NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Planning for Change: A Leader’s Vision

Medication errors (MEs) pose a significant challenge at Mercy General Hospital (MGH). They impact patient safety, healthcare quality, and operational efficiency. This presentation outlines strategies to mitigate these errors and foster a culture of safety and excellence. The goal is to refine institutional workflows, improve staff practices, and enhance system functionality to drive better patient outcomes. It minimizes medical mistakes and lays the groundwork for continuous quality improvement.

Presentation Objectives

This presentation will: 

• Emphasize MEs as the primary focus when assessing the organization’s quality of care and commitment to patient safety.
• Outline a structured approach to resolve the issue and strengthen the MGH safety framework, preventing errors that compromise patient well-being.
• Assess the existing workflows, staff practices, and operational dynamics that influence patient safety outcomes.
• Benchmarking metrics like medication error frequency, patient experience scores, and staff adherence rates before and after implementation help gauge progress.
•  Provide targeted strategies to enhance safety performance, drive improvements, implement key changes, and strengthen staff training initiatives.
• Present a vision for a safety-focused, quality healthcare setting, emphasizing the nurse leader’s pivotal role in driving and sustaining this change.

Organizational Problem

MEs remain a persistent issue within our organization, occurring at a rate of 40 per 1,000 patient days. These errors threaten patient safety, care standards, and institutional credibility. At MGH, key contributing factors include a high patient influx that strains staff capacity. It limits the time available for meticulous medication administration. The complexity of treatment plans, especially for individuals managing multiple chronic illnesses, heightens the risk of dosage miscalculations and adverse drug interactions (Tariq et al., 2024). Additionally, workforce shortages and excessive workloads amplify the problem.

It leads to fatigue, miscommunication, and inconsistent adherence to safety protocols. The repercussions are severe, resulting in patient harm, prolonged hospitalizations, escalating healthcare expenses, and eroding public trust. In the United States, preventable MEs adverse events account for an estimated 44,000 to 98,000 hospital deaths annually, exceeding fatalities from motor vehicle accidents (Tariq et al., 2024). MEs negatively impact staff well-being, increasing stress levels and diminishing job satisfaction. Addressing these systemic challenges is essential to cultivating a culture of safety. It minimizes errors and enhances patient outcomes.

Comprehensive Quality and Safety Plan

The execution of an inclusive strategy is proposed to reduce MEs, as detailed below:

Enhancing Medication Safety with BCMA

The plan is to prioritize the implementation of enhanced Barcode Medication Administration (BCMA) systems to reduce MEs. BCMA is a technology-driven solution that uses barcode scanning to verify patient identity, medication type, dosage, and timing before administration. This technology will support clinicians in making safer decisions. It prevents patient harm (Tariq et al., 2024). As part of this initiative, establishing policies that promote the effective use of BCMA and ensuring staff training is essential. Proper training will facilitate the standardization of safety protocols and improve key aspects such as medication safety and accurate patient data management for care teams.

Integration of EHRs with Decision-Support Tools

The strategy prioritizes the integration of advanced Electronic Health Records (EHRs) equipped with clinical decision-support systems to mitigate MEs. These systems incorporate real-time alerts for potential drug interactions, adverse events, and dosage adjustments. It empowers staff to make safer, well-informed clinical decisions (Tariq et al., 2024). Establishing inclusive policies that promote optimal EHR utilization is essential to ensure the successful execution of these solutions. Staff training on EHR functionalities will be crucial in standardizing safety protocols and providing instant access to critical information regarding medication management and patient data for healthcare providers.

Standardized Handoff Communication Protocols

MGH can enhance patient safety by adopting structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to minimize errors during handoffs, especially medication-related. This method ensures clear, concise, and complete information transfer (Bindra et al., 2021). Regular training sessions, simulated scenarios, and performance evaluations will reinforce SBAR’s use among multidisciplinary teams. Employing comprehensive training programs will ensure healthcare professionals develop strong communication skills and apply SBAR in clinical practice. Effective and precise communication will strengthen patient care, reduce miscommunication, and cultivate a safety culture. 

