Assessment 4: Improvement Plan Tool Kit

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1ImprovementPlanToolKitPLAGIARISM.docx

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1 Improvement Plan Tool Kit

Perla Rodriguez

Capella University NURS-FPX 4030: 1 Improving Quality of Care and Patient Safety Dr. Brandi Ballantyne June 19, 2022

Introduction

1 Reducing medication errors has been discussed in various settings and by various persons. However, it still remains an issue of concern to the safety of patients as well as the quality of care offered. Therefore, in this paper, I will devise an improvement plan tool to help healthcare professionals especially nurses to minimize medication errors. The paper contains annotated bibliography of twelve articles, in four topics, each having three articles.

Importance of communication

Alert, S. E. (2017). Inadequate hand-off communication. 2 Sentinel event alert, 58(1), 6. https://jointcommission.new-media-release.com/2017_hand_off_communication/assets/SEA_58_Hand_off_Comms_83017_EMBARGOED.PDF This publication addresses inadequate hand-off communications. During hand-offs, healthcare professionals are encouraged to provide accurate information regarding patients. This is important in maintaining safety of patients through out their care. Inadequate handoffs have been linked to several medication mistakes, including double medication administration. This article helps nurses tu understand the importance of gathering and compiling all patient data, accurately and handing them over to the incoming nursing staff timely and properly.

1 Center for Drug Evaluation and Research. (2019, August 23). Working to Reduce Medication Errors. https://www.fda.gov/drugs/drug-information-consumers/working-reducemedication-errors The article delivers comprehensive information regarding medication errors. This includes causes, adverse effects, and also ways of minimizing medication errors. Additionally, it offers important information of how nurses should practice good communication with patients, involving them in their own care. This article may be useful to nurses in including their patients in their own care, like reporting any side effects, or any reactions caused by drugs. Nurses can also utilize the document to educate patients on importance of communicating any problems in regard to their health.

Raley, J., Meenakshi, R., Dent, D., Willis, R., Lawson, K., & Duzinski, S. (2017). The role of communication during trauma activations: investigating the need for team and leader communication training. Journal of Surgical Education, 74(1), 173-179.

This article discussed the importance of team leader training. It indicates that continuous training of team leaders concerning communication is important. This increases their communication skills, among healthcare professionals, reducing medication errors. Nurses need to seize the available opportunities for training. This will help them enhance their communication skills, and ultimately result to promote effective communication in the healthcare settings. Nurses may use this source to understand the importance of continuous communication training.

Proper documentation

3 Billstein-Leber, M., Carrillo, C. J. 3 D., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). 3 ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493-1517.

This article examines several ways of preventing medication errors. One of the mentioned initiatives is proper recording. according to the authors, if an adverse drug reaction occurs, the patient should be stabilized first and then the reaction (eg, allergy, contraindication, side effect, or intolerance) should be documented in the patient’s medical record to allow all practitioners caring for the patient access to the event. Nurses may utilize this document to understand why comprehensive record keeping is important in reducing medical errors

1 Martin, A., & Holland, J. (2019). 1 35 Assessing the completeness of medication reconciliation documentation by resident physicians at hospital admission for pediatric asthma patients. Paediatrics & Child Health, 24, e14-e15.

The publication investigates the impacts of failure to maintain medication reconciliation on patients. According to the authors, failure to document the medications previously taken at home during admission may post a challenge on discharge prescription, and cause medication errors. Therefore, by understanding the underlying risks, nurses need to utilize this knowledge to capture all the details during admission, as well as take part in reviewing discharge prescription for their patients, since they are patient’s advocates.

Wang, L., Blackley, S. V., Blumenthal, K. G., Yerneni, S., Goss, F. R., Lo, Y. C.,. & Zhou, L. (2020). 1 A dynamic reaction picklist for improving allergy reaction documentation in the electronic health record. Journal of the American Medical Informatics Association, 27(6), 917-923.

In this article, the authors discuss about the importance of not only disclosing medication errors, but also recording them properly and clearly. The author argues that there are increased chances of committing an additional medication error when the initial one is not recorded. In regard to nurses, they need to develop the culture of documenting errors, irrespective of the repercussions that might occur, in order to protect the patient from more errors, as well as to ensure patient safety and quality of care.

Individual Measures to Reduce Medication Errors

Melnyk, B. 4 M., Orsolini, L., Tan, A., Arslanian-Engoren, C., Melkus, G. D. 5 E., Dunbar-Jacob, J.,. & Lewis, L. M. (2018). 5 A national study links nurses’ physical and mental health to medical errors and perceived worksite wellness. Journal of Occupational and Environmental Medicine, 60(2), 126-131.

The article talks about the physiological and psychological wellbeing of nurses, the connection between health and clinical mistakes, and the link between how nurses feel about wellness endorsement and their wellbeing. Health should be a top primary concern for healthcare systems if they want to improve the health of healthcare professionals, improve the effectiveness of care, and reduce the risk of risky medical mistakes that could have been avoided. Nurses can utilize this article to learn about the negative impact their poor health can have on a patients’ safety, and be willing to report any signs of ill health.

