NURS FPX 6212 Assessment 3 Outcome Measures, Issues, And Opportunities

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Assessment 3: Outcome Measures, Issues