PRACTICE IMPROVEMENT PLAN PROPOSAL
pdf
keyboard_arrow_up
School
Western Governors University *
*We aren’t endorsed by this school
Course
MISC
Subject
Health Science
Date
Jan 9, 2024
Type
Pages
8
Uploaded by cutiepiecantu
PRACTICE IMPROVEMENT PLAN PROPOSAL Cristina Cantu Western Governors University ORGANIZATIONAL SYSTEMS AND HEALTHCARE TRANSFORMATION — D221 Molly Hall 12/12/23
Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, and recommendation using the (SBAR) format. S – Situation: Patient safety is a top priority in a hospital setting. Nurses have many responsibilities when caring for patients. This includes assessments, advocating for patients, and medication administration. In collaboration with medical providers, nurses treat patients based on doctor’s orders and treatment plans. A small error can jeopardize patient safety and result in unexpected consequences. In this healthcare-related situation, errors in medication administration are a major cause for concern and needs consistent and continuous discussions to put policies in place to minimize the problem. B – Background: Describe the data that supports or would support the need for change. In a recent article published in 2023 regarding medication errors statistics and facts, the Food and Drug administration receives over 100,000 reports each year of medication errors in the United States and of that 100,000, 10% of those patients are in a hospital setting. 1 in 5 doses of medication during a patient's hospital visit will be administered incorrectly (Zauderer 2023). That constitutes a great safety concern and a need for solutions. Patient safety is one of the national standards and many healthcare organizations make this a priority every year. There must be ever evolving interventions to help prevent the reoccurrence of most medication errors among the patient population. Explain how one or more national patient safety standards apply to this situation. There’re two national safety standards that would be applicable to this situation of Medication Administration Errors. The first is to “Identify patients correctly”, this is done by verifying their full name and date of birth. Second, is the “Use medicines safely NPSG.03.04.01”. Medications that are not labeled, like syringes,
cups, or basins should be labeled and set up where medication is stored. These two safety standards should help reinforcement and minimize medication errors and help maintain patient safety. A – Assess: Medication errors have a huge impact for patients in the healthcare setting because patients want to feel safe and trust that the medical team is doing their part to the best of their ability and as accurately as possible. Patients expect to feel better after going to the hospital or clinic and after receiving treatment which creates value in their experience. 7 million Americans have been impacted in some way by medical errors each year. Of those patients in America, 7,000
to 9,000 people will die from medical errors. That number is way to high for an error that can potentially be prevented. Nurses are impacted tremendously because it’s their main job to keep patients safe from the start of a patients visit until the end of the visit. Administering the wrong medication will create distrust from the patient toward the nurse. Medication errors can lead to legal issues and malpractice claims against the health care facility which can result in financial penalties, damage to reputation, and increased scrutiny. Healthcare organizations end up spending over $40 billion each year for patients that have had a negative impact from medical errors. R – Recommend: Discuss how this recommendation aligns with the principles of a high-
reliability organization. Highly reliable organizations like, The Institute For Safe Medication Practices, promote consistent processes like Barcode scanning medication administration or BSMA, which enforces a standardized approach to medication verification and administration. Healthcare providers follow a consistent and standardized workflow ensuring that the right medication is given to the right patient, in the right dose, right route, and right time. The goal of highly reliable organizations is to minimize errors and improve patient safety. Barcode scanning medication administration significantly reduces the potential for medication errors and also verifies medications at the point of administration,
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
reducing reliance on manual processes and decreasing the risk of human error. Barcode scanning ensures that medication information is captured and transmitted electronically. Reducing the likelihood of transcription errors or misinterpretation of handwritten information. It also promotes accurate documentation and enhances the integrity of medication errors which is crucial for patient safety and continuity of care. b. Describe two potential barriers to the recommended practice change. Two barriers to the recommended practice change of a Bar Code Medication Administration are learning how to use the new system properly and policy deviations. Increased workload or disrupted workflow with the use of BCMA, could result in workarounds
or task-related deviations where tasks involving use of barcode scanning during dispensing and administration aren’t followed per policy, such as carrying prescanned medications or not scanning meds at all. The staff not knowing how to use BCMA programs will increase the workflow time to scan and administer the medication thus creating a real challenge in an emergency situation. c. Identify two potential interventions to minimize the barriers to the recommended practice change. Two interventions to minimize the barriers to the recommended practice change of a Bar Code Medication Administration is providing education for staff members on how to properly use the programs with demonstrations and hands on classes where staff can get familiar with the new system. A survey can also be given at the end of the class where staff can give their feedback on things that they might have found challenging which will give good insight on what needs to be addressed to make the change successful.
