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NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit

NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit

Improvement Plan Tool Kit

Medication administration errors 

Medication administration errors reduce the quality of care and increase the threat to patient safety. As a result, an improvement plan based on EBP needs to be implemented to increase safety and quality. However, designing and implementing the plan requires resources such as guidelines, literature, protocols, measures, action plan, and training and education resources. The purpose of this improvement plan tool kit is to provide EBP resources for nurses to implement a QI plan at different levels to sustain safety measures in a health care setting. The kit identified four major themes of the plan. They are preventive measures, best EBP quality and safety practices, interprofessional collaboration, and education and training to increase competencies and skills.

Annotated bibliography


NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit

Preventive measures

Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administration safety by reducing distractions and interruptions. Journal Of Nursing Care Quality35(4), E58-E62. https://doi.org/10.1097/ncq.0000000000000473

The article presents a lean approach, which includes value stream maps to identify possible interruptions during medication administration, real-time possible solutions to manage increased interruptions, and evaluating the impact of solutions to find best-suited solutions for different scenarios. The article uses a separate purpose-built medication administration room to reduce unrelated conversations. The article is useful as it identifies the need to collaborate with other nurses to manage interruptions and avoid conversations during the administration process to reduce errors. As nurses predict possible interruptions, other nurses can attend to the interruption to allow the medication administering nurse to cognitively active. The second important aspect is the article highlights the importance of real-time decision-making and outcome analysis to determine whether they were successful in avoiding interruptions and unwanted conversations. Reduced interruptions decrease error rate and increase throughput. As a result, it increases patient safety and timely care. This preventive measure is better than corrective measures, which will be applied post errors as preventive measures safeguard patients, reduces hospital stay, and health care cost. 

Palese, A., Ferro, M., Pascolo, M., Dante, A., & Vecchiato, S. (2019). “I am administering medication—please do not interrupt me”: red tabards preventing interruptions as perceived by surgical patients. Journal Of Patient Safety15(1), 30-36. https://doi.org/10.1097/pts.0000000000000209

This article uses different colored tabards to prioritize interruptions and allows patients and individuals who will interrupt to wait for the completion of the medication administration process. Also, the article helps in analyzing patient’s perceptions after implementing tabard protocol in health care. The red tabards with signs do not disturb reduced interruptions significantly, but some patients had negative perceptions as they could not contact nurses. As a result, this article recommends nurses to establish stronger nurse and patient relationships to educate patients about the importance of timely care and medication errors. This creates a supportive collaboration between health care professionals and patients, which aids in preventing delayed care and errors. The study also highlighted that only 10% of patients required emergency services. The nurses should understand the need to prioritize the patients who need emergency service whenever needed and collaborate together to handle other queries. 

Tariq, R., Vashisht, V., Sinha, A., & Scherbak, y. (2021). Medication dispensing errors and prevention. Retrieved 17 March 2021, from https://www.ncbi.nlm.nih.gov/books/NBK519065/

The article addresses the importance of identifying and preventing prescription errors, documentation errors, transcription errors, dispensing errors, administering errors, and monitoring by using error reporting system, checklists, and identifying different causes such as expired medication, incorrect duration, incorrect prescription, wrong dosage and strength, known allergen and contradictions. Also, the paper identifies the importance of evaluating illegible writing, the use of abbreviations, and wrong medical history to reduce errors. The nurses, physicians, pharmacists, and EHR nurses should collaborate with each other to check all the information thoroughly to prevent errors. Errors from a physician can be detected by nurses and pharmacists. The errors at pharmacists can be detected by nurses. However, errors by nurses can be harder to detect as they are at the end of the chain. As a result, the paper recommends nurses to use guidelines by QSEN and IOM along with the checklist, conversation and decision documentation, confirmation on order, and hospital medication error protocols to increase patient safety by preventing errors at different stages. 

NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit

Best EBP quality and safety practices

Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal Of Medical Informatics111, 112-122. https://doi.org/10.1016/j.ijmedinf.2017.12.022

The article analyzes the impact of computerized physician order entry (CPOE) systems in preventing and managing different medication errors. The article is useful as it reviews 14 EBP articles to determine whether the CPOE systems are beneficial in preventing medication errors. Also, the article highlights that prescription errors lead to medication administration errors. The most frequent errors were wrong dosage and wrong medication errors. This highlights that error in one stage transforms to an error in another stage leading to patient safety issues and low-quality care. By implementing a CPOE system it is possible to prevent errors, but not completely. As a result, nurses, pharmacists, and physicians should review the information from EHRs, patient history, and relevance of medication and its dosage to decide whether the medication is suitable for the patient or not. The article recommends the health care professionals to report the errors by verifying prescriptions, a patient’s HER data, and dispensed medicine to reduce and prevent all kinds of errors, which might lead to adverse and sentinel events. 

