NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

 

Enhancing Quality and Safety

Every step is crucial in healthcare, and medication has essentiality among all steps because any wrong prescription of delivering wrong medication can lead to putting danger someone’s life. Medication errors refer to wrong administration, whether orally or intravenously. For this purpose, healthcare practitioners focus on providing secure and safe medication by enhancing its quality. Hence, this assessment will determine the leading factors that help in patient-safety risk, especially in medication administration. The role of nurses and the best-practice solution will also be considered to improve the quality and reduce costs. Furthermore, stakeholder involvement in this scenario cannot be avoided, so we will emphasize their role in better coordination and driving safety enhancement with medication administration.

Scenario Chosen for Medication Administration

St. Luke’s Magic Valley medical center performed a medication error that caused the 7-month-old infant to die after receiving a dose of saline solution infused intravenously with potassium phosphate, which is used for adult patients (Prentice, 2022). The whole process occurred by mismanagement and misunderstanding as one nurse prepared the adult’s medication which was mistaken by another nurse and administered to the infant. The child’s name was August Elliot, and the prescribed medication for the adult patient was reported in August’s room. When August faced cardiac arrest after 10 minutes of taking medication, the staff started making continuous efforts to save him. After 13 minutes, nurses analyzed the medication and realized that august had injected the cardiac medication. After that incident, the hospital tightened its medication administration, and the investigations were forwarded to the Nation’s top hospital accreditation board and the Twin Falls County Coroner (Ross, 2019). 

The incident takes place because of lacking focus and responsibility by the nurses. The nurses did not perform their duties well and lack of professionalism which caused one family to lose their child. The nurses did not fulfill the SOPs, nor were the policies considered in the hospital.  

NURS FPX 4020 Assessment 1 Attempt 1 Enhancing Quality and Safety 

Evidence-based and Best Practices 

Despite all other medical errors, medication errors are on the top list and most common in hospitals, impacting thousands of lives and leading them to deaths. The Melnyk et al. study evaluated the healthcare outcomes measures, medication errors, and pharmacy, staffing, and demographic variables. That study demonstrated that 913 hospitals reported medication errors from 1116 hospital population that impacted the patient care outcomes, and each hospital faces 5.07% (Melnyk et al., 2018) medication error each year and experience medication error every 22.7 hours.  

Hence, some best practices were introduced by the American Society of Health-System Pharmacists (ASHP) and the National Center for Biotechnology Information (NCBI) to prevent medication errors in hospitals. The main motive was to figure out at what functions the medication errors occur, so Ordering/prescribing, documenting, transcribing, dispensing, administering, and monitoring are the main functions of medication errors. 

For all these issues World Health Organization (WHO) and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) emphasize providing best practices such as: 

• Verifying orders 
• Usage of barcodes (Cleveland Clinic, 2019)
• Alert on the same name or pronounce medication 
• Double checking each prescribing 
• Implementation of effective warning systems 
• Improve the involvement of patient
• Outlining the issues with details 
• Effective communication among doctors, nurses, and pharmacists
• Document conversation and decisions  (Tariq & Scherbak, 2021)

Safety and quality enhancement require strong insights and decision-making, which exceptional leadership skills can bring. Those leaders with a strong grip on their guts and insights can deliver high-quality results and improve medication administration at the right time for the right person. Medical errors can be prevented through proper monitoring and technological record systems, which reduce the impact of same-name pronunciation errors or bad writing do

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