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NURS FPX 6212 Assessment 2 Executive Summary

Executive Summary

Quality and safety outcomes are the essential elements of the healthcare organization to provide evidence-based care and recognize the gaps in the outcomes so changes and improvements can be made to address the gaps. The systemic problem that would be focused on is medication errors in the healthcare organization of Vila Health facility. Some indicators can be helped to evaluate the outcomes measures like compliance rate with the evidence-based practice guideline, mortality rates, patient satisfaction, and patient safety indicators.

NURS FPX 6212 Assessment 2 Executive Summary

Explaining Key Quality & Safety Outcomes

Healthcare organizations use quality outcomes as measures to evaluate the performance of the nurses or the interventions towards healthcare issues. The outcome measures that are mainly evaluated for medication error are patient satisfaction, patient-reported outcomes, mortality, and readmission rates. There can be finance and process outcomes related to this, like the adherence to the guidelines and cost per patient or the duration of the patient’s stay. Both the quality and safety outcomes are essential to understand the severity of the issue. For example, in the case of medication errors, there is a decrease in the quality outcomes of patient satisfaction and trust the patients have in healthcare (Tariq et al., 2022). Regarding safety, 7,000 to 9,000 people die yearly due to medication errors in the US, and the cost of treating patients with medication errors exceeds $40 billion each year (Tariq et al., 2022). These significant consequences need interventions and outcome measures to address the situation effectively. 

The strength of these outcome measures is that they help establish a benchmark for the organization to do better; there is recognition of the areas of weaknesses so they can be targeted with interventions and strategies; this also leads to increased accountability and or provides standardized and objective measures for the performance of the healthcare organization. 

The weakness of these outcome measures can be the time-consuming process of collecting data and evaluating it. It may not reflect the exact perspectives of the healthcare providers and the patients. Outcome measures may also need to capture the external factors that impact the outcomes. For example, the mortality rates in healthcare could also vary with age, gender, and socioeconomic status rather than just medication errors. There is also a potential for manipulation; for example, to reduce the cases of medication errors, instead of interventions that educate the nurses, the organization may resort to strict punishments for healthcare providers, which may result in limited reporting of the cases by them leading to less number of cases overall.

Determining the Strategic Value

The safety and quality outcome measures have strategic values that must be determined. They are essential as they help achieve an organization’s goals and make improvement plans. Strategic value can be provided to the organization by improving patient outcomes with increased satisfaction after the quality and safety outcomes enable the healthcare stakeholders to identify the areas where there can be an improvement to reduce medication errors. The organization can better understand where the staff is lacking and where there is underperformance. For example, standardized medication administration processes can improve the outcome measure of high readmission rates due to medication errors (Uitvlugt et al., 2021). The safety and quality outcome measures can also bring the organization’s value to the stakeholders, like the patients, clinicians, or nurses. For example, the outcome measure of high patient satisfaction may attract more patients to receive their treatment. This can increase revenue, making everything more cost-effective. The outcome measures also support decision-making related to different changes or interventions. For example, the Bar-code medication administration system (BCMA) intervention can be prioritized after evaluating the quality and safety outcomes of high mortality rates. This could be because BCMA has proven to be effective in reducing medication errors by providing intelligent tools that check prescriptions’ safety automatically to develop a culture of safety that is also timely (Naidu & Alicia, 2019).

The existing outcome measures can add value to the organization by combining all the measures, like patient satisfaction, adverse events, readmission rates, and mortality rates, to gain an even deeper understanding of the organizational performance. Trends can be studied through graphs and charts to see if the organization’s mission and goals are being met.

Analyzing Relationships Between Medication Errors & Quality and Safety Outcomes

Since medication errors are rising and a severe concern for Vila’s health as they lead to adverse events and even fatalities, it is essential to analyze the relationships between medication errors and specific quality and safety outcomes. The specific safety and quality outcomes studied are adverse events, patient satisfaction, length of stay, mortality rate, and hospital readmissions. Medication errors are usually due to inadequate training of staff, lack of communication, high workload, and poor work environment. Such factors increase the risk of medication errors, leading to patient complications and adverse events (Neugebauer et al., 2021). Adverse events harm patients and lead to healthcare costs. Medication errors also contribute to the quality outcomes of stay as medication errors and adverse events leading to complications increase the length of stay for more treatment, increasing the costs and decreasing patient outcomes (Rasool et al., 2020). Due to all of this, medication errors reduce patient satisfaction, impacting healthcare’s reputation and patient trust. Medication errors can also lead to hospital readmission, negatively impacting patient outcomes.