d. Discuss the significance of shared decision-making among the healthcare setting’s relevant stakeholders in implementing this recommendation. Shared decision making is a collaborative approach that involves patients, health care providers, and relevant stakeholders working together to make informed healthcare decisions. By involving patients in the decision making process, health care providers can explain the benefits of barcode scanning administration, address any concerns or questions and ensure that patients understand the importance of medication safety. Implementing barcode scanning medication administration requires the support and cooperation of various stakeholders including hospital administrators, pharmacist, nurses, and IT professionals. Shared decision making allows these stakeholders to collaborate, share their expertise, and collectively determine the best strategies for successful implementation. e. Describe an outcome measure that could be used to evaluate the results of the recommendation. A way to measure the outcome that would be used to evaluate the results of the recommended implementation of the Bar Code Medication Administration system into the healthcare setting would be the number of medication errors reported at the end of the year versus the previous year where the BCMA was not used. When scanning a patients wristband barcode, then scanning a medication, the information is compared with details in the electronic medication administration record (eMAR) and if a mismatch is detected, the nurse is alerted, typically with a visual or auditory warning on the computer screen. By having to acknowledge this alert, it will keep track of how many times this is occurring and at what time of day its occurring to show a trend, if there is one. Those trends can be looked at specifically and investigated to see what can be done to help improve the outcome. f. Describe the care delivery model currently being used in the healthcare setting. The Total Patient Care Model is the method currently being used. This is where one nurse is assigned to a group of
patients to provide care. The nurse has a huge responsibility to provide quality care within a certain timeframe and as efficient as possible. Any ways to help the nurse manage her time more efficiently using technology benefits the nurse as well as the patients. i. Explain how the current care delivery model in the healthcare setting identified be impacted by the recommended change. With the implementation of the recommended change of using a BCMA, Total Patient Care Model would be greatly impacted because nurses can scan pts wristbands. serving as an identifier, and scan medication, which the computer will let the nurse know whether the medication is the right medication for that person. In addition, it will alert the nurse of any allergies or contraindications for that patient when used in conjunction with the eMar. This should increase time and efficiency while decreasing medication errors thus saving potential injury and harm to patients. This recommended practice change will positively impact the organization by reducing rates in medication administration errors, increase nurse satisfaction, and improve patient outcomes.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
References
Targeted Medication Safety Best Practices for Hospitals
. (2023, February 14). Institute for Safe Medication Practices. https://www.ismp.org/guidelines/best-practices-hospitals Medication administration errors and associated factors among nurses
. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7764714/ Medication dispensing errors and prevention - StatPearls - NCBI bookshelf
. (2023, May 2). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK519065/ 29 medication errors statistics & facts (2023)
. (2023, December 6). Life-Changing ABA Therapy - Cross River Therapy. https://www.crossrivertherapy.com/medication-errors-statistics# Hamilton, V. (2022, October 26). What are the 7 rights of medication?
WebMD. https://www.webmd.com/drug-medication/what-are-the-7-rights-of-medication National Patient Safety Goals
. (n.d.). A Trusted Partner in Patient Care | The Joint Commission. https://www.jointcommission.org/standards/national-patient-safety-goals/ Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations
. (n.d.). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8606443
Nursing care delivery models and Intraprofessional collaborative care: Canadian nurse leaders’ perspectives
. (2022, January). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9583196/