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FPX 6109

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FPX 6214

FPX 6021

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NURS FPX 6212 Assessment 1: Safety and Gap Analysis

Capella 6212 Assessment 1

Assessment 1: Safety and Gap Analysis

Student Name

Capella University

School of Nursing and Health Sciences, Capella University

NURS-FPX 6212 Assessment 1:

Health Care Quality and Safety Management

Prof. Name:


Safety and Gap Analysis

Every year, over 250,000 patients seeking healthcare encounter adverse incidents, underscoring a pervasive issue in the healthcare system (Skelly et al., 2022). Addressing systemic problems underlying these adverse events (AEs) is imperative to ensure quality and safety in health services. This paper delves into the gap analysis between existing and desired performance concerning AEs, mainly focusing on medication errors (MEs) as a significant contributor to avoidable AEs.

The Significance of Medication Errors

Medication errors have emerged as a leading cause of AEs, necessitating attention to prevention strategies. Incomplete data, unresolved issues, and unidentified variables compound the potential for mistakes. Such errors during medication administration can result in adverse outcomes ranging from physical harm to psychological distress and even mortality (Skelly et al., 2022).

Recognizing the Need for Improvement

Understanding that MEs are critical contributors to AEs highlights the urgency of intervention. Effective collaboration is essential to elevate hospital care quality and safety, ultimately reducing adverse effects and improving health outcomes. Conducting a gap analysis to discern areas for improvement is crucial in this pursuit.

Proposed Changes

Prioritizing patient safety and treatment quality is paramount for healthcare organizations. Adverse drug events (ADEs) arising from medication administration errors pose substantial risks to patient safety (Fracica & Fracica, 2021). Capella 6212 Assessment 1. Identifying primary ADE causes is essential for implementing preventive measures and bridging the performance gap (Fracica & Fracica, 2021). This paper proposes practice adjustments within healthcare organizations, focusing on education, technology integration, medication administration protocols, communication enhancement, and regular evaluation.

NURS-FPX 6212 Assessment 1: Safety and Gap Analysis

Regular training sessions should be prioritized to enhance staff awareness, educating employees about safety protocols and common MEs to avoid (Fracica & Fracica, 2021). Establishing a timely information dissemination framework for medication policy changes is also necessary. Incorporating technology, such as a barcode portal for medication management, can improve accuracy (Kangasniemi et al., 2019).

A double-check system during medication administration could significantly reduce MAEs (Schutijser et al., 2019). A revised medication administration record can include dose, route, and timing details. Emphasizing communication and collaboration among employees is pivotal, potentially via structured reconciliation procedures or standardized handoff protocols (Cardwell et al., 2020). Regular audits and evaluations will be indispensable in assessing progress and identifying further improvements (Cardwell et al., 2020).

Prioritizing Practice Adjustments

Prioritizing practice adjustments is essential for effective implementation. Starting with education and technology integration forms a strong foundation for reducing MEs. Subsequent steps, such as refining medication administration, enhancing communication, and performing audits, build on this foundation, maximizing medication safety.

Cultivating a Culture of Quality and Safety

Implementing proposed practice changes fosters a culture of quality and safety. Capella 6212 Assessment 1. Encouraging teamwork, transparent communication, and learning enhances patient care quality and staff satisfaction (Cardiff et al., 2020). Outcome measures, including adverse events and medication error rates, are pivotal in promoting quality and safety (Säfholm et al., 2019). Capella 6212 Assessment 1.

Evaluation Strategy

Employing the Plan-Do-Study-Act (PDSA) strategy allows for a comprehensive evaluation of the proposed changes’ effectiveness. Each stage, including staff education, technology deployment, medication processes, communication, and audits, should be subjected to iterative PDSA cycles involving data collection, analysis, and adaptation.

Culture’s Impact on Quality and Safety Outcomes

Hierarchical structures can hinder communication and foster a blame culture, potentially compromising patient safety. Cultivating a culture of safety, openness, and continuous learning promotes early issue detection and resolution, benefiting patients and staff. NURS-FPX 6212 Assessment 1: Safety and Gap Analysis

Justifying Necessary Changes

Root causes of adverse events should be identified, and targeted interventions developed to justify necessary changes. Pilot testing and stakeholder engagement ensure successful implementation. Regular monitoring and evaluation confirm the changes’ efficacy in enhancing quality and safety outcomes.

Analyzing and addressing the discrepancy between existing and desired performance regarding AEs, particularly MEs, is essential for healthcare organizations. A culture of quality and safety can be cultivated by prioritizing education,  technology integration, improved protocols, enhanced communication, and consistent evaluation. NURS-FPX 6212 Assessment 1: Safety and Gap Analysis. Through systematic assessment and continuous improvement efforts, healthcare organizations can minimize AEs, improve patient outcomes, and uphold a commitment to excellence.


Cardiff, S., Sanders, K., Webster, J., & Manley, K. (2020). Guiding lights for effective workplace cultures that are also good places to work. International Practice Development Journal, 10(2).  

Cardwell, K., Smith, S. M., Clyne, B., McCullagh, L., Wallace, E., Kirke, C., & Moriarty, F. (2020). Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: A non-randomised pilot study. BMJ open, 10(6), e035087. 

Fracica, P. J., & Fracica, E. A. (2021). Patient safety. Medical Quality Management: Theory and Practice, 53-90. 

Kangasniemi, M., Karki, S., Colley, N., & Voutilainen, A. (2019). The use of robots and other automated devices in nurses’ work: An integrative review. International Journal of Nursing Practice, 25(4), e12739. 

NURS-FPX 6212 Assessment 1: Safety and Gap Analysis

Kaplan, B. (2020). Revisiting health information technology ethical, legal, and social issues and evaluation: telehealth/telemedicine and COVID-19. International journal of medical informatics, 143, 104239.  

Moore, W., & Frye, S. (2019). Review of HIPAA, Part 1: History, protected health information, and privacy and security rules. Journal of nuclear medicine technology, 47(4), 269-272. 

Nana-Sinkam, P., Kraschnewski, J., Sacco, R., Chavez, J., Fouad, M., Gal, T., … & Behar-Zusman, V. (2021). Health disparities and equity in the era of COVID-19. Journal of Clinical and Translational Science, 5(1), e99. 

Säfholm, S., Bondesson, Å., & Modig, S. (2019). Medication errors in primary health care records: A cross-sectional study in Southern Sweden. BMC Family Practice, 20, 1-7. 

Capella 6212 Assessment 1

Schutijser, B. C. F. M., Jongerden, I. P., Klopotowska, J. E., Portegijs, S., de Bruijne, M. C., & Wagner, C. (2019). Double checking injectable medication administration: Does the protocol fit clinical practice?. Safety Science, 118, 853-860. 

Skelly, C. L., Cassagnol, M., & Munakomi, S. (2022). Adverse events. In StatPearls [Internet]. StatPearls Publishing. 

Smith, A. F., & Plunkett, E. (2019). People, systems and safety: Resilience and excellence in healthcare practice. Anaesthesia, 74(4), 508-517. 

Walker, M., Hutchison, J., Lesak, D., Calvo, L., Friese, J., Garza, C., & Budin, L. (2022). Decreasing medication errors at discharge: A quality improvement project. Pediatrics, 149(1 Meeting Abstracts February 2022), 145-145.

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