Rodziewicz, T. 1 L., Houseman, B., & Hipskind, J. E. (2022). 1 Medical error reduction and prevention. StatPearls [Internet].

1 The article describes various ways that can be used to prevent medication errors. It does comment about double -checking. The authors stated that double-checking patients’ information right before a surgical procedure is important, to prevent surgical errors. Similarly, double checking medications before administration is crucial in reducing medication errors. Inviting the patient to confirm the procedures that are about to be done on then is a way of double checking, to prevent errors. This article invites nurses to double check procedures and medications, to verify them and ultimately reduce medication errors.

Jones, J. 1 H., & Treiber, L. A. (2018, July). 1 Nurses’ rights of medication administration: Including authority with accountability and responsibility. In Nursing forum (Vol. 53, No. 3, pp. 299-303).

1 Although the five rights of medication administration have been made mandatory in efforts to reduce medications errors, the authors state that these rights are still not followed. The article calls upon all nurse to ensure that they perform their role as caregivers, in providing quality and safe care to their patient through observing the rights of medication administration. This article is important to nurses since it urges them to take a personal and individual responsibility to ensure that patient receive the right medication, and dosages via the right route.

Disclosing medication errors

Mansour, R., Ammar, K., Al-Tabba, A., Arawi, T., Mansour, A., & Al-Hussaini, M. (2020). 6 Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center. BMC medical ethics, 21(1), 74. https://doi.org/10.1186/s12910-020-00513-2 Employing simulation seminars to educate practitioners on mistake disclosure has improved their knowledge and competence in this crucial area. They had a better understanding of Medical and Health Liability Law after attending the session. instruction on medical error disclosure, local rules, and understanding of the Medical and Health Liability Law is recommended to reduce medication errors. after reading this article, nurses can understand the importance of continuous training concerning disclosing medical errors and be vigilant to grab such opportunities when they present.

Robertson, J. 1 J., & Long, B. (2018). 1 Suffering in silence: medical error and its impact on health care providers. The Journal of emergency medicine, 54(4), 402-409.

Many of the medication errors go unreported due to the fear or imperfection, according to the author. This study aims to give understanding and encouragement for those who are trying to recover after being engaged in an unpleasant medical incident but feel as if they are battling the healing process alone. This paper encourages nurses and other health care providers to report any medication errors to ease the guilty that be associated with the error committed.

Borz-Baba, C., Johnson, M., & Gopal, V. (2020). 7 Designing a Curriculum for the Disclosure of Medical Errors: A Requirement for a Positive Patient Safety Culture. Cureus, 12(2), e6931. https://doi.org/10.7759/cureus.6931 Developing a training program on preventable medical mistakes Disclosure provides a chance to analyze the challenges that residents have when reporting and disclosing mistakes, to develop a program that is more individually tailored, and to evaluate residents' performance in a variety of core competency areas. This article can be helpful for nurse educators in their periodic review of curriculum, or during curriculum development, to ensure that nurses receive knowledge that is improves their error reporting habits.

References

Alert, S. E. (2017). Inadequate hand-off communication. 2 Sentinel event alert, 58(1), 6. https://jointcommission.new-media-release.com/2017_hand_off_communication/assets/SEA_58_Hand_off_Comms_83017_EMBARGOED.PDF Billstein-Leber, M., Carrillo, C. J. 3 D., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). 3 ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493-1517.

Borz-Baba, C., Johnson, M., & Gopal, V. (2020). 7 Designing a Curriculum for the Disclosure of Medical Errors: A Requirement for a Positive Patient Safety Culture. Cureus, 12(2), e6931. https://doi.org/10.7759/cureus.6931 Center for Drug Evaluation and Research. 1 (2019, August 23). Working to Reduce Medication Errors. https://www.fda.gov/drugs/drug-information-consumers/working-reducemedication-errors.

Robertson, J. 1 J., & Long, B. (2018). 1 Suffering in silence: medical error and its impact on health care providers. The Journal of emergency medicine, 54(4), 402-409.

Rodziewicz, T. 1 L., Houseman, B., & Hipskind, J. E. (2022). 1 Medical error reduction and prevention. StatPearls [Internet].

1 Wang, L., Blackley, S. V., Blumenthal, K. G., Yerneni, S., Goss, F. R., Lo, Y. C.,. & Zhou, L. (2020). 1 A dynamic reaction picklist for improving allergy reaction documentation in the electronic health record. Journal of the American Medical Informatics Association, 27(6), 917-923.

NURS-FPX4020_007780_1_1223_OEE_33 - NURS-FPX4020 - SPRING 2022 - SECTION 33

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3 3 https://www.coursehero.com/file/p1a0qa4q/Reference-Buljac-Samard%C5%BEi%C4%87-M-van-Woerkom-M-2018-Severity-and-workload-of/  ~~Citation is highlighted. Click to remove highlighting~~ 

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6 6 https://en.wikipedia.org/wiki?curid=718324  ~~Citation is highlighted. Click to remove highlighting~~ 

7 7 https://www.cureus.com/articles/27149-designing-a-curriculum-for-the-disclosure-of-medical-errors-a-requirement-for-a-positive-patient-safety-culture  ~~Citation is highlighted. Click to remove highlighting~~ 