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Capella 4020 Assessment 1

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    Capella 4020 Assessment 1

    Capella 4020 Assessment 1 Enhancing Quality and Safety

    Student Name

    Capella University

    NURS-FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name


    Enhancing Quality and Safety – Medication Administration

    The administration of medication is a global health concern and the leading cause of patient complications in hospitals. In hospitals, medication administration is the most commonly reported safety incident. The selection of a medication administration route, such as orally or intravenously, is influenced by drug characteristics and pharmacokinetics, as well as convenience (Panagioti et al., 2019). Nurses are primarily responsible for administering medication, and like pharmacists, they can also prepare and distribute pharmaceuticals, following hospital policies for medication administration on the units.

    Registered Nurses (RNs) are also responsible for interpreting and comprehending prescriptions, suggesting medication modifications, and assessing and reporting drug effects. To increase patient safety, nurses must anticipate potential errors in drug administration and take precautions to avoid them. Implementing complex multi-professional interventions to foster a culture of safety is challenging, but effective programs can be achieved through effective leadership, organizational control, and performance evaluation based on relevant data.

    Elements of Successful Quality Initiative

    Adverse Drug Events (ADEs) are more commonly associated with drugs that have complicated dosing schedules or are prescribed in specialized settings such as critical care units, emergency rooms, and diagnostic and interventional sections. The Comprehensive Accreditation Manual for Critical Access Hospitals (CAHs) outlines the detailed medication safety quality requirements in conjunction with the Joint Commission, but only 328 out of 1,328 CAHs have achieved Joint Commission accreditation (Remick et al., 2020).

    Fatal medication errors often involve medicines for the cardiovascular system, anti-neoplastic, and the central nervous system (Bourneau‐Martin et al., 2023). Inappropriate dose (38%), incorrect medication (15%), prescription errors (24%) and incorrect mode of administration are the most common types of errors leading to high patient mortality (9.5%) (Mulac et al., 2021). Verbal and written errors, name ambiguity, similar or dubious container labelling, skill or technical shortcomings, inappropriate packaging, and poor device design can all be blamed for these fatalities. It is imperative to address these causes to prevent ADEs and ensure patient safety.

    Using Technology

    Various technologies have been developed to prevent medication errors, which can have harmful consequences for patients. Electronic prescribing entry, pharmaceutical safety alerts, medicine and patient barcoding, intelligent Iv fluid pump, and single-use medication packages are a few examples of such technology. These technologies have proven to be very effective in minimizing medication errors when implemented in combination with efficient procedures, well-trained personnel, and a distraction-free environment.

    For instance, computerized order entry systems can reduce errors in prescribing, while medication safety alerts can provide warnings when a medication may be contraindicated for a patient due to their medical history or current medication regimen. Similar to smart infusion pumps, barcode technology might guarantee that the right drug is being given to the right patient and that the right dose is being supplied. Moreover, single-use medication packets can prevent mix-ups caused by similar-looking or sounding medications. Overall, these technologies can significantly improve patient safety by minimizing the occurrence of medication errors (Wolf & Hughes, 2019).

    Barcode Administration

    Barcode medication administration (BMA) technology has proven  to be highly effective in reducing medication errors related to patient identification, medication selection, and dosage. Implementation of extensive barcoding and electronic medical administration technology has resulted in a 41 percent decrease in medication errors and a 51 percent decrease in potential ADE. The technology has also led to a 54.5%  risk reduction in medication errors (Kung et al., 2021). By scanning both the medication and the patient barcode, the system is able to match the medication to the correct patient, verify the dosage, and provide real-time documentation of the medication administration. The implementation of barcode medication administration technology has the potential to greatly improve medication safety and patient outcomes (Zheng et al., 2021).

    Health Literacy

    To ensure patient safety and adherence to medication regimens, it is essential to provide adequate information to patients and their caregivers regarding medication administration and potential side effects. Such information should be conveyed both orally and in written form. Patients with poor health literacy may require additional support to understand instructions, and social workers can be engaged to assist in such cases (Marquez et al., 2021).

    Taking Care of LASA Drugs

    To minimize medication errors, it is important to take steps to prevent confusion between medications that have similar sounds or appearances (LASA drugs). Ruutiainen et al (2021) identified a list of drugs that are particularly problematic due to their similarity in names, packaging, or administration device designs. One effective technique to reduce errors is the use of a strategy which emphasizes the differences between similar-sounding medication names. Additionally, labels can be added to alert healthcare providers to the presence of LASA drugs. To prevent confusion, it is also essential to teach patients and carers about LASA drugs and how to recognize them. By implementing these measures, medication errors due to LASA drugs can be minimized.

    Factors Leading to Patient Safety Risk

    There are a number of elements that can increase the potential risks to medication administration safety. The Medicare Beneficiary Quality Improvement Project (MBQIP) has identified medication safety as a significant area of concern, and research has identified specific factors that can increase the risk of medication errors and adverse drug events (ADEs) during medication administration (Herzog et al., 2022).