Montgomery, A., Azuero, A., Baernholdt, M., Loan, L., Miltner, R., & Qu, H. et al. (2020). Nurse burnout predicts self-reported medication administration errors in acute care hospitals. Journal For Healthcare QualityPublish Ahead of Print. https://doi.org/10.1097/jhq.0000000000000274

This article is very beneficial as it addresses the impact of burnout in nurses on medication errors. The study highlighted that increased workload and the lower nurse-to-patient ratio will lead to stress. This further reduces cognitive abilities and job satisfaction. A nurse who has more patients is more likely to commit errors during medication administration. Also, poor support in the work environment and timing of medication administration led to errors. To reduce medication errors, health care should reduce nurse burnout by increasing nurse to patient ratio, providing support in the workplace through interprofessional collaboration and decision-making, and implementing work-life balance strategies. The nurses and other health care professionals should identify the importance of burnout while administering medication to reduce errors to increase patient safety. The EBP approach is to limit the number of patients per nurse to provide timely and quality care and also manage burnout in nurses. 

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 & Outcomes2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001  

The article evaluates the effects of bar-code medication administration (BCMA) in reducing medication administration errors. The article is useful as it highlights the need for competencies, skills, and knowledge related to technologies to prevent errors. The article highlights that barcode system not only reduced medication errors, but it also reduced adverse events by 55%. This indicates that nurses can detect errors by just scanning each medicine, comparing the medicine with patient history, EHR information, prescription, and dispense reports. The nurse can directly collaborate with physicians and pharmacists to report the error and request for new orders to prevent adverse effects and increase patient safety. 

Interprofessional collaboration strategies

Alabdulhafith, M., Alqarni, A., & Sampalli, S. (2018). Customized communication between healthcare members during the medication administration stage. Proceedings Of The 20Th International Conference On Human-Computer Interaction With Mobile Devices And Services18. https://doi.org/10.1145/3229434.3229483  

The article proposes a mobile application-based customized communication model for nurses, physicians, and pharmacists to detect, report, and manage medication administration errors. A mobile application with e-mail messaging, SMS integration, and internet-based texting allows nurses and others to directly communicate with the concerned personnel. This is critical as reporting errors and getting a response from others might take time, but this approach reduces the issue as all the information will be directly sent to mobile devices. As a result, errors can be reduced and timely care can be provided. This mode of communication and collaboration also reduces the need for documentation as every piece of information is stored electronically or digitally. By applying this EBP approach, medication errors can be reported and corrected in a timely manner. 

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 Management25(7), 539-548. https://doi.org/10.1111/jonm.12491  

The article evaluates double-checking information through collaboration and staff training and safety vests in preventing interruptions during medication administration. The paper is beneficial as it identifies that this approach reduces medication errors considerably and increases quality care, patient safety, and satisfaction among nurses. Also, the article recommends the nursing management to acknowledge the need for establishing interprofessional collaboration and a support system to reduce interruptions and using interruptive communication practices along with physical barriers to increase medication safety. The approach combined with training staff to manage the interruptions and implement double-check protocol increases patient safety in a hospital setting. 

Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opinion On Drug Safety17(3), 259-275. https://doi.org/10.1080/14740338.2018.1424830   

This source uses an integrated review approach to evaluate the best EBP interprofessional and interdisciplinary collaboration strategies in health care to prevent and report medication errors including administration errors. The article is very helpful as it identifies that five key interdisciplinary collaboration strategies to prevent medication errors are communication via tools including protocols, communication logs, and guidelines; pharmacists participation in the interdisciplinary teams to discuss issues; collaborative medication reporting, review, and root-cause identification on patient’s admission and discharge from health care; collaborative workshops, conferences, and training to understand protocols, systems, and guidelines; and differentiation of complexities in the role and identifying effects of the environment. Such tailored and individualized communication protocols including every stakeholder and assigning job-specific roles limit blame culture and medication errors as it increases greater understanding between the team. 

Training to increase competencies and skills

Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal Of Biosciences And Medicines08(06), 135-147. https://doi.org/10.4236/jbm.2020.86013  

The article addresses the issue of lack of knowledge, competencies, and skills related to safer medication administration in nurses and other health care professionals. The study is highly relevant as it identifies that there is a significant correlation between medication administration errors, knowledge level among ICU nurses, competencies related to medication process, and skill in determining errors. Also, it was found that educational degree, age, professional experience, medication administration education program, and specific critical care wad or unit played a major role. The study recommended to train nurses and provide clinical guidelines by using both unit-specific and medication administration education programs to reduce medication errors and increase patient safety. 

