NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

Improvement Plan Tool Kit

     Mediation errors in healthcare reduces patient outcomes and increase risk of adverse reaction. This improvement plan tool kit will provide a list of sources that are important for medical professionals to use as guidelines for safety improvement pertaining to safe medication administration. The tool kit will identify four categories of plan along with three annotated sources. They are Preventative measures, Implementation of medication safety technologies, interdisciplinary collaboration, and education and training to increase competencies and skills.

Preventative measures

Pereira Lermontov, S. , Carreiro Brasil, S. & Rezende de Carvalho, M. (2019). Medication 

Errors in the Context of Hematopoietic Stem Cell Transplantation. Cancer 

Nursing, 42 (5), 365-372. doi: 10.1097/NCC.0000000000000613.

This article presents study that was aimed at identifying the incidence, related factors, consequences, and prevention mechanisms of medication errors. It identifies that medication administration is an activity of great activity for nursing however, in order to decrease medication administration errors a whole team approach is warranted as it affects the patients family, healthcare teams, and the healthcare system.

Kavanagh, A. & Donnelly, J. (2020). A Lean Approach to Improve Medication Administration 

Safety by Reducing Distractions and Interruptions. Journal of Nursing Care Quality, 35 (4), E58-E62. doi: 10.1097/NCQ.0000000000000473.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

This article presents an approach which identified a value stream maps which identified interruptions that occurs during medication administration, solution to manage the interruptions. This article is useful as it identifies solution such as collaborating with  other nurses during medication administration and to avid conversations during such times. The research carried out in this article suggest that reduced interruptions during medication administration decrease error rates and increases patient safety and timely care.

Shao, S. , Lai, E. C. , Owang, K. L. , Chen, H. & Chan, Y. (2018). Look-Alike Medication 

Packages and Patient Safety. Journal of Patient Safety, 14 (3), e47-e48. doi: 

10.1097/PTS.0000000000000506.

This article presented a case study of a medication error that occurred due to dispensing and  packaging issues. It identified that Among LASA medication errors, 33 % can be attributed to packaging or labeling confusions. The article identifies strategies such as tall man letters for sound alike medication with similar drug names, use of automated drug dispensing machines for oral medication refilled into bottles, and using color lines to distinguish different medications with look-alike packages, which is effective for accurate dispensing.

Implementation of medication safety technologies

Baysari, M. T., Zheng, W. Y., Li, L., Westbrook, J., Day, R. O., Hilmer, S., Bethany Annemarie, 

V. D., Hargreaves, A., Kennedy, P., Monaghan, C., Doherty, P., Draheim, M., Nair, L., & 

Samson, R. (2019). Optimising computerised decision support to transform medication safety and reduce prescriber burden: study protocol for a mixed-methods evaluation of drug–drug interaction alerts. BMJ Open, 9(8)http://dx.doi.org.library.capella.edu/10.1136/bmjopen-2018-026034

This article identified how the use of electronic medical management can aid in identifying drug – drug interaction. The study aimed to Determine the impact of drug-drug interaction( DDI ) alerts on DDI rates and patient harm, Identify barriers and facilitators to optimal use of alerts. Quantify the alert burden posed to prescribers with implementation of DDI alerts in hospital medication systems and Develop algorithms to predict clinically relevant DDIs. The use of these systems is generated at the point of prescribing to warn doctors about potential interactions in their patients’ medication orders before prescribing it. Using this form of electron medical management has been proven to decrease the likelihood of medication errors and decrease adverse events.

Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). 

Implementation of bar-code medication administration to reduce patient harm. Mayo 

Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001  

This article is very beneficial as it evaluates the effects of the use of bar-code medication administration in decreasing medication administration errors. This article is ideal as it points out the need for healthcare providers to be competent, retain skills, and be knowledgeable to technologies to prevent medication errors from occurring. The article provided statistics that the bar-cod system reduced adverse events by 55%. This system allows for nurse to scan each medication and can easily compare the medication so that it is given to the right patient. Nurses can also easily collaborate with doctors and pharmacist directly to clear up any errors or issues related to the medication at that given time of medication administration.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

Prusch, A. E., Suess, T. M., Paoletti, R. D., Olin, S. T., & Watts, S. D. (2011). Integrating 

Technology to improve medication administration. American Journal of Health-System 

Pharmacy, 68(9), 835–842. https://doi.org/10.2146/ajhp100211

 This article discussed the development, implementation, and evaluation of an integration of IV program to increase medication safety at the bedside when using IV infusion pumps. The pumps allow for better calibration of high patent medication to decrease adverse events when administering IV medications. Another important aspect of this IV pump is that it provided auto programming rate after inputting the drug of choice and came with a built-in drug library for nurses to access information about the drug if needed. It also increased collaboration between nurses and pharmacist. The workload is more simplified and medication errors were reduced.

