Safety quality issue in a health care setting.

Develop a 3–5 page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.
Introduction
Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).
The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.
You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.
Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.
Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.
Scenario
Select one of the safety quality issues presented in the Assessment 01 Supplement: Enhancing Quality and Safety [PDF] Download Assessment 01 Supplement: Enhancing Quality and Safety [PDF]resource and incorporate evidence-based strategies to support communication and ensure safe and effective care.
Instructions
For this assessment, you will analyze a safety quality issue in a health care setting and identify a quality improvement (QI) initiative.
Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.
• Explain factors leading to a specific patient-safety risk in a health care setting.
• Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
• Explain how nurses can help coordinate care to increase patient safety and reduce costs.
• Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
• Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
• Length of submission: 3–5 pages, plus title and reference pages.
• Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
• APA formatting: References and citations are formatted according to current APA style.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
• Competency 1: Analyze the elements of a successful quality improvement initiative.
o Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
• Competency 2: Analyze factors that lead to patient safety risks.
o Explain factors leading to a specific patient-safety risk in a health care setting.
• Competency 4: Explain the nurse's role in coordinating care to enhance quality and reduce costs.
o Explain how nurses can help coordinate care to increase patient safety and reduce costs.
o Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
• Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
o Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
o Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

Full Answer Section

      Factors Leading to Medication Errors Medication errors stem from various factors within the complex healthcare system. Here are some key contributors:
  • Look-alike/Sound-alike Drugs: Medications with similar names or appearances can lead to confusion during selection or administration (James, 2019).
  • Inadequate Communication: Incomplete or unclear communication among healthcare providers regarding allergies, medication history, and dosage can be detrimental (Institute for Safe Medication Practices [ISMP], 2023).
  • Understaffing and Workload: Limited staffing and heavy workloads can contribute to fatigue and distraction, increasing the risk of errors (Agency for Healthcare Research and Quality [AHRQ], 2023).
  • Technology Issues: Inadequate medication administration systems or poorly designed interfaces can lead to errors during order entry or dispensing (AHRQ, 2023).
Evidence-Based Solutions for Medication Safety Implementing evidence-based solutions can significantly reduce medication errors. Here are some key strategies:
  • Standardized Medication Naming: Standardizing medication names using tall man lettering and avoiding abbreviations minimizes confusion due to look-alike/sound-alike drugs (ISMP, 2023).
  • Tall Man Lettering: Utilizing uppercase letters for all brand and generic names emphasizes key differences, improving medication identification (ISMP, 2023).
  • Bar-code Medication Administration Systems (BCMA): Implementing BCMA systems provides an extra layer of safety by verifying medication at the point of care (Institute of Medicine [IOM], 2006).
  • Computerized Physician Order Entry (CPOE): CPOE systems with built-in drug interaction checks can prevent potentially harmful combinations (IOM, 2006).
  • Improved Communication: Encouraging clear and concise communication among healthcare providers regarding medication history, allergies, and rationale for medication selection promotes patient safety (ISMP, 2023).
The Role of Nurses in Enhancing Medication Safety Nurses play a pivotal role in ensuring medication safety at the bedside. Here's how nurses can contribute:
  • Double-checking medications: Nurses should independently verify medications against physician orders before administration.
  • Patient education: Educating patients about their medications, including their purpose, dosage, and potential side effects, empowers them to participate in their care.
  • Reporting errors: Creating a culture of safety where nurses feel comfortable reporting medication errors without fear of blame is crucial for identifying and preventing future occurrences (AHRQ, 2023).
  • Advocacy for best practices: Nurses can advocate for implementing evidence-based practices, such as BCMA and CPOE systems, to enhance safety within their institutions.
  • Collaboration: Effective collaboration between nurses, pharmacists, and physicians regarding medication management promotes comprehensive patient care and reduces medication errors.
Stakeholders in Medication Safety Ensuring medication safety requires collaboration among various stakeholders:
  • Nurses: Nurses are at the forefront of medication administration and play a critical role in identifying and preventing errors.
  • Physicians: Physicians hold the responsibility for prescribing medications with clear and accurate orders.
  • Pharmacists: Pharmacists serve as medication experts, reviewing orders for accuracy and dispensing medications safely.
  • Hospital Administration: Hospital administration provides the resources and leadership to implement safety initiatives and invest in technology like BCMA and CPOE systems.
  • Regulatory Agencies: Regulatory agencies, like The Joint Commission, set national standards and monitor medication safety practices within healthcare institutions.
Conclusion Medication errors are a persistent threat to patient safety. By implementing evidence-based solutions, fostering clear communication, and empowering nurses to advocate for best practices, healthcare institutions can significantly reduce medication errors. Collaboration among nurses, physicians, pharmacists, and hospital administration is vital to create a culture of safety where patient well-being remains the top priority.  

Sample Answer

  Patient safety is paramount in healthcare delivery. Medication errors, however, remain a significant threat, causing patient harm and increasing healthcare costs. Nurses, comprising the largest healthcare workforce, play a vital role in safeguarding patients from medication errors. This paper examines medication errors in acute care settings, analyzing contributing factors, evidence-based solutions, and the role of nurses in driving safety improvements.