NURS FPX 8030 Assessment 1 Building the Case for Healthcare Improvement
Student Name
Capella University
NURS-FPX 8030 Evidence-Based Practice Process for the Nursing Doctoral Learner
Prof. Name
Date
PRESENTATION OUTLINE
Medication or Drug Error as a Patient Safety Issue at Healthy Elite Metropolitan Medical Center
Objectives:
- Identify internal practices necessitating change to address medication errors.
- Determine organizational priorities in addressing medical errors.
- Develop interventions and a Quality Improvement Project.
PATIENT SAFETY ISSUE: Medication/Drug Errors
- Medication errors rank as the third leading cause of death in the United States (Ferrah et al., 2017).
- One in seven patients in healthcare organizations falls victim to medication errors.
- Key medical errors include technical errors, delayed diagnosis, medication errors, inadequate post-procedure monitoring, and failure to act on test results.
PATIENT SAFETY ISSUE: Medication Error at Healthy Elite Metropolitan Medical Center
- Medication errors attributed to poor communication, administration of incorrect dosages, negligence by healthcare staff, and electronic medical record failures.
INTERNAL EVIDENCE OF MEDICATION/DRUG ERROR
- Medication errors at Health Elite Metropolitan Medical Center contribute to increased lawsuits, patient deaths, and healthcare service costs.
- The organization incurred a loss of over $17.4 million in lawsuits within the last 12 months.
- Medication errors resulted in the layoff of over 20 healthcare workers, impacting healthcare service delivery.
INTERNAL EVIDENCE OF MEDICATION/DRUG ERROR
- Timeframe
- Within 12 months: 40 –
- Within 4 weeks: 15 –
- Within 8 weeks: 13 –
EXTERNAL EVIDENCE OF MEDICATION/DRUG ERROR
- Medication errors are a common patient safety concern globally (Mulac et al., 2021; Ferrah et al., 2017).
- Research indicates a 19% prevalence of medication errors in over 36 US healthcare organizations (Mulac et al., 2021).
- Causes include unauthorized medication administration (4%), omission errors (43%), and wrong dosage administration (17%).
ORGANIZATIONAL PRIORITY FOR INTERVENTION
- Medication/drug errors significantly impact patient health, organizational operations, and community health.
- Consequences include severe physical, emotional, and psychological injuries, financial burdens, reduced community trust, and potential caregiver shortages.
- Creating awareness among patients can reduce errors, and community concern arises from loss of loved ones and caregiver shortages.
QUALITY IMPROVEMENT PROJECT AND PATIENT OUTCOME
- Quality improvement interventions:
- Development of a verification system for medication prescriptions.
- Use of barcodes.
- Creating awareness about counterchecking lookalike drugs.
- Implementing an effective medication error warning system.
- Encouraging interdisciplinary collaboration.
REFERENCES
- Ferrah, N., Lovell, J. J., & Ibrahim, J. E. (2017). Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents. Journal of the American Geriatrics Society, 65(2), 433-442.
- Hines, S., Kynoch, K., & Khalil, H. (2018). Effectiveness of interventions to prevent medication errors: an umbrella systematic review protocol. JBI Evidence Synthesis, 16(2), 291-296.
- Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy, 28(e1), e56-e61.
- Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business. Australian prescriber, 41(3), 73.
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