interdisciplinary collaboration

Jeanette, S. J., Havnes, K., Halvorsen, K. H., Haustreis, S., Skaue, L. W., Kamycheva, E., 

Mathiesen, L., Viktil, K. K., Granås, A. G., & Garcia, B. H. (2018). Interdisciplinary 

collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial. BMJ Open, 8(1)http://dx.doi.org.library.capella.edu/10.1136/bmjopen-2017-020106

This very useful article identifies the importance of interdisciplinary collaboration amongst healthcare staff to decrease medication errors in the aging population. It identified that adverse drug events alone contributed to 30-40% of acute hospital admissions in the elderly. Communication barriers were identified as problems associated with medication errors due to multiple prescribers, frequent transition of care, and poor follow up. The articles identified ways in which providers can decrease such incidence. The use of  integrated medicines management (IMM) model is a multifactorial interdisciplinary methodology aiming to optimize individual medication therapy throughout the hospital stay.  Based on the article, IMM has been shown to reduce readmissions and drug-related hospital readmissions. The model is based on interdisciplinary collaboration where pharmacists, doctors, nurses and patients work during and after entering a hospital. The interdisciplinary team come together and do a medication review, patient education, and follow up care post discharge. This effort has proven to decrease the risk of medication errors in the elderly population.

Liu, Wei (10/2016). “Creating opportunities for interdisciplinary collaboration and patient‐

centered care: how nurses, doctors, pharmacists and patients use communication 

strategies when managing medications in an acute hospital setting”. Journal of clinical nursing (0962-1067), 25 (19-20), p. 2943.

This article is very helpful as it identifies how interdisciplinary collaboration directly aligns to quality care provided to patients. The use of effective communication strategies by nurses, doctors, pharmacist, and patients created improved opportunities to identify the barriers that can greatly affect medication errors. Languages used by each discipline was shown to have an impact on how patient perceived the information they received regarding their medication. Using a dialogue that is clear and understandable can shape the outcome between patients and clinicians. This will aid in the decrease of medication errors.

Huckels-Baumgart, S., Niederberger, M., Manser, T., Meier, C., & Meyer-Massetti, C. (2017). A 

combined intervention to reduce interruptions during medication preparation and double-

checking: a pilot-study evaluating the impact of staff training and safety vests. Journal Of Nursing Management, 25(7), 539-548. https://doi.org/10.1111/jonm.12491  

This article provided useful information regarding double-checking of patient information through staff training and collaboration and using safety vest in preventing interruptions and distractions during medication administration. It identifies that this approach of safety mechanism decreases the incidence of medication errors and subsequently increases patient safety and  quality care provided by nurses. It also showed that it built a sense satisfaction among nurses. The article also stressed the importance of managing establishing a premise where interprofessional collaboration and providing support system is important for the success of medication administration errors in the healthcare setting.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

Training to increase competencies and skills

Armstrong, G. (2019). QSEN safety competency: the key ingredient is just culture. The Journal    

of Continuing Education In Nursing, 50(10), 444-447. https://doi.org/10.3928/00220124-20190917-05

This article highlights the importance of having a culture of safety by following what is called Quality and Safety Education for Nurses (QSEN )safety competencies in healthcare that is used to educate and train healthcare professionals to identify when there is a medication error to improve safety outcomes for patients. This article is very relevant as it addresses the concerns regarding patient centered care, teamwork and collaboration, evidenced based practice all which will aid in preventing medication errors from occurring. It also highlights that healthcare need to be vigilant in educating nurses and other healthcare provider to provide a culture of safety for patients. 

Simone, E. D., Tartaglini, D., Fiorini, S., Petriglieri, S., Plocco, C., & Muzio, M. D. (2016). 

Medication errors in intensive care units: Nurses’ training needs. Emergency Nurse (2014+), 24(4), 24. http://dx.doi.org.library.capella.edu/10.7748/en.2016.11577

This article highlights the importance of continued education for nursing staff to decrease medication error. It identifies those various interventions such as forums in which nurses ask questions, displaying information about high-risk medications on wall posters, video-based training sessions, and medication management and errors have been shown to effectively increase knowledge and reduce medication errors. The article further suggests that education programs must also focus on safety aspects such as the organization systems and how they can contribute to medication errors, the importance of reporting errors, and documenting mistakes that they can be ‘learned from as to prevent future occurrences. Also, technologies such as barcode drug admiration, smart infusion pump, and computerize system must be readily available and nurse trained fully prior to use is important for safe drug administration.

