconciliation is usually effective if the pharmacists actively review prescriptions and when clinicians are encouraged and supported to use medication reconciliation.

Improvement Plan with Evidence-Based and Best-Practice Strategies

The proposed safety improvement plan to reduce medication errors in the care home is computerized medication reconciliation. “Medication reconciliation is a process that involves comparing a patient’s medication list with the prescribing physicians to ensure accuracy of drug type, frequency, dose, and route of medication during hospital admission, transfer, and discharge and decrease medication errors” (Tamblyn et al., 2019). “The Joint Commission included medication reconciliation into a National Patient Safety goal. It requires healthcare organizations to maintain and convey accurate drug information and compare the drug information the patient brings into the hospital with the drugs ordered for the patient by the hospital to identify and address discrepancies” (Kreckman et al., 2018). Since most medication errors occur at care transition points, the care home will have a computerized medication reconciliation to reconcile medication lists during admission, transfer, and discharge of patients, which is a critical step in improving patient safety.

During the admission of every patient, nurses will carry out a two-step verification of prescribed medications, update the EMR, and inform the physician to sign off on the list. At discharge, drugs will be reconciled in the care home, and ambulatory records will be forwarded to the patient’s provider. “During follow-up visits, a nurse and physician will verify the medication list” (Kreckman et al., 2018). Nurses will kick off the ambulatory medication reconciliation at admission, review the list within 24 hours of discharge, and attend the follow-up visit to ensure continuity of care. The goal is to improve medication reconciliation and reduce medication errors.

Existing Organizational Resources

The available organizational personnel and resources that would enhance the implementation of the computerized medication reconciliation plan include nurses, physicians, pharmacists, and the hospital’s drug information system. “The nurses, physicians, and pharmacists will be involved in medication reconciliation and resolve any issues identified in the reconciliation process” (Ceschi et al., 2021). The drug information system will help in grouping drugs by their pharmacologic class and display them as per their clinical importance. This will decrease the cognitive load on the providers while reconciling drugs.

Conclusion

Patients in care homes are usually frail with multiple illnesses and are often on multiple medications, which increases their risk of medication errors. Medication errors at the care home have led to poor health outcomes among elderly patients due to adverse drug reactions, drug-drug interactions, and allergic reactions, which result in prolonged patient stays and high healthcare costs. Environmental, human, and communication factors were identified as contributing factors to medication errors. Various studies recommend implementing provider education, computerized systems, medication reconciliation, and the involvement of pharmacists. Computerized medication reconciliation is the proposed safety improvement plan to reduce medication errors in the care home at admission, discharge, and follow-up of patients.

References

Ceschi, A., Noseda, R., Pironi, M., Lazzeri, N., Eberhardt-Gianella, O., Imelli, S., … & Ferrari, P. (2021). Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical trial. JAMA network open, 4(9), e2124672-e2124672. https://doi.org/10.1001/jamanetworkopen.2021.24672

Kreckman, J., Wasey, W., Wise, S., Stevens, T., Millburg, L., & Jaeger, C. (2018). Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team. BMJ open quality, 7(2), e000281. https://doi.org/10.1136/bmjoq-2017-000281

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Therapeutic Advances in Drug Safety. https://doi.org/10.1177/2042098620968309

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel, Switzerland), 8(9), 46. https://doi.org/10.3390/medicines8090046

Tamblyn, R., Abrahamowicz, M., Buckeridge, D. L., Bustillo, M., Forster, A. J., Girard, N., … & Winslade, N. (2019). Effect of an electronic medication reconciliation intervention on adverse drug events: a cluster randomized trial. JAMA network open, 2(9), e1910756-e1910756. https://doi.org/10.1001/jamanetworkopen.2019.10756