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NURS FPX 4020 assessment 4 Improvement Plan Tool kit

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    NURS FPX 4020 assessment 4 Improvement Plan Tool kit

    Student Name

    Capella University

    NURS FPX 4020 Improving Quality of Care and Patient Safety

    Prof. Name


    Toolkit for Enhancing Safety Measures

    To formulate an effective safety improvement plan, a comprehensive set of information is essential, disseminated among the relevant stakeholders. In healthcare settings, information crucial for crafting a safety improvement plan is shared among healthcare professionals, administrators, leaders, and other allied professionals associated with healthcare facilities. This communication incorporates data from authentic, credible, and relevant evidence-based resources, ensuring the implementation of a justified safety improvement plan. This toolkit focuses on medication administration errors (MAEs) and is developed through an assessment using databases such as Google Scholar, PubMed Central, Capella Online Library, CINAHL, ScienceDirect, and JSTOR. The objective of this resource toolkit is to empower nurses and nurse leaders with the knowledge and understanding needed to successfully implement a medication safety improvement plan.

    Toolkit for Implementation and Sustainability

    This resource kit is structured into four easily understandable categories, facilitating nurses and nurse leaders in addressing specific concerns. The categories encompass: a) risk factors of medication administration errors, b) nurses’ and nurse managers’ roles in medication safety, c) medication error reporting, and d) evidence-based solutions for enhancing medication safety.

    Risk Factors of MAEs

    The study conducted by Assunção-Costa et al. (2022) observed medication administration errors in a Brazilian University Hospital, identifying factors such as interruptions, excessive workload, and errors in the route of administration. This study is valuable for healthcare professionals, providing insights into common factors contributing to medication administration errors and enabling the implementation of targeted safety improvement plans.

    Rostami and colleagues (2019) conducted a retrospective multicenter study in English NHS Hospitals, highlighting the prevalence of medication administration omission errors and identifying predictors such as the high number of prescribed medications. This study emphasizes the need for healthcare professionals to identify high-risk populations to implement specific strategies for preventing omission errors.

    Wondmieneh et al. (2020) conducted a cross-sectional study in Ethiopian tertiary hospitals, revealing factors like lack of training, experience, absence of standardized guidelines, and disruptions during administration as contributors to medication administration errors. This study provides actionable strategies, including continuous education and preparation of standardized guidelines, to enhance medication safety.

    Role of Nurses and Managers in Medication Safety

    Abdulmutalib and Safwat (2020) describe nursing strategies for reducing medication errors, emphasizing the role of nurses as the last line of safety in the medication process. The strategies suggested, such as increasing the workforce, managing workload effectively, and enhancing knowledge about drugs, provide concrete recommendations for nurse leaders to improve patient safety.

    Lappalainen, Härkänen, and Kvist (2019) conducted a study on the relationship between nurse managers’ transformational leadership style and medication safety. The study underscores the positive impact of a transformational leadership style on nurses’ perceptions related to medication safety, encouraging nurse leaders to adopt such a leadership approach.

    Nurmeksela et al. (2021) explored the relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level. The study recommends strategies for nurse managers to support and motivate nurses, fostering a culture of safety and patient-centered care within their workplaces.

    Medication Error Reporting

    Afaya, Konlan, and Kim Do (2021) conducted an integrative review identifying barriers to reporting medication administration errors among nurses. The study suggests changes, such as creating an enabling environment with minimal punishments, to encourage nurses to report errors and improve the overall reporting system.

    Mutair et al. (2021) conducted a methodological review, recognizing effective strategies to avoid medication errors and improve reporting systems. The study emphasizes the role of nurse managers in supporting and encouraging nurses to report errors promptly.

    Unal and Seren İntepeler (2019) presented a quasi-experimental study on the development of a medical error reporting system, showcasing a substantial increase in medication error reporting after the introduction of the system. This study highlights the importance of online reporting systems in promoting a culture of patient safety.

    Evidence-based Solutions

    Larson and Lo (2019) conducted a literature review on the potential cost savings and reduction of medication errors through the implementation of computerized provider order entry and bar-coded medication administration systems. The study recommends the combined use of these systems to prevent up to 72% of medication errors.

    Manias, Kusljic, and Wu (2020) conducted a systematic review, proposing interventions such as providers’ education, medication reconciliation, and interprofessional collaboration to reduce medication errors in medical and surgical settings. This resource provides a holistic approach to medication management, offering relevant strategies for stakeholders in the safety improvement plan.

    Salar, Kiani, and Rezaee (2020) conducted a qualitative study in Iranian hospitals, suggesting strategies like training and development of healthcare professionals, enhanced abilities of nurses in reading medication orders, and accreditation for medication practices. The study emphasizes the importance of these strategies in preventing medication errors.


    This comprehensive improvement plan toolkit, supported by credible and relevant resources, equips healthcare professionals, administrators, nurse leaders, and policymakers to implement positive reforms in medication safety. Training healthcare professionals, establishing standard guidelines, adopting technological advancements, and promoting collaboration among the interprofessional team are vital components for achieving sustainable improvement in medication safety, ultimately enhancing the quality of care and ensuring patient safety.


    Abdulmutalib, I., & Safwat, A. (2020). Nursing strategies for reducing medication errors. Egyptian Journal of Nursing and Health Sciences, 1(1), 26–41.

    Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1).

    Assunção-Costa, L., de Sousa, I. C., Silva, R. K., do Vale, A. C., Pinto, C. R., Machado, J. F., Valli, C. G., & de Souza, L. E. (2022). Observational study on medication administration errors at a University Hospital in Brazil: Incidence, nature, and associated factors. Journal of Pharmaceutical Policy and Practice, 15(1).

    NURS FPX 4020 assessment 4 Improvement Plan Tool kit

    Lappalainen, M., Härkänen, M., & Kvist, T. (2019). The relationship between nurse manager’s transformational leadership style and medication safety. Scandinavian Journal of Caring Sciences, 34(2), 357–369.

    Larson, K., & Lo, C. (2019). Potential cost savings and reduction of medication errors due to implementation of computerized provider order entry and bar-coded medication administration in the Fraser Health Authority. Univ Br C Med J, 10, 45-46.

    Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 204209862096830.

    Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., & Al-Omari, A. (2021). The effective strategies to avoid medication errors and improve reporting systems. Medicines, 8(9), 46.

    Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: A correlational study. BMC Health Services Research, 21(1).

    Rostami, P., Heal, C., Harrison, A., Parry, G., Ashcroft, D. M., & Tully, M. P. (2019). Prevalence, nature and risk factors for medication administration omissions in English NHS Hospital Inpatients: A retrospective multicentre study using medication safety thermometer data. BMJ Open, 9(6).

    NURS FPX 4020 assessment 4 Improvement Plan Tool kit

    Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13, 100235.

    Unal, A., & Seren İntepeler, S. (2019). Medical error reporting software program development and its impact on pediatric units’ reporting medical errors. Pakistan Journal of Medical Sciences, 36(2).

    Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing, 19(1).