NURS4020 Improving Quality of Care and Patient Safety ​​​​​​​Enhancing Quality and Safety

The primary purpose of the healthcare system is to provide improved quality of care that enhances patient safety and satisfaction. This paper explains the factors involved in patient safety risks due to Medication Administration Errors (MAEs) that lead to adverse events or sometimes cost a patient’s life. MAEs occur due to violating the five medication administration rights, including incorrect drug, patient, dose, frequency, and time. Further in the paper, evidence-based practices and solutions are provided to improve patient safety by reducing MA errors. Moreover, the nurse’s role and collaboration with different stakeholders are also explained, which reduces the cost and enhances the quality of care within the healthcare system.  

Factors Leading to Specific Patient Safety Risks 

The patient, Jiliana, is a 60-year-old woman with anaphylactic symptoms who came to the emergency room in the community hospital. The patient’s medical history revealed hypertension and obesity. Upon the examination, the doctor prescribed a handwritten prescription which mentioned to “administer Epinephrine 1mg” only. The duty nurse without further probing into the correct route, administered her Epinephrine to aid with allergic symptoms through an intravenous route, which immediately caused an intense, crushing pain that made her lose consciousness. The resuscitation team in the hospital was called. Through supplemental oxygen and other resuscitation methods, the patient was reverted.

However, this incident was a life-threatening situation for the patient. Hence, a comprehensive case investigation was performed. The case investigation revealed several factors involved in this incident that led to the mild but reversible condition. One of the factors is the negligence of healthcare professionals while prescribing and administering medications. While the physician neglected to consider the patient’s hypertensive history before ordering a drug and did not mention the route in the prescription, the nurse neglected to double-check with the doctor and the pharmacist before administering the drug.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Another factor is the communication gap among the healthcare professionals as there was a lack of collaboration among the physician, pharmacist, and nurses which led to the adverse drug event, eventually causing complications for the patients. According to the literature, most MAEs occur due to negligent behaviour and lack of communication among healthcare professionals. This negligence and communication gap leads to several preventable adverse events which are harmful to patient safety (Tariq & Scherbak, 2023). Health literacy is another important factor. Like in the given scenario the doctor did not check the patient’s medical history as she has hypertension, and prescribed medication that could be harmful to the patient.

Health literacy of healthcare providers related to medication and risk factors associated with medication administration is an essential component of preventing patients’ safety (Mueller et al., 2019). Lastly, the lack of technological involvement in the medication management process led to a significant issue in Jiliana’s case. If the hospital had the Electronic Health Records (EHR) and Electronic Medication Administration Records (EMAR) system, there would be minimal chances of medication errors as a shared portal would have improved communication and alerted every healthcare professional for potential errors.

Evidence-Based and Best Practice Solutions 

Incidences like the one described above may bring various challenges related to patient safety which can be addressed using several evidence-based and best practices. 

Standardized Guidelines:

The Joint Commission International Accreditation (JCIA) body has helped healthcare organizations and healthcare professionals to create a safer evidence-based practice and environment for patients and healthcare providers to enhance patient safety by providing standardized patient safety goals (patient identification and medication management). These goals are related to medication administration as, which will help in preventing errors if followed adequately in the healthcare settings (ElLithy et al., 2023). 

Effective Communication:

The communication between healthcare professionals, such as physicians, pharmacists, and nurses, helps to improve patient safety in the healthcare setting. Effective Communication of the healthcare providers is enhanced when the experienced professional provide training and session to the novice nurse about medication administration. Effective communication during novice nurse training reduces the hospital’s cost to hire experien