    One factor is medication errors, which can occur due to various reasons, such as illegible handwriting, confusion between medications with similar names or packaging, and a lack of adequate information or training among healthcare providers and patients. A study by Rocha et al. (2021) found that smart pumps with integrated decision-support software can help reduce ADEs, with 50% of avoidable ADEs occurring due to pump-related errors (Howlett, 2020). Another factor is inappropriate medication dosing, which can lead to adverse drug events, especially among vulnerable patient populations such as children and the elderly.

    According to a study by Khalil and Huang (2020), inappropriate medication dosing is a common medication error in pediatric patients, which can result in adverse drug events. Another factor is missed medication doses, which can result in suboptimal treatment outcomes and increased healthcare costs. A study by Mertens et al. (2022) found that missed medication doses are a common issue among hospitalized patients, especially in patients with cognitive impairment or polypharmacy. Low health literacy is another factor that can lead to medication safety risks, as patients may not understand medication instructions or be able to communicate effectively with healthcare providers.

    Capella 4020 Assessment 1

    A study by Persell et al. (2020) found that low health literacy was associated with higher rates of medication non-adherence and medication errors among patients with chronic diseases. Inadequate patient-provider communication is another factor that can contribute to medication safety risks, as patients may not receive adequate information about their medications or be able to communicate concerns or questions to healthcare providers. A study by Alqenae et al. (2020) found that inadequate communication between healthcare providers and patients is a significant contributor to medication errors and adverse drug events.

    Standard safety procedures are also essential for medication administration to reduce medication errors and ADEs. A study by Paulino et al. (2019) found that implementing standard safety procedures, such as using barcode scanning and medication reconciliation, can help reduce medication administration errors in the emergency department.

    In conclusion, medication safety risks during medication administration can arise due to various factors, including medication errors, inappropriate dosing, missed doses, low health literacy, inadequate patient-provider communication, and the absence of standard safety procedures. Addressing these factors through effective communication, education, and the implementation of standard safety procedures can help reduce medication errors and improve patient outcomes.

    Organizational Interventions To Promote Patient Safety

    • CPOE for Improper medicine: This risk can be mitigated by using computerized physician order entry (CPOE) systems, which can reduce the likelihood of transcription errors and miscommunication between healthcare providers. A study by Gates et al. (2019) found that CPOE systems reduced the rate of medication errors by 44.7%.
    • CPOE for Inappropriate dose: CPOE systems can also help with this risk by providing decision support for dosing based on patient characteristics such as weight, age, and renal function. Additionally, implementing standardized order sets for commonly prescribed medications can reduce the risk of dosing errors (Corny et al, 2020).
    • Technological Advances: Patient education and clear instructions for medication administration can help reduce the risk of missed doses. Additionally, electronic reminders and alerts for missed doses can be implemented in CPOE systems and electronic health records (EHRs) (Melton et al., 2021).

    Capella 4020 Assessment 1

    • Health literacy: Providing patients with clear and concise medication instructions in plain language can help improve understanding and reduce the risk of medication errors. Using teach-back techniques, where patients are asked to repeat back instructions in their own words, can also help ensure comprehension. In addition to providing clear medication instructions, healthcare providers can also use visual aids such as pictograms to help patients understand how to take their medications. Using medication therapy management services, where a pharmacist works with the patient to manage their medications, can also help improve medication adherence and reduce the risk of errors (Marquez et al., 2021).
    • Patient-provider communication: Improving communication between healthcare providers and patients can help reduce the risk of medication errors. This can include using plain language, involving patients in decision-making, and providing opportunities for patients to ask questions (Marquez et al., 2021).
    • Standard safety procedures: Implementing standard safety procedures such as the “five rights” of medication administration (right patient, right medication, right dose, right route, and right time) can help reduce the risk of medication errors. Additionally, using barcode scanning technology for medication administration can improve accuracy and reduce the risk of errors (Kung et al., 2021).

    Role of Nurses

    In order to effectively drive quality and safety enhancements with medication administration, nurses must identify and coordinate with a variety of stakeholders. One key stakeholder group is patients and their families, who play a crucial role in ensuring accurate medication administration by communicating any allergies, previous adverse reactions, and current medications to healthcare providers. Nurses must also involve physicians in medication administration, as they are responsible for prescribing and adjusting medications.

    Pharmacists are another important stakeholder group, as they can provide medication expertise and help to ensure that medications are properly stored, dispensed, and administered. In addition, healthcare administrators and leaders play a critical role in driving quality and safety enhancements, as they can provide resources, establish policies and procedures, and promote a culture of safety within the healthcare organization.

    Nursing supervisors and managers are also key stakeholders, as they provide oversight and support to nurses in their medication administration duties and can help to identify and address any barriers to safe medication practices. Finally, advocacy groups and professional organizations can play an important role in promoting medication safety by advocating for policy changes, developing best practices, and providing education and training opportunities for healthcare providers.

    Capella 4020 Assessment 1

    By coordinating with these stakeholders, nurses can drive quality and safety enhancements in medication administration and ensure that all individuals involved in the healthcare system are working together to promote patient safety and positive health outcomes.