NURS FPX 6212 Assessment 2 Executive Summary

The additional data that could be collected to gain an even better understanding of the medication errors is understanding the underlying factors contributing to it with root-cause analysis, data can be collected on the different types of medication errors and their severity, and data can also be collected on the training and education level of the healthcare providers to determine the relationship.

Strategic Initiatives

The strategic initiatives that can be taken for a culture of safety and quality related to the outcome measure of patient satisfaction can be the development of educational programs for patients that increase their awareness and confidence in medications (Cha et al., 2021). Patients can be given surveys or questionnaires to rate their medical experience and satisfaction. The initiative for the outcome measure for the length of stay can be providing training and workshops to the healthcare providers so they are confident in preventing medication errors. There can be the implementation of technology like BCMA for checking prescriptions to avoid errors and adverse events that may prevent prolonged stays at the hospital for the patient (Naidu & Alicia, 2019). A medication safety committee can also be formed to analyze the trends of medication errors and root causes for the outcome measure of adverse events. 

The Vila Health strategic plan is to provide patient-centered care by reducing harm while minimizing human errors at the facility. In light of the current situation with increasing medication errors, the organization must adapt to technologies like BCMA, address workforce challenges, address lack of competency and training, and improve healthcare disparities.

Leadership Team Supporting Adoption of Proposed Practice

A leadership team is crucial to implementing safety and quality outcomes changes. The leadership team helps gather and provide the necessary resources for the implementation of the proposed changes described before. The resources can include equipment, staffing, and finances to train healthcare providers to prevent medication errors. The leadership team will also enhance communication and collaboration by engaging all the stakeholders and effectively communicating the initiatives for the changes to the stakeholders. The interprofessional collaboration promoted by the leadership team would ensure that high-quality care is delivered to the patients and that professionals from different disciplines are engaged for shared-decision making and quality improvements. The leadership team would gather all the relevant data related to the quality and safety outcomes to monitor the progress of the implementations to evaluate the success. Barriers and gaps can be identified to make adjustments accordingly. The leadership team is essential to manage change so there is a smooth transition for the members of the organization when the change is being implemented (Oreg & Berson, 2019).


Safety and quality outcomes are crucial to the healthcare issue of medication errors. Implementing technologies like BCMA, educating staff, and educating patients can help improve patient healthcare outcomes and patient satisfaction and reduce the cases of adverse events. The role of leadership also plays a vital role in adapting to the changes.

NURS FPX 6212 Assessment 2 Executive Summary


Cha, S. S., Kim, M., Moon, H. S., & Lee, E. (2021). Development and effectiveness of a patient safety education program for inpatients. International Journal of Environmental Research and Public Health, 18(6), 3262. https://doi.org/10.3390/ijerph18063262

Naidu, M., & Alicia, Y. L. Y. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health, 11(05), 511–526. https://doi.org/10.4236/health.2019.115044

Neugebauer, J., Tóthová, V., Chloubová, I., Hajduchová, H., Brabcová, I., & Prokešová, R. (2021). Causes and interventions of medication errors in healthcare facilities. Příčiny a intervence medikačního pochybení ve zdravotnických zařízeních. Ceska a Slovenska farmacie : casopis Ceske farmaceuticke spolecnosti a Slovenske farmaceuticke spolecnosti, 70(2), 43–50.

Oreg, S., & Berson, Y. (2019). Leaders’ impact on organizational change: Bridging theoretical and methodological chasms. Academy of Management Annals, 13(1), 272–307. https://doi.org/10.5465/annals.2016.0138

Rasool, M. H., Rehman, A. U., Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Hassali, M. A., & Hayat, K. (2020). Risk factors associated with medication errors among patients suffering from chronic disorders. Frontiers in Public Health, p. 8. https://doi.org/10.3389/fpubh.2020.531038

Tariq, R., Vashisht, R., Sinha, A., & Scherbak, Y. (2022). Medication Dispensing Errors And Prevention. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Uitvlugt, E. B., Janssen, M. J. A., Siegert, C. E., Kneepkens, E., Van Den Bemt, B. J. F., Van Den Bemt, P. M. L. A., & Karapinar-Çarkit, F. (2021). Medication-related hospital readmissions within 30 days of discharge: Prevalence, preventability, type of medication errors and risk factors. Frontiers in Pharmacology, 12. https://doi.org/10.3389/fphar.2021.567424

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