NURS FPX 6016 Assessment 2
[Student Name]
Capella University
Professor’s Name
September 2025
Quality Improvement Initiative Evaluation
People who want to work in medicine are imperfect human beings. Regretfully, among the most common causes of patient death, healthcare mistakes are not an exception. Among the top five medical mistakes that have a negative impact on patients are mistakes in the administration of medications. The proposed study will involve evaluating quality improvement initiatives. It will also examine the successes and failures of quality improvement in the context of pharmaceutical errors. The two-person verification is being examined as a method for improving quality.
Current QI initiative
As noted in NURS FPX 6016 Assessment 2, we are now concerned with verifying and replacing firewalls to stop surgical staff from injuring patients by giving them the wrong prescription. Double-checking is most often done when the medication is being administered because there are more potential mistakes during this time (Mcmullan et al., 2023). This double-checking feature in barcode medicine administration scanning helps reduce errors that could occur during the administration process. The nurse will also apply the five rights when administering medication during this period.
Prescription medications, narcotic drips, insulin therapy drips, sedative drips, vesicant drugs, TPN/PPN, and blood transfusions are all used at the facility to prevent major injury.
The two-person check is a version of additional verification when a second health professional enters her login credentials into the EMR system and confirms that everything is in order and that it is safe to provide the medication as it is being given. Research on this process to avoid negative effects and errors shows that distractions are still a significant cause to errors and uncertainty about pharmaceutical labeling (Koyama et al., 2020).
The need for analytics for program evaluation and quality improvement is highlighted by the numerous studies they conducted. The studies revealed that nurses frequently only entered their credentials because they are busy, trust the other nurse, and lack the confidence to notify the clinical supervisor in the event of an error (Pfeiffer et al., 2020).
Determining Benchmarks & Outcome Measures
In the United States alone, medication errors are thought to be responsible for between 7,000 and 9,000 fatalities annually, and the nation spends over $40 billion on treating those who have been harmed by medication errors (Justinia et al., 2021). With the exception of the Leapfrog hospital safety rating on medicine administration in the spring of 2024, it received a score of 100/100, with the lowest score being 25/100 and the average being 93.42/100. Another suggestion Leapfrog made in the report was that medication errors are significantly lower when barcode technology is used properly than when it is not used, since technology makes it more difficult for nurses to make mistakes (Hospital Safety Grade, n.d).
NURS FPX 6016 Assessment 2: Interprofessional Perspective
As noted in NURS FPX 6016 Assessment 2, current studies have shown that permitting interprofessional teams to work together can enhance treatment quality and results. This would include physicians, nurses, clinical managers, psychologists, pharmacists, and other healthcare workers. By maximizing interprofessional team collaboration it can prevent errors from emerging in the many stages of the drug process, including prescription, transcription, medication distribution, and administration. A mistake can be made at any point during these phases, and the role of the doctor, pharmacist, and nurse is to identify these mistakes before the patient becomes a victim. The last line of defense against errors is a nurse (Irajpour et al., 2019). Some of the challenges we may face when putting inter-professional collaboration into practice
include a lack of data, a heavy workload, a lack of time, a lack of understanding, and poor leadership.
I learned about the advantages and disadvantages of the two-person medication check procedure by discussing it with my coworkers. The supervisor believes it is a great way to guarantee that errors are not made when administering high-risk medications and to improve patients’ overall satisfaction. However, the bedside nurses said it was both a barrier to delivering high-quality treatment in the critical care unit and a useful tactic to avoid unfavorable results.
It may take a while for another nurse to check off and sign a medication, which could cause care to be delayed, especially if the patient is critically ill. These kinds of obstacles are the reason why we find in several research studies that nurses only believe their own signature or that of their other nurses, as they have individual patients to care for and may not have the time to stop their work to check with someone else to examine their medication. A quality improvement plan is necessary since it places one patient’s care in a better position than the other and puts obstacles in the way of nurses.
NURS FPX 6016 Assessment 2: Additional Indicators & Protocols
Temecula Valley Hospital has been developing and reimagining the patient experience for eleven years. They have reviewed their strategy, protocols, and standardized care multiple times and enhanced their delivery methods to increase patient safety and care quality. Potential indicators and steps that could be taken in coordination with pharmacists and during monthly team meetings to guarantee that all prescriptions for pharmaceuticals are quickly reconciled. Establishing an order set of patients who are cardiac or stroke patients and who should be automatically entered for discharge has been discussed as a way to discharge these patient types. PGY2 inhibitors, Brilinta, and 81 mg of aspirin are significant medications to prevent blockages.
In accordance with hospital policy, which states that patients cannot leave the hospital until they have picked up their medication and given it to the nursing staff, the staff will be able to enter the order set swiftly. By transmitting the drug to the pharmacy electronically, this reduces pharmaceutical errors compared to manual scripts, inadequate communication, and erroneous dosage. It also lessens the possibility of miscommunications and giving the patient the wrong instructions before their release. As an example of a quality improvement plan, it would also ensure that the established orders are already in the EMR, lessen the workload for the physicians.
As mentioned in NURS FPX 6016 Assessment 2, the nursing staff will have access to a quiet medication area to help them avoid errors. Medication preparation and collection should take place in a calm, restricted-access area so nurses won’t be distracted by noise. According to current research, medication errors were considerably reduced in facilities that gave their nursing staff a secure space where they could prepare and retrieve their medications without any disruptions (Berdot et al., 2021). It is challenging to accomplish this effectively due to limited accessibility, space constraints, and the combination of the drug counter and the pharmacy with supplies.
References
Koyama, A. K., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ quality & safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552
Temecula Valley Hospital. CA – Hospital Safety Grade. (n.d.). https://www.hospitalsafetygrade.org/h/temecula-valley hospital?findBy=hospital&hospital=Temecula%2BValley%2BHospital&rPos= &rSort=grade
Irajpour, A., Farzi, S., Saghaei, M., & Ravaghi, H. (2019). Effect of inter professional education of medication safety program on the medication error of physicians and nurses in the intensive care units. Journal of education and health promotion, 8, 196. https://doi.org/10.4103/jehp.jehp_200_19
McMullan, R. D., Urwin, R., Wiggins, M., & Westbrook, J. I. (2023). Are two-person checks more effective than one-person checks for safety critical tasks in high-consequence industries outside of healthcare? A systematic review. Applied ergonomics, 106, 103906. https://doi.org/10.1016/j.apergo.2022.103906
Pfeiffer, Y., Zimmermann, C., & Schwappach, D. L. B. (2020). What are we doing when we double check? BMJ quality & safety, 29(7), 536–540. https://doi.org/10.1136/bmjqs- 2019-009680
Justinia, T., Qattan, W., Almenhali, A., Abo-Khatwa, A., Alharbi, O., & Alharbi, T. (2021). Medication errors and patient safety: Evaluation of physicians’ responses to medication-related alert overrides in clinical decision support systems. Acta informatica medica : AIM : Journal of the society for medical informatics of Bosnia & Herzegovina :
casopis Drustva za medicinsku informatiku BiH, 29(4), 248–252. https://doi.org/10.5455/aim.2021.29.248-252
Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T. T., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Lê, L. M., & Sabatier, B. (2021). Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: A multi center cluster randomized controlled trial. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00671-7
