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NURS FPX 4020 Assessment 3 Improvement Plan In-Service Presentation JJ

NURS FPX 4020 Assessment 3 Improvement Plan In-Service Presentation JJ

Content
Medication errors
Safe medication administration
Implementation strategy and agendas
Resources used
Role of nurses
Expected outcomes of the implementation plan
The purpose of this in-service is to discuss medication safety and ways to reduce the risk of errors. Nurses are the stakeholder of the health care system health provisions. Medication starts with you and so does the risk of errors. The high load of the medication errors have been reported worldwide, You can use this information to better analyze the situation and make your ways to utilize the information in practice.
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NURS FPX 4020 Assessment 3 Improvement Plan In-Service Presentation JJ

Introduction
Medication errors are common in healthcare organizations related to process of prescription and administration of medicine (Simone et al., 2020)

This in-service session is formulated to address the issue of medication errors and plan a strategy to reduce the medication errors

It will require the stakeholder analysis, individual change in nurses and availability of resources
Errors are inevitable in human nature and so are in professionalism, however it can be minimized by individual improvement and motivation.
Some errors like medication errors can have unrecoverable effects like drug abuse, side effects leading to collapse of certain organs and their functions
Medication errors are common in the health care organizations regarding process of prescription, administration dissemination of medication
In every particular health facility, public or private, we encounter several such errors

The purpose of this in service session is to address the issue of ‘medication errors’ in terms of its gravity and frequent causes as well as plan a strategy to mitigate or reduce certain type of medication error or as whole

The key players of this session action plan are analyzed after critical thinking, stakeholders are nurses and administration which trigger and regulate the individual change in the availability of the resources and health care provisions
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NURS FPX 4020 Assessment 3 Improvement Plan In-Service Presentation JJ

Elements of quality health
Safe
Efficient
Effective
Patient satisfaction
(Chassin, and Loeb, 2013)
Elements of quality health are safe and effective health services according to the clinical guidelines and policies ascribed by the health care officials, provided by the nurses with efficient and skillful evidence based knowledge with objective to fulfill the health needs of the patient, improves his health status and provide a patient satisfactory health measures (Chassin, and Loeb, 2013)
Safe: Measures oh health care provisions are free of any harm and health promoting
Efficient: Health measures are correct according to the requirement and all the proper resources to treat the patient are available
Effective The medication and health treatment options can cure the respective health issue:
Patient satisfaction: Patient’s health is improving, he feels satisfied and puts his trust in the treatment method
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Issues in provision of quality health
Medication errors
Health costs
Resource imbalance
Lack of skill and knowledge
(Hammoudi et al., 2018)
The main issues we encounter while providing a quality health to the community are medication errors, increasing health expenditures, unavailability of the resources at the hospital care facilities and lack of skill and knowledge of nurses to make them able of providing health care services. The issue I will be addressing is the medication errors (Hammoudi et al., 2018)
Medication errors are defined as the any preventable event that may have been causes or further lead to poor medication use related to causing harm to the patient in the control of health care professional
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NURS FPX 4020 Assessment 3 Improvement Plan In-Service Presentation JJ

Medication errors
Manufacturing
Prescription
Dispensing medicine
Administration errors
Monitoring the therapy
Medication errors can occur at several steps, at manufacturing units of medications by incorporating some wrong formula or expired chemical
At the time of prescription of medicine an ambiguous health conditions can be handled with wrong prescription of medicine leading to general drug side effects, nausea, vomiting and diarrhea
At the time of dispensing the medication at the pharmacy
The administration of medication are one of the most frequent errors of these, which is ascribed as wrong method of medication in terms of dose, route or timing
The monitoring of therapy is also prone to errors by negligence in monitoring, wrong analysis of the situation
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Major medication administration errors
Wrong administration route (Oral /Intravenous)
Wrong timing of drug administration
Wrong dose administration
Poor record keeping of dose administered
Wrong infusion
Drug reaction neglection
However, major medication administration errors are wrong administration route, for example nurse was supposed to administer a drug orally rather it was delivered intravenously causing sudden reaction
Wrong timing of administration, nurse missed out the morning insulin dose and administered it at wrong hour
wrong dose, the calculations of the dose formation is sometimes complicated, increased ml of analgesic can cause discomfort
negligence in drug reaction, as certain drugs react in some patients in the from of severe anaphylactic shock, skin eczema or gastric discomfort, nurse may forget to check on the possible drug reaction effect
wrong infusion estimation of the medicine, wrong medicine may be infused in place of another, mix up of the medications
After the administration the wrong record keeping of dose administered or negligence in this step can also cause overdosing or underdosing of patient effecting the hospital stay and health of patient
Wrong route of administration, is the most common error, a medicine that was meant to be given orally is administered via IV
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Factors effecting the issue
Organizational
Availability of resources
Costs of health care
Overcrowding