Armstrong, G. (2019). QSEN safety competency: the key ingredient is just culture. The Journal Of Continuing Education In Nursing50(10), 444-447. https://doi.org/10.3928/00220124-20190917-05 

The resource highlights the importance of establishing a culture of safety and just culture by following QSEN safety competencies in health care to educate and train health care professionals to identify effective error gaps to improve patient safety. The article is important as it addresses the need to include patient-centered care, safety mechanisms, EBP, teamwork and collaboration, and nursing informatics to prevent medication errors. Also, the article highlights that health care should educate nurses to increase their knowledge, skills, competencies, and attitude towards a culture of safety to create a sustainable safety culture. This combined approach will be beneficial as it will increase collaboration and quality of care. As a result, it increases patent safety. 

Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian Journal Of Critical Care Medicine22(5), 346-352. https://doi.org/10.4103/ijccm.ijccm_63_18  

The article aimed to understand elements such as nurse’s behavior, knowledge, attitude, and training needs in preventing medication errors in the ED while implementing all the steps of protocols of administration of intravenous (IV) medications. The article highlighted that only 15.6% of ED nurses had excellent knowledge related to preparation, administration, and management of IV medication. More than 85% of nurses found that they need to improve knowledge and skills regarding IV and other medication processes. Also, the article highlighted that they want to gain pharmacological knowledge for better decision-making. This indicates that nurses and health care administration should collaborate with each other to create a culture of lifelong learning to gain knowledge and skills to improve medication administration. Better skills lead to better practice. As a result, nursing education programs should be implemented to reduce errors and increase patient safety. 


Bosma, B., Hunfeld, N., Roobol-Meuwese, E., Dijkstra, T., Coenradie, S., & Blenke, A. et al. (2020). Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands. International Journal Of Clinical Pharmacy43(1), 66-76. https://doi.org/10.1007/s11096-020-01101-5

Desai, M., Patel, N., Shah, S., Patel, P., & Gandhi, A. (2016). A study of medication errors in a tertiary care hospital. Perspectives In Clinical Research7(4), 168. https://doi.org/10.4103/2229-3485.192039

Kang, H., Park, H., Oh, J., & Lee, E. (2017). Perception of reporting medication errors including near-misses among Korean hospital pharmacists. Medicine96(39), e7795. https://doi.org/10.1097/md.0000000000007795

Kavanagh, A., & Donnelly, J. (2020). A lean approach to improve medication administration safety by reducing distractions and interruptions. Journal Of Nursing Care Quality35(4), E58-E62. https://doi.org/10.1097/ncq.0000000000000473

Musharyanti, L., Claramita, M., Haryanti, F., & Dwiprahasto, I. (2019). Why do nursing students make medication errors? A qualitative study in Indonesia. Journal Of Taibah University Medical Sciences14(3), 282-288. https://doi.org/10.1016/j.jtumed.2019.04.002

Palese, A., Ferro, M., Pascolo, M., Dante, A., & Vecchiato, S. (2019). “I am administering medication—please do not interrupt me”: red tabards preventing interruptions as perceived by surgical patients. Journal Of Patient Safety15(1), 30-36. https://doi.org/10.1097/pts.0000000000000209

Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal Of Africa Nursing Sciences13, 100235. https://doi.org/10.1016/j.ijans.2020.100235

Schmidt, K., Taylor, A., & Pearson, A. (2017). Reduction of Medication Errors: A Unique Approach. Journal Of Nursing Care Quality32(2), 150-156. https://doi.org/10.1097/ncq.0000000000000217

Stewart, D., MacLure, K., Pallivalapila, A., Dijkstra, A., Wilbur, K., & Wilby, K. et al. (2020). Views and experiences of decision‐makers on organisational safety culture and medication errors. International Journal Of Clinical Practice74(9). https://doi.org/10.1111/ijcp.13560

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 & Outcomes2(4), 342-351. https://g/10.1016/j.mayocpiqo.2018.09.001doi.or

Trakulsunti, Y., Antony, J., Dempsey, M., & Brennan, A. (2020). Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study. International Journal Of Quality & Reliability Management38(1), 339-362. https://doi.org/10.1108/ijqrm-10-2019-0334

NURS FPX 4020 Assessment 4: Improvement Plan Tool Kit


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