    Nurses must employ various tactics to prevent or reduce the likelihood of medication administration errors, such as verifying the right prescription for the right patient, having procedures in place for medication reconciliation when transferring patients, familiarizing themselves with medication policies, and being aware of medication standards like the Beers list, black box warning labels, and look-alike/sound-alike medicine lists. Educating nurses on the institution’s procedures for ordering, transcribing, administering, and documenting medications is also critical. By working collaboratively with stakeholders, nurses can ensure successful outcomes that benefit all those involved in the healthcare system (Tagwa, 2019).


    The healthcare system faces numerous challenges in terms of management and delivery. One critical area of concern that has been identified by international health organizations is medication administration errors, which impede the provision of effective and patient-centered care. A variety of factors, including nursing staff, management practices, and working conditions, may contribute to errors in medication administration. However, with appropriate management and oversight strategies, nurses can improve patient outcomes and healthcare standards by promoting engagement, coordination, and equitable compensation.


    Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug safety43, 517-537.  

    Bourneau‐Martin, D., Babin, M., Grandvuillemin, A., Mullet, C., Salvo, F., Singier, A., … & French Network of Regional Pharmacovigilance Centres. (2023). Adverse drug reaction related to drug shortage: A retrospective study on the French National Pharmacovigilance Database. British Journal of Clinical Pharmacology89(3), 1080-1088. 

    Corny, J., Rajkumar, A., Martin, O., Dode, X., Lajonchère, J. P., Billuart, O., … & Buronfosse, A. (2020). A machine learning–based clinical decision support system to identify prescriptions with a high risk of medication error. Journal of the American Medical Informatics Association27(11), 1688-1694. 

    Gates, P. J., Baysari, M. T., Gazarian, M., Raban, M. Z., Meyerson, S., & Westbrook, J. I. (2019). Prevalence of medication errors among paediatric inpatients: systematic review and meta-analysis. Drug Safety42, 1329-1342. 

    Herzog, M. B., Fried, J. E., Liebers, D. T., & MacKinney, A. C. (2022). Development of An All‐Payer Quality Program for the Pennsylvania Rural Health Model. The Journal of Rural Health38(1), 270-281. 

    Howlett, M. (2020). The Impact of Technology on Medication Safety in Paediatric Critical Care (Doctoral dissertation, Royal College of Surgeons in Ireland). 

    Capella 4020 Assessment 1

    Khalil, H., & Huang, C. (2020). Adverse drug reactions in primary care: a scoping review. BMC health services research20(1), 1-13.  

    Küng, K., Aeschbacher, K., Rütsche, A., Goette, J., Zürcher, S., Schmidli, J., & Schwendimann, R. (2021). Effect of barcode technology on medication preparation safety: a quasi-experimental study. International journal for quality in health care33(1), mzab043. 

    Márquez Fosser, S., Mahmoud, N., Habib, B., Weir, D. L., Chan, F., El Halabieh, R., … & Tamblyn, R. (2021). Smart about medications (SAM): a digital solution to enhance medication management following hospital discharge. JAMIA open4(2), ooab037.  

    Melton, G. B., McDonald, C. J., Tang, P. C., & Hripcsak, G. (2021). Electronic health records. In Biomedical Informatics: Computer Applications in Health Care and Biomedicine (pp. 467-509). Cham: Springer International Publishing. 

    Mertens, V., Jacobs, L., Knops, N., Alemzadeh, S. M., Vandeven, K., Swartenbroekx, J., … & Vandewoude, M. (2022). Bedside medication review with cognitive and depression screening by a clinical pharmacist as part of a comprehensive geriatric assessment in hospitalized older patients with polypharmacy: A pilot study. Plos one17(10), e0276402. 

    Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy28(e1), e56-e61.  

    Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., … & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMI366. 

    Capella 4020 Assessment 1

    Paulino, E., Thomas, D., Lee, S. W. H., & Cooper, J. C. (2019). Dispensing process, medication reconciliation, patient counseling, and medication adherence. In Clinical Pharmacy Education, Practice and Research (pp. 109-120). Elsevier. 

    Persell, S. D., Karmali, K. N., Lee, J. Y., Lazar, D., Brown, T., Friesema, E. M., & Wolf, M. S. (2020). Associations between health literacy and medication self-management among community health center patients with uncontrolled hypertension. Patient Preference and Adherence, 87-95.  

    Remick, K. E., Janofsky, S., & Leetch, A. (2020). Pediatric readiness: A safeguard for emergency department patients and providers. Emergency Medicine Reports41(20). 

    Ruutiainen, H. K., Kallio, M. M., & Kuitunen, S. K. (2021). Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets. European Journal of Hospital Pharmacy28(e1), e151-e156. 

    Tagwa, A. (2019). Nurses’ Knowledge regarding Medication Error at Royal Care International Hospital, Khartoum State, Sudan (2019). 

    Wolf, Z. R., & Hughes, R. G. (2019). Best practices to decrease infusion-associated medication errors. Journal of Infusion Nursing42(4), 183-192. 

    Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2021). The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: A systematic review. Research in Social and Administrative Pharmacy17(5), 832-841.