Environmental
Imbalance of patient/nurse ratio
Distraction and interruption
Complex medication calculations
Individual
Skill and knowledge
Workload
Poor coordination, communication
Stress
Job satisfaction
Keers et al., (2013)
The medication administration issues are frequently experienced because of organizational, environmental and individual factors
The organization, public or private hospital experience issues related to availability of resources, increased health care costs because of medications and longer hospitalization stays of the patients and overcrowding
The environmental factors like imbalance of patient/nurse ratio causes overload on the shift nurse leading to frustration and increased pressure, The integrating organizational and environmental factors can cause distraction while administering the dose, that may appear as wrong dose preparation, wrong administration route or negligence while admisntring, Complex medication calculations can also put a pressure of work and misunderstanding of the procedure leading to error
Individual skill and evidence based knowledge of the nurse, workload, poor coordination and communication with the fellow nurses, job stress and dissatisfaction can cause individual disinterest in the administration process eventually leading to medication error (Keers et al., 2013)
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Improvement plan agenda
Enhancing coordination among the nurses
Enhancing knowledge about medication errors
Nurses skill development and evidence based knowledge
Test Electronic record keeping/documentation of medication
Duration 3 days
Resources: distribution of pamphlets, written copies of policies
The purpose of this session to work on the agenda of reducing the medications errors according to the suggested agenda plan
Enhancing coordination among nurses, by mutual conversation, professional positive behavior and attitude, can reduce the miscommunication and enhanced patient centered communication
Enhancing knowledge about medication errors, we can achieve this agenda by consulting to the currently available medication administration policies by NHS and international policies by WHO to lay out all the guidelines that are required for the medication administration thus it will reduce the chances of error
The nurses skill and knowledge development is necessary for the agenda in order to achieve a long run cultural change in the medication errors prevalence. Nurses can do this by themselves or by conducting meetings and frequent information sessions
The electronic record keeping and documentation of medication is the key to preventing medication errors by providing a daily report of the medication resources used
The duration of agenda will be 3 days in order to analyze its outcome implications
The resource sued for this plan will be pamphlets designed with infographics of medication administration process and distributing written copies of policies and guidelines
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NURS FPX 4020 Assessment 3 Improvement Plan In-Service Presentation JJ

Role of Nurses
Analyze the medication administration errors
Review the medication administration policies
Active listening and analysis
Ask questions
Mindset of patient centered health care provisions
Implement the learning and evidence based knowledge
The role of nurses in this activity is to analyze the medication administration errors at individual level at the facility and personal practice, use own critical thinking and analysis skills to report the errors
Review the medication administration policies, provided as a resource and check for its applications scope in the facility, try practicing them in your own practice and find the difference of medication error reported by self assessment
Active listening of the sessions and analysis, it will help you to understand the agenda as it is crucial for remedy of medication errors
Ask relevant questions to address the shortcomings and future considerations. After the activity if you find more input to the matter feel free to share.
Make a mindset of patient centered health care provisions, as patient should be the center of our practicing goals. The health of patient, preventing his disease condition is our job and obligation
Implement the learnings of the sessions and individual knowledge, keep learning after the activity, use evidence based literature to develop a vision of own about the subject issue, consult the fellow peers and physicians for the questions
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Expected outcomes
Enhanced knowledge and skill of nurses
Prevent medication demonstration errors
Decision making capacity
Enhanced patient safety and care
Decrease manual fatigue
Efficient record keeping
Increased coordination between nurses

