NURS FPX4020 Assessment 1 Enhancing Quality and Safety – Medication Errors

Assessment 1: Enhancing Quality and Safety – Medication Errors

Student Name
NURS-FPX4020: Improving Quality of Care and Patient Safety
Capella University
Prof Name
Month Date, Year

Enhancing Quality and Safety – Medication Errors

The health-care system is responsible for providing patients with effective, secure, and optimum health interventions. Nowadays, the health-care system is dealing with interdisciplinary challenges that are causing underperformance and patient health outcomes. One of the key challenges that invalidates the expertise and delivery of safe and effective care delivery practices to patients is medication administration mistake. The high frequency of reported clinical hazards has raised worries about the health care system’s issues, which need quick attention to organizational, management, staff, and patient concerns in order to rehabilitate the health care system’s performance.

Scenario related to a medication administration error

Louis, a 43-year-old person suffering from suspected angina pectoris discomfort, was brought to the hospital’s intensive care unit (ICU). Because of the patient’s hypertension background and present increased blood pressure, the doctor recommended an atorvastatin and β – blockers for the night duty. Following night, the patient was examined for any more complaints and was identified with epigastric pain. He was transferred to the appropriate unit, but the notes on his bed were not updated. On the same bed, a new patient, Sheila, 54, was hospitalised in the day with shortness of breath and an underlying background of hypertensive history, hyperglycemia, and cardiovascular indications. The nurse on the morning shift gave Sheila the dosages indicated to Louis, which resulted in diarrhea, nausea, and low blood sugar. This problem arose as a result of nursing staff miscommunication and negligent notes replacement (Kane-Gill et al., 2018).

Medical Case Study

Elements of quality improvement initiatives

Quality enhancements have a direct impact on healthcare performance. Quality improvements will be more efficient and effective, and the level of performance will rise. Healthcare organisation that continues to use old techniques and approaches cannot expect to improve their performance. Quality improvements provide a chance for healthcare companies to replace inefficient processes and focus on more important topics. Switching to digital records for patient health analysis, for example. You may also use the programme to keep track of things. There are quality management software solutions available for healthcare manufacturers that enable them to manage product and process quality and reduce quality concerns through standardization and industry best practices (Asensi et al., 2018).

evidence-based practice solutions to improve patient safety

In hospitals, paper is still the most popular method of documenting information about duties. This increases the danger of missing tasks, misplacing documents, and trying to manage resources during task handover at the conclusion of shifts — all of which jeopardize patient safety. Staff would have sight of all essential information, updated centrally and in real-time, if they switched from paper to a digital system. The digitalization of task management allows personnel to reclaim time formerly spent making phone calls and bleeping colleagues to find out task and patient information, hence improving patient safety. Tasks and essential information are maintained in a user-friendly platform with digital task management, allowing employees to manage their workload more effectively. Digital task management helps multidisciplinary teams to collaborate and increase communication across hospital departments, freeing up time for patient care (Marvanova et al., 2018).  

medical ethics woman

Patient flow improvements always have a favorable knock-on effect on patient safety within hospitals. In hospitals, the treatment of a patient is frequently organized using a combination of paper lists and whiteboards. Staff may obtain essential information in real-time via a secure digital task management system, making patient organisation easier and safer. Patient safety and its significance extend beyond therapeutic outcomes (Asensi et al., 2018). According to the NHS’s Patient Safety Strategy, digitalization of resources might result in “transformational advances” in enhancing patient safety. Staff have quicker access to the relevant information with real-time updates thanks to digital task management solutions, allowing them to make fully informed choices concerning patients. According to one Infinity user, employees are now spending less time reacting to bleeps and phone calls from colleagues, which allows them to spend more time caring for patients and adds to a safer, less stressful working environment.

Risk factors of patient’s safety in medication errors

Doctors communication

Many systemic elements contribute to the chance of a medical mistake. Risky conduct by healthcare personnel, staffing shortages, sleep deprivation, and environmental concerns are among the most critical. The apparent benefits of adopting a dangerous shortcut led to repeated unsafe actions, even if the healthcare professional is aware, on some level, that patient safety may be jeopardized. Furthermore, if one healthcare professional achieves apparent success with an at-risk activity, they will most likely influence colleagues until that conduct becomes normal practice. Risky behaviour might evolve as a result of systemic issues within a healthcare institution, such as an organizational culture that tolerates such actions. Healthcare executives should conduct frequent audits of their organizations’ actions. Unnecessary complexity in processes creates several possibilities for personnel to incur risks while delivering patient care (Donaldson et al., 2017).