Existing Organizational Functions, Processes, and Behaviors

Several organizational factors contribute to MEs at MGH. It includes a high patient load, complex medication regimens, excessive workload, and inadequate staffing. Inefficient communication channels and poorly coordinated handoffs hinder the accurate transfer of critical medication data. It increases the risk of errors (Bindra et al., 2021). The absence of integrated EHRs with decision-support features limits access to real-time data and alerts. It restricts providers’ ability to prevent medication-related mistakes. Moreover, the lack of structured staff training on proper medication management compromises patient safety by failing to reinforce standardized best practices (Lou et al., 2022).

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

However, without BCMA, manual verification processes increase the risk of administration mistakes. It contributes to preventable adverse drug events. Organizational culture is pivotal in ensuring medication safety and care quality. A culture that prioritizes transparency, accountability, and collaboration encourages staff to report errors and near misses for learning and improvement without fear of punishment (Tariq et al., 2024). Conversely, a high-pressure work environment with inadequate procedural support leads to non-compliance with safety protocols, as seen at MGH.

At MGH, numerous uncertainties and unresolved questions persist regarding medication safety. A gap in identifying the primary contributors to MEs, whether they originate from systemic inefficiencies or human mistakes, remains unclear. Additionally, concerns exist about the efficiency of current training programs and clinical practices in minimizing these errors. A deeper analysis is required to determine the precise impact of staffing shortages on error rates. Limited insights on the challenges obstructing the full integration of BCMA and decision-support functionalities within the EHR system are available. Addressing these knowledge gaps through targeted research and strategic interventions is essential for enhancing patient safety.

Current Outcome Measures

At MGH, medication safety and quality evaluation will rely on three key indicators: the frequency of MEs, patient satisfaction ratings, and staff adherence to set medication guidelines.

1. The MEs rate is a clear and quantifiable metric for assessing medication safety. It provides precise data on the rate of errors within the organization. It helps pinpoint areas needing improvement and tracks progress over time. However, this measure has limitations, as it may not capture all errors. It includes near misses or incidents that did not result in harm. It does not identify underlying causes, such as staffing deficiencies or communication breakdowns, making it insufficient for conducting a thorough cause-and-effect analysis.
2. Patient satisfaction scores offer insight into the perceived quality of care. They reflect patients’ experiences with medication management and treatment (Lee et al., 2021). Higher ratings indicate improved care delivery and enhanced patient safety. However, these scores are subjective and can be affected by external factors such as the hospital environment and prescription wait times. They may not fully capture specific safety concerns or identify medication-related issues. It limits their usefulness in analytic areas for targeted improvement.
3. Staff adherence metrics assess the extent to which healthcare personnel follow established safety protocols. It impacts medication safety (Berdot et al., 2021). High adherence indicates effective execution of safety measures across the MGH. However, this metric does not necessarily correlate with care quality. It focuses on procedural compliance rather than patient outcomes. It may fail to reflect how protocols are applied in complex clinical scenarios or under time constraints. It limits its ability to capture real-world challenges in medication administration.

Actionable Plan to Achieve Improved Outcomes

The actions necessary to achieve the anticipated outcomes for each planned strategy are as follows: 

Enhancing Medication Safety with BCMA

1. Implement necessary policy updates to mandate BCMA usage for enhanced medication safety.
2. Regular audits should be carried out to verify conformity with BCMA protocols.
3. Train staff on using BCMA to verify medication interactions, allergies, and accurate dosages.
4. Implement monitoring mechanisms to detect and prevent potential MEs as part of the BCMA system.
5. Regularly enhance the system with updated clinical guidelines and enhanced safety protocols.

Integration of EHRs with Decision-Support Tools

1. 1. Integrate instant notifications to detect and prevent potential MEs within EHR systems.

Standardized Handoff Communication Protocols

1. 1. Incorporate SBAR training into onboarding programs and constant professional development for staff.