Expected outcomes of this agenda activity will be:
Enhanced knowledge and skill of nurses regarding appropriate medication administration and possible medication errors, the resources provided in the activity and analysis of the policies and guidelines of the medication errors will make a holistic image of the normal medication administration procedure and detailed analysis of what should be considered while administering a dose of medicine
Prevent medication demonstration errors, that are evident in the practice discussed earlier that is wrong timing, wrong dose, wrong dose, wrong infusion and wrong type of medicine
Decision making capacity at the time of emergency: The activity of practice will help you to take decisions on basis of affirmative information. The evidence based knowledge will provide the base for the decision making role
Enhanced patient safety and care: which is the primary goal of the health care system and this presentation, health of patient will improve with provision of safe efficient and effective medicine
Decrease manual fatigue, the process of reporting the error and use of technology as a medicine recording system will reduce the manual fatigue factor of recording the data and automatically generate the patient medication profile which can be tested every day
Efficient record keeping, the technology use can automatically cause the data to store in a better way
Increased coordination between nurses, the overall activity will increase our coordination, as we will share our knowledge of the evidence based research, medication errors seen in the research activity and tehri possible solution and prevention measures,
On the whole it can lead to a good effort of medication error prevention
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Why need safety from medication errors
Medication errors increases medication and health cost expenditure (Walsh et al., 2017)
Delays hospital stay of patients causing over crowding
Patients health deteriorates adverse side effects of wrong administration (Asensi-Vicente, et al., 2018)
Medication errors increases medication and health cost expenditure (Walsh et al., 2017)
Delays hospital stay of patients causing over crowding
Patients health deteriorates adverse side effects of wrong administration (Asensi-Vicente, et al., 2018)

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Outcomes of safe medication administration
Reduced cost of medication and health
care system
Reduced hospital stay of patients
Prevent overcrowding
Ample availability of resources
If we are successful in reporting the medication administration errors and preventing the prevalence at our facility, it will somehow have broader implications on the economic and health care sector
Reduced cost of medication and health care system , less budgetary waste on over consumption of medicine and longer hospital stays of patients
Reduced hospital stay of patients, which will also reduce cost expenditure per day of the hospital stay and improve patients health
Prevent overcrowding, patient will be discharged early with satisfactory care and good health, preventing the overcrowding of facilities and nurse patient ratio can be balanced, Each nurse will have less job stress, less patients to attend and overall better health care provisions
Ample availability of resources

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Conclusion


Medication administration errors are the most common errors
Wrong dose, infusion, route, poor administration, drug reaction negligence
It reduces the health quality of patient put a load on the economic and health care sector
Generating awareness agenda, based on revision of the existing guidelines and policies
Technology use for data reporting
Reduce medication errors, save the implications of errors, improved nurse knowledge

Medication administration errors are the most common type of errors which are presented as wrong route, infusion, dose and possible drug reaction negligence
These errors tends to reduce the health quality of patient increases his hospital stay effecting his health and increased load on the economic expenses on his medications and hospital stay
The agenda based on the generating awareness among the stakeholders that are nursing staff about the general guidelines and policies and revising the existing literature can help to develop a holistic image of the safe medication methods. Technology use for data reporting will also report the error on time. This activity tends to gain the benefits of increased patient health reduced medication error and their effects on the economic and budgetary factors
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References


Asensi-Vicente, J., Jiménez-Ruiz, I. and Vizcaya-Moreno, M.F. (2018). Medication errors involving nursing students: A systematic review. Nurse educator, 43(5), pp.E1-E5.
Chassin, M.R. and Loeb, J.M. (2013). High‐reliability health care: getting there from here. The Milbank Quarterly, 91(3), pp.459-490.
Keers, R.N., Williams, S.D., Cooke, J. and Ashcroft, D.M. (2013). Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug safety, 36(11), pp.1045-1067.

Di Simone, E., Fabbian, F., Giannetta, N., Dionisi, S., Renzi, E., Cappadona, R., Di Muzio, M. and Manfredini, R. (2020). Risk of medication errors and nurses’ quality of sleep: a national cross-sectional web survey study. Eur Rev Med Pharmacol Sci, 24(12), pp.7058-7062.
Hammoudi, B.M., Ismaile, S. and Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences, 32(3), pp.1038-1046.
Walsh, E.K., Hansen, C.R., Sahm, L.J., Kearney, P.M., Doherty, E. and Bradley, C.P. (2017). Economic impact of medication error: a systematic review. Pharmacoepidemiology and drug safety, 26(5), pp.481-497.

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