Sarfati, L., Ranchon, F., Vantard, N., Schwiertz, V., Larbre, V., Parat, S., Faudel, A., & Rioufol, 

C. (2019). Human‐simulation‐based learning to prevent medication error: A systematic 

review. Journal of Evaluation in Clinical Practice25(1), 11–20. https://doi.org/10.1111/jep.12883

This journal is helpful for looking at training healthcare professionals to increase their competencies and skills when dealing with medication administration. According to the journal, Simulation‐based medical education is defined as the use of a device, such as a mannequin, a task trainer, virtual reality or a standardized patient, to emulate a real device, patient or care situation or environment to teach therapeutic and diagnostic procedures, processes, medical concepts and decision‐making to a healthcare professional. Simulation‐based training relies on learning from experience: as the saying goes, “Never first time on a patient.” The journal discussed using simulation and integrating human factors as a way to practice real life situations in an effort to decrease medication errors. Another important aspect of this type of training is that it provides for a better understanding of interdisciplinary collaboration. The journal suggest that the simulation incorporates pharmacists, nurses, and physicians as part of the learning process as they are the key factors when ordering, dispensing and administering medication. 

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit TS

Reference

Armstrong, G. (2019). QSEN safety competency: the key ingredient is just culture. The Journal    

of Continuing Education in Nursing, 50(10), 444-447. https://doi.org/10.3928/00220124-20190917-05

Baysari, M. T., Zheng, W. Y., Li, L., Westbrook, J., Day, R. O., Hilmer, S., Bethany Annemarie, 

V. D., Hargreaves, A., Kennedy, P., Monaghan, C., Doherty, P., Draheim, M., Nair, L., & 

Samson, R. (2019). Optimising computerised decision support to transform medication safety and reduce prescriber burden: study protocol for a mixed-methods evaluation of drug–drug interaction alerts. BMJ Open, 9(8)http://dx.doi.org.library.capella.edu/10.1136/bmjopen-2018-026034

Huckels-Baumgart, S., Niederberger, M., Manser, T., Meier, C., & Meyer-Massetti, C. (2017). A 

combined intervention to reduce interruptions during medication preparation and double-

checking: a pilot-study evaluating the impact of staff training and safety vests. Journal Of Nursing Management, 25(7), 539-548. https://doi.org/10.1111/jonm.12491  

Jeanette, S. J., Havnes, K., Halvorsen, K. H., Haustreis, S., Skaue, L. W., Kamycheva, E., 

Mathiesen, L., Viktil, K. K., Granås, A. G., & Garcia, B. H. (2018). Interdisciplinary 

collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial. BMJ Open, 8(1)http://dx.doi.org.library.capella.edu/10.1136/bmjopen-2017-020106

Kavanagh, A. & Donnelly, J. (2020). A Lean Approach to Improve Medication Administration 

Safety by Reducing Distractions and Interruptions. Journal of Nursing Care Quality, 35 (4), E58-E62. doi: 10.1097/NCQ.0000000000000473.

Liu, Wei (10/2016). “Creating opportunities for interdisciplinary collaboration and patient‐

centered care: how nurses, doctors, pharmacists and patients use communication 

strategies when managing medications in an acute hospital setting”. Journal of clinical nursing (0962-1067), 25 (19-20), p. 2943.

Pereira Lermontov, S. , Carreiro Brasil, S. & Rezende de Carvalho, M. (2019). Medication 

Errors in the Context of Hematopoietic Stem Cell Transplantation. Cancer 

Nursing, 42 (5), 365-372. doi: 10.1097/NCC.0000000000000613.

Prusch, A. E., Suess, T. M., Paoletti, R. D., Olin, S. T., & Watts, S. D. (2011). Integrating 

Technology to improve medication administration. American Journal of Health-System 

Pharmacy, 68(9), 835–842. https://doi.org/10.2146/ajhp100211

Sarfati, L., Ranchon, F., Vantard, N., Schwiertz, V., Larbre, V., Parat, S., Faudel, A., & Rioufol, 

C. (2019). Human‐simulation‐based learning to prevent medication error: A systematic 

review. Journal of Evaluation in Clinical Practice25(1), 11–20. https://doi.org/10.1111/jep.12883

Shao, S. , Lai, E. C. , Owang, K. L. , Chen, H. & Chan, Y. (2018). Look-Alike Medication 

Packages and Patient Safety. Journal of Patient Safety, 14 (3), e47-e48. doi: 

10.1097/PTS.0000000000000506.

Simone, E. D., Tartaglini, D., Fiorini, S., Petriglieri, S., Plocco, C., & Muzio, M. D. (2016). 

Medication errors in intensive care units: Nurses’ training needs. Emergency Nurse (2014+), 24(4), 24. http://dx.doi.org.library.capella.edu/10.7748/en.2016.11577

Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). 

Implementation of bar-code medication administration to reduce patient harm. Mayo 

Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001  

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