Evaluation of Quality Improvement Actions and Technologies

Assignment 1
Introduction
Patient safety is the top priority in healthcare settings. Despite initiatives to improve
safety through technology advancements, training, and quality improvement (QI)
programs, medical errors still happen. While some mistakes cause only small
damage, others have disastrous results. Finding weaknesses and enhancing patient
safety requires analyzing adverse occurrences and near misses (Agency for
Healthcare Research and Quality, 2019). An adverse event in a healthcare context is
thoroughly examined in this study, along with its consequences for stakeholders, root
cause analysis, current quality improvement initiatives, and a suggested QI project to
stop such incidents in the future.
Implications of the Adverse Event for Stakeholders
Many parties are impacted by an unfavorable occurrence, including patients, medical
professionals, organizations, and government agencies. Patients go through mental
and physical pain, which makes them less trusting of medical services. Healthcare
professionals may experience mental hardship, reputational harm, and legal
repercussions, all of which could exacerbate burnout (Caspi et al., 2023). Institutions
face financial obligations, regulatory scrutiny, and damage to their reputation.
Regulators have the authority to enforce stronger safety regulations and levy fines.
Examining these ramifications aids in creating focused strategies to reduce potential
hazards.
In addition, families of patients impacted by unfavorable incidents frequently endure
emotional anguish and suffering (Agency for Healthcare Research and Quality,
2019). When mistakes are made, the effect also extends to caregivers, who may
experience moral discomfort. Policymakers and insurers must also modify their
regulations to resolve liability issues and stop similar catastrophes in the future. A
thorough approach to enhancing healthcare quality and safety is ensured by an
understanding of the wider effects of adverse events.
This analysis assumes that medical errors create a ripple effect, extending beyond
immediate harm to patients and affecting the broader healthcare system. It is based
on the premise that adverse events impact trust, financial stability, and professional
well-being, reinforcing the need for systemic interventions. Additionally, it assumes
that regulatory agencies respond to safety incidents by implementing stricter policies,
which in turn influence institutional practices and safety protocols.
Sequence of Events and Root Cause Analysis
A pharmaceutical administration error that resulted in serious patient problems was
the subject of a root cause analysis (RCA). Among the things that happened were
incorrect dosage calculations, a breakdown in communication between physicians
and nursing personnel, and a failure to cross-reference with computerized medical
data (Caspi et al., 2023). Processes that were neglected included inadequate
medication reconciliation, a lack of double-checking procedures, and verbal
instructions rather than written documentation. Communication breakdowns,
ineffective workflow, and insufficient training were the main factors found.
Interviews with participating personnel, a study of patient data, and an analysis of
hospital policy were all part of the RCA process. The bad incident was caused by
systemic problems such as shift changes, nursing workload, and insufficient alert
systems. Preventing recurrence and enhancing patient safety in general require
addressing these underlying causes.
While the RCA identified major contributing factors, knowledge gaps remain
regarding the specific role of environmental and human factors in the error. Further
investigation is needed into how staff fatigue, stress levels, and cognitive overload
may have influenced decision-making. Additionally, analyzing whether institutional
policies on medication safety were effectively communicated and adhered to could
provide deeper insights. More detailed data on near-miss incidents and the
effectiveness of existing intervention measures could further strengthen the findings
and lead to more targeted solutions.
Evaluation of Quality Improvement Actions and Technologies
To lower pharmaceutical errors, a number of QI initiatives and technologies are used
in different institutions. Prescription mistakes are decreased by Electronic Health
Records (EHR) systems that incorporate medication reconciliation. By guaranteeing
that the appropriate patient receives the appropriate drug, barcode medication
administration (BCMA) improves accuracy. Prescriptions are digitized by
computerized physician order entry (CPOE), which reduces transcription errors
(Harris et al., 2022). The usefulness of automated verification methods is
demonstrated by the notable decreases in medication errors reported by institutions
using these technologies.
Principles of human factors engineering can also improve the usability and uptake of
technology. Alerts for possible medication interactions and dosage errors are
provided by the use of real-time clinical decision support systems (CDSS). These
systems are improved through regular audits and staff feedback procedures,
guaranteeing their efficacy in lowering unfavorable incidents.
Comparison with Other Institutions’ Solutions
Globally, healthcare facilities have used some tactics to avoid unfavorable outcomes.
For example, some hospitals require that high-risk drugs be verified by two nurses.
Others regularly teach employees about pharmaceutical safety procedures (Mahat et
al., 2022). Proactive mistake prevention is encouraged by establishing a culture of
safety where employees can report near-misses without worrying about
consequences. Institutions can improve patient safety by honing their QI activities by
studying successful models.
