For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your

Improvement Plan Kit Tool

Megan Couillez

Capella University

FPX 4020

Michelle McGonigal

January 8, 2025

Improvement Plan Kit Tool

This improvement plan tool kit will aim at ensuring patient safety regarding medication administration within the healthcare setting. It has been organized into four different categories. Evidence based practice, risks and safety, patient education, and staff led strategies. It is important to remember that this is informational to professional staff as it helps identify where the organization may be lacking and how with better communication and education, patient safety and quality will improve.

Annotated Bibliography

Evidence Based Practice

Bengtsson, M., Ekedahl, A.-B., & Sjöström, K. (2021). Errors linked to medication management in nursing homes: An interview study. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00587-2

Nursing homes are very common with medication administration errors. The article discussed the perceptions of errors that have been related to medication management in nursing homes by speaking with the staff. The results showed that mistakes that do occur in medication administration are often complex. This study categorized their results into manmade, technology, and the organization concept. Often, it was found lack of knowledge from the non-licensed staff played a significant role in the study as the registered nurses were able to delegate medication administration to other staff members due to the lack of personnel. This delegation became a priority over patient safety in most cases. This led to underreporting medication error incidents as the entire care team lacked the knowledge to write an incident report if a medication error occurred or because they didn’t have time to change their routine due to limitation with staffing. In the end, the goal to minimize mistakes, you must have adequate communication when delegating and to have continuing education on safety related to administrating medication.

Jessurun, J., Hunfeld, N., de Roo, M., van Onzenoort, H., van Rosmalen, J., van Dijk, M., & van den Bemt, P. (2022). Prevalence and determinants of medication administration errors in clinical wards: A two‐centre prospective observational study. Journal of Clinical Nursing, 32(1-2), 208–220. https://doi.org/10.1111/jocn.16215

The case study followed a couple of organizations with electronical medication systems that had identified risk factors for increased medication administration errors. They observed 2576 medication administrations by registered nurses that showed an increased risk for medication administration errors during the time windows of 10am-2pm and 6pm-7am. Research concluded that registered nurses that have a higher educational level were more prone to make medication administration mistakes. The findings from the study can assist the healthcare organizations by adjusting medication administration times and encouraging continuous training and education on medications to nurses.

Kim, S., Kim, H., & Suh, H. (2022). Priorities in the prevention strategies for medication error using the analytical hierarchy process method. Healthcare, 10(3), 512. https://doi.org/10.3390/healthcare10030512

This study aims at prioritizing certain ways to help prevent medication administration errors by using the analytic hierarchy process (AHP) method. The hierarchy consists of three individual stages. Those stages are the goal of decision, decision criteria, and possible alternatives. It is a team effort to help prevent medication administration errors. One person cannot prevent all medication errors. Errors can occur for any reason, but it was found that human factors, defects in the system, and inadequate healthcare products. It has been identified that theAHP is one of the most popular methods to help solve complex problems in the healthcare setting. To help set priorities within the organization, the multiple criteria decision analysis (MCDA) is used to make those decisions and the priority set. The MCDA has been adopted by many levels of care, those being international, national, regional, and hospital setting. The preferred criteria in the system is reporting, followed by cultural and system improvement in the counterplan proposed. Providing more education and programs to the patients are the most vulnerable to medication administration errors have deemed to be the most effective from preventing medication errors from occurring.

Wolf, Z. R., Stubin, C. A., Tait, M. L., & Hughes, R. G. (2022). Best Practices Checklist for Preventing Infusion Errors: Expert Review. Medsurg Nursing, 31(1), 24-31. https://library.capella.edu/login?url=https://www.proquest.com/scholarly-journals/best-practices-checklist-preventing-infusion/docview/2630950403/se-2

The article looking into the best practice for use of medication administration processes and to validate the best infusion practices checklist, as identified in the article. The checklist provided was created by using policies and procedures. These checklists have been used in medication administration to help prevent medication errors from happening. Implementation of education on the checklists with staff and in departments that can utilize provided more awareness. The use of electronic health records (EMR), computerized physician order entry, and the barcod3e system of scanning medication also helped reduced medication related errors. These checklist help address memory failures that occur when busy, such as skipping a step. Checklists have been an aid in enhancing human shortfalls and are a way to ensure documentation of completed tasks. Medication infusion errors have been seen as the most harmful to occur to patients. By being able to trace IV infusions during a shift can decrease confusion about medications ordered and where they have infused. Being organized only helped with preventing mistakes from occurring.

Safety and Risks

Huckels-Baumgart, S., Baumgart, A., Buschmann, U., Schüpfer, G., & Manser, T. (2021). Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: A prospective observational study. Journal of Patient Safety, 17(3), e161–e168. https://doi.org/10.1097/pts.0000000000000335

This study investigated the impact of having a separate medication prep room to help improve medication safety during the medication preparation stage. Researchers in this study compared medication preparation when the organization did not have a separate medication room compared to when they had a designated medication room. The results showed that during significant interruption rate decreased during the post intervention. The decreased from 51.8 interruptions an hour to 30 interruptions an hour. It was found that nurses were the frequent sources of interruptions due to the common frequent use of the room. The study showed that organizations that do not have a designated medication room should consider implementing having one to help decrease interruptions during medication preparation, which led to reducing medication administration errors. The study also noted that the nursing staff need to recognize the effect of their interruptive ways and how to do it less.

Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223

This study identified what caused policy deviation when using the barcode medication administration system (BCMA) in the hospital. It was found that the most common variations is that the medications were not dispenses, missing barcode level, or the wrong medication dose was dispensed. It also found that organizations often do not have the functional software or equipment, such as computers or scanners. This overall affects the staff efficient during medication administration. This study would be useful for any organization to identify implications for implementing technology and strategies for improvement to promote patient safety. Examples were given of having non labeled medications be addressed so it can decrease the workload by having the label on them. It also stated that having technology that is working and functionally for the services being rendered would promote staff to use the resources more efficiently. Overall having the resources only improves patient safety and lowers the risk for medication errors.

Staff Led Strategies

Arkin, L., Schuermann, A., Penoyer, D., & Loerzel, V. (2022). Exploring nurses' attitudes, skills, and beliefs of medication safety practices. Journal of Nursing Care Quality, 37(4), 319–326. https://doi.org/10.1097/ncq.0000000000000635

The article looked into the overall beliefs and attitudes of the nursing staff held regarding medication administration errors and safety practices within the workplace. The study demonstrates that nurses are willing to report medication administration errors. It was found it did not matter how severe or minor the medication error was, it was mostly reported. Covered in the study are the severity of the medication error, retiming medications or holding medications without notifying physicians had different responses. Some stated they would use nursing judgement as it is within the scope of practice while others stated they would notify the physician before holding or retiming medications. This study shows that there is a variety in nurses’ knowledge regarding medication administration error severity and their nursing scope of practice. Organizations should focus on educating the nurses in the concepts covered in the study.

Dinius, J., Philipp, R., Ernstmann, N., Heier, L., Göritz, A. S., Pfisterer-Heise, S., Hammerschmidt, J., Bergelt, C., Hammer, A., & Körner, M. (2020). Inter-professional teamwork and its association with patient safety in german hospitals—a cross sectional study. PLOS ONE, 15(5), e0233766. https://doi.org/10.1371/journal.pone.0233766

The article focused on interdisciplinary concept. It focused on teamwork and the relationship it holds with patient safety. Teamwork, as shown in the article, is the basic definition of any interaction with at least two different health care professionals. Teamwork is the most prominent factor in the quality of care with patients. This study investigated the interprofessional teamwork, the safety related behavior, and the patient safety in hospitals. It showed that with higher teamwork comes better patient safety outcomes. Recommendations to implement team interventions is to use team building activities. This study was unique in the aspect physicians assessed patient safety and quality of care higher than the nurses did. It also showed that the longer times nurses spend with patients impacts the safety related behavior in all aspects of care. In all, if working as a team, it only promotes and perceives a high level of patient safety and care in the hospital

Salami, I., Subih, M., Darwish, R., Al-Jbarat, M., Saleh, Z., Maharmeh, M., Alasad, J., & Al-Amer, R. (2019). Medication administration errors. Journal of Nursing Care Quality, 34(2), E7–E12. https://doi.org/10.1097/ncq.0000000000000340

This study was done to get insight into the nurses’ views on perceived risk factors for medication administration errors. Most reported factor that came into contributing to medication administration errors in the study was the workload. It showed that the increased workload during times they are short staffed and having high acuity patients leads to the perception of medication administration errors was just a common practice. Organizations, once again, should use the study to advocate for adequate staffing and safe patient ratios to increase patient safety and lessen the risk of medication administration errors.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, Volume 13, 1621–1632. https://doi.org/10.2147/ijgm.s289452

The article covered the medication administration errors directly from reports and the risk factors that follow. It found that medication administration errors were two times higher in registered nurses that do not receive safe medication administration education or training. It also found that there was a higher risk with nurses who were interrupted during medication administration that medication administration errors were found to occur the most. The organizations who employ the nurses should promote medication safety and education for nurses throughout the year. The study also reported that staff should report a common trend to administration to help address interruptions to lower the risk and rate of medication administration errors.

Patient Education

Latimer, S., Hewitt, J., de Wet, C., Teasdale, T., & Gillespie, B. M. (2022). Medication reconciliation at hospital discharge: A qualitative exploration of acute care nurses' perceptions of their roles and responsibilities. Journal of Clinical Nursing, 32(7-8), 1276–1285. https://doi.org/10.1111/jocn.16275

The article shows the role of the nurse during medication reconciliation. It identifies the barriers that can occur during this time. The study acknowledges that medication reconciliation is often a collaborative effect due the complexity of patients’ health. It points out that there is often a lack of specialized training and guidance with medication reconciliation, leading to an incomplete list. In the article, it states that nurses have a minor role in reconciliation, but with more training, education, and support, nurse can lead contribute to faster discharges and increased patient safety with more efficient medication reconciliation

Suzuki, R., Uchiya, T., Nakamura, A., Okubo, N., Sakai, T., Takahashi, M., Kaneko, M., Aiba, I., & Ohtsu, F. (2022). Analysis of factors contributing to medication errors during self-management of medication in the rehabilitation ward: A case control study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07679-y

This study shows some of the causes of home medication administration errors that the patients who are discharged may have to deal with. The study focuses on reviewing and simplifying medication routines for at risk patients may be helpful to reduce medication errors at home after discharge. It is important to understand that adherence, forgetfulness, and medication costs tend to be possible causes for medication administration errors at home. The study concludes to ensure that all patients, no matter what background they come from, are educated and supported.

References

Bengtsson, M., Ekedahl, A.-B., & Sjöström, K. (2021). Errors linked to medication management in nursing homes: An interview study. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00587-2

Wolf, Z. R., Stubin, C. A., Tait, M. L., & Hughes, R. G. (2022). Best Practices Checklist for

Preventing Infusion Errors: Expert Review. Medsurg Nursing, 31(1), 24-31. https://library.capella.edu/login?url=https://www.proquest.com/scholarly-journals/best-practices-checklist-preventing-infusion/docview/2630950403/se-2