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NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan CM

Elements of a successful Quality Improvement Initiative

NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan CM

NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan CM

As America’s aging population grows so does the need for a focus on age friendly health care. Patient safety and safe medication administration can vary greatly for the older population than that of the younger generation. For example: as we age our body’s natural ‘flushing system’ slows down giving medications a chance to build up rather than break down thus increasing the risk of morbidity and mortality for the elder. High risk medication and other medication risk such as, medication interactions and unnecessary medications can be identified and eliminated with careful management of the interdisciplinary team (Guth et al., 2020).

Factors that lead to Patient Safety Risk

Evidence based research shows that elders are at a higher risk of medication related adverse effects that other adults. Medication related safety risk to the elderly can be contributed to; comorbidities, lack of education, multiple medications among others. Best practice shows that medication related risk to the elderly can be greatly minimized though enhanced health empowerment and education to the elders and caregivers. Empowering the patients and care givers to play an active role in making informed health care decisions and enabling them to have a clear understanding of potential medication interactions and adverse effects. Interdisciplinary communication among health care workers can also reduce medication safety risk as well as reduce cost by eliminating medication related adverse effects to elderly patients (Brandt et al., 2021)

Organizational Interventions to Promote Patient Safety

Health care facilities have increased patient education, focusing on medication education to help prevent adverse effects. Evidence has shown that when nurses educate the patients and care givers on the benefits and risk of prescribed medication the patient health and safety will increase significantly. Providing verbal and written education along with follow up education and answering any medication related questions can help eliminate adverse medication effects to empower the elders live a happier life outside the hospital which will in turn help decrease the cost of multiple re-hospitalization. Nurses can help coordinate care between the patient, caregiver and provider by making follow up appointments prior to discharge and making follow up phone calls after hospital discharge (Goodman et al., 2021)

The nurse’s role

NURS FPX 4020 Assessment 1 Root-Cause Analysis and Safety Improvement Plan CM

Coordinating an interdisciplinary team of stakeholders that consist of at least a mid or upper level provider, pharmacist, nurse and patient or caregiver is essential in providing safe and effective patient care. By collaborating with the medical doctor and pharmacist the nurse can effectively provide the patient and /or caregiver with detailed education they need to make informed health care decisions that will help reduce the risk of adverse effects of medication and thus reducing cost of medication errors or reactions and will help eliminate the cost of re-hospitalizations. The more the patient and care giver understand about their comorbidities and medications the more successful their lives will be without having complications of medication administration. Research shows that non- compliance with the medication regimen in the older generation can lead to higher mortality rates but it also proves that higher medication compliance rates can decrease adverse effects and re-hospitalizations. Higher compliance rates are directly related to better education and the elder having not only a greater understanding of their disease processes but also medication administration and adherence (Journal of Gerontological Nursing, 2021)


Brandt, N. J., & Lee, M. (2021). Medication Safety in Older Adults: Learning From 2020 as We Launch into 2021. Journal of Gerontological Nursing, 47(1), 7-11. http://dx.doi.org/10.3928/00989134-20201208-02

Goodman. (2021). Introducing Nurse-Led Patient Education Visits. Journal of Nursing Care Quality.36(1), 43–49. https://doi.org/10.1097/NCQ.0000000000000489

Guth, A., Chou, J., Courtin, S. O., Ford, C., Hennawi, G., & Brandt, N. (2020). An Interdisciplinary Approach to Implementing the Age-Friendly Health System 4Ms in an Ambulatory Clinical Pathway     With a Focus on Medication Safety. Journal of Gerontological Nursing, 46(10), 7-11. http://dx.doi.org/10.3928/00989134-20200909-02              Lessons Learned: A Process Evaluation of the Rural Elder Awareness of Medication Safety (REAMS) Program. (2021). Journal of Gerontological Nursing, 47(4), 7-12. http://dx.doi.org/10.3928/00989134-20210309-02

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