The advantages of interdisciplinary cooperation and patient involvement in
medication management are illustrated by case studies from top institutions. To
reduce administration errors, for instance, several institutions have put in place
patient education initiatives and bedside medication verification. Comparing
healthcare settings to high-performing hospitals can help find best practices and
promote ongoing improvement.
Metrics Supporting the Need for Improvement
Metrics are essential for defending QI programs. According to hospital incident
records, drug errors cause over 7,000 deaths in the United States each year (Harris
et al., 2022). Medication errors that cause patient damage lengthen healing periods
and raise healthcare expenses. The necessity of implementing evidence-based
treatments was shown by data from institutions that used BCMA, which revealed a
50% decrease in administration errors.
The frequency of avoidable errors is highlighted by additional examination of
hospital-acquired conditions (HACs) and patient safety indicators (PSIs) (Mahat et
al., 2022). Adverse drug event (ADE) rates, readmission rates, and medication
reconciliation compliance rates are examples of performance metrics that are used
as benchmarks in QI initiatives. Tracking these metrics over time helps assess the
effectiveness of implemented initiatives and directs the creation of new strategies.
Proposed Quality Improvement Initiative
A comprehensive QI strategy is suggested to stop negative situations in the future.
Important elements consist of:
Enhanced Staff Training: Regular competency assessments and mandatory
training sessions on medication safety.
Integration of Technology: Expansion of EHR, BCMA, and CPOE systems to
minimize manual errors.
Standardized Communication Protocols: Implementing structured handoff
procedures and requiring written documentation for verbal orders.
Error Reporting System: Encouraging a non-punitive reporting culture to identify
near misses and prevent recurrence.
Patient Education: Involving patients in medication management through clear
communication and education initiatives.
Continuous Monitoring and Evaluation: Establishing a quality improvement
committee to review error reports and implement corrective actions based on data
trends.
Staff participation, resource allocation, and leadership commitment are necessary for
the implementation of this QI effort. Stakeholder involvement, employee incentives,
and feedback loops are examples of change management techniques that can
improve the initiative’s uptake and sustainability.
While this initiative aligns with best practices, conflicting data and alternative
perspectives must be considered. Some studies suggest that increased reliance on
technology, such as BCMA and CPOE, can introduce new types of errors, such as
alert fatigue or system downtime, which may hinder rather than enhance patient
safety (Harris et al., 2022). Additionally, while a non-punitive reporting culture
encourages transparency, some healthcare professionals may still fear
repercussions or perceive reporting as time-consuming. Resource constraints,
particularly in smaller healthcare institutions, may limit the feasibility of full-scale
implementation. Addressing these concerns by balancing human oversight with
technology, simplifying reporting processes, and tailoring solutions to institutional
capacities can help create a more effective and adaptable improvement strategy.
Conclusion
Examining adverse occurrences and near-misses offers important information about
weaknesses in patient safety. A root cause analysis identifies structural problems
that call for focused fixes. Evidence-based practice improvements are informed by
assessing other institutions’ effective QI procedures. The planned QI program
combines technology, training, enhanced communication, and a strong reporting
mechanism to increase pharmaceutical safety. By putting these safeguards in place,
a culture of safety will be promoted, which will ultimately improve patient outcomes
and lower avoidable medical errors.
References
Agency for Healthcare Research and Quality. (2019, September 7). Adverse events,
Near misses, and Errors. Ahrq.gov.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
Caspi, H., Perlman, Y., & Westreich, S. (2023). Managing near-miss reporting in
hospitals: The dynamics between staff members’ willingness to report and
management’s handling of near-miss events. Safety Science, 164, 106147.
https://doi.org/10.1016/j.ssci.2023.106147
Clifton, D. (2024, February 29). What Are Near-Miss Events in Healthcare?
MedTrainer. https://medtrainer.com/blog/near-miss-events-in-healthcare/
Harris, I. B., Dowell, P., & Mossburg, S. E. (2022, April 27). Annual Perspective:
Topics in Medication Safety. Annual Perspective: Topics in Medication Safety.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety?utm
_source=chatgpt.com
Mahat, S., Rafferty, A. M., Vehviläinen-Julkunen, K., & Härkänen, M. (2022).
Negative emotions experienced by healthcare staff following medication
administration errors: a descriptive study using text-mining and content analysis of
incident data. BMC Health Services Research, 22(1).
https://doi.org/10.1186/s12913-022-08818-1
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