Role of nurses in enhancing the quality of health provisions

The nurse executive sets the vision and obtains the resources needed to guarantee the success of the organization’s quality improvement activities. Nurse managers contribute to the remaking of the health care environment by encouraging and empowering their employees in their efforts to enhance the method by which health care is delivered. The professional nurse is critical to the qualitative enhancement of health care services. However, nurses cannot implement these advances in a vacuum; they must collaborate with other experts and ancillary employees. Total quality commitment must extend to all levels of an organization’s structure. Positive interactions across departments working together to establish a dynamic system that constantly improves the processes and outcomes of health care services will result in quality patient care services. Those who provide direct services are in a great position to detect the need for change in service delivery methods (Donaldson et al., 2017)

Professional nurses have two roles in quality improvement (QI): carrying out multidisciplinary procedures to accomplish organizational QI goals and measuring, improving, and controlling nursing-sensitive indicators (NSI) impacting patient outcomes unique to nursing practices. Nurses are critical to providing safe, high-quality care at both the individual and system levels. Nurses must solve issues, make decisions, establish priorities, and work together with other team members. Nurses must detect and fix gaps in treatment that might jeopardize patients’ health. Nurses play a key role in maintaining patient safety by monitoring patients for clinical deterioration, recognizing mistakes and near misses, comprehending care procedures and system flaws, and executing a plethora of other activities (Tariq, Vashisht, & Scherbak, 2020).

Role of Stakeholders

Stakeholders are individuals or organisation who have an interest in the program’s outcomes, are interested in the evaluation’s findings, and/or have a stake in what happens with the evaluation’s findings. Patients or customers, advocacy organisation, community members, and elected officials are among those serviced or affected by the programme. Individuals and organisation such as caregivers, physicians, advocacy groups, and legislators are examples of stakeholders. By including stakeholders in your quality improvement (QI) efforts, you can assist guarantee that they are implemented properly, achieve the desired results, and contribute. Healthcare stakeholders have a significant impact on the healthcare industry’s trajectory (Elliott et al., 2018). Their assistance is critical since they give money, support, strategic direction, solutions, and other services to the healthcare sector as a whole. Their assistance is essential since they supply the resources, skills, and expertise required for the project’s implementation. Furthermore, they have an impact on the public’s perception of projected


Patient safety is critical to providing high-quality vital health services. Indeed, there is broad agreement that great health care should be effective, safe, and people-centered across the world. Furthermore, for the advantages of quality health care to be realized, health services must be timely, equitable, integrated, and efficient. Clear policies, leadership ability, data to drive safety improvements, experienced health care personnel, and effective patient engagement in their care are all required to enable the effective execution of patient safety programs.


Asensi-Vicente, J., Jiménez-Ruiz, I., & Vizcaya-Moreno, M. F. (2018). Medication errors involving nursing students: A systematic review. Nurse educator43(5), E1-E5.

Donaldson, L. J., Kelley, E. T., Dhingra-Kumar, N., Kieny, M. P., & Sheikh, A. (2017). Medication without harm: WHO’s third global patient safety challenge. The Lancet389(10080), 1680-1681.

Elliott, R., Camacho, E., Campbell, F., Jankovic, D., St James, M. M., Kaltenthaler, E., … & Faria, R. (2018). Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK.

Kane-Gill, S. L., Dasta, J. F., Buckley, M. S., Devabhakthuni, S., Liu, M., Cohen, H., … & Smith, B. S. (2017). Clinical practice guideline: safe medication use in the ICU. Critical care medicine45(9), e877-e915.

Marvanova, M., & Henkel, P. J. (2018). Collaborating on medication errors in nursing. The clinical teacher15(2), 163-168.

Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet].

World Health Organization. (2017). Medication without harm (No. WHO/HIS/SDS/2017.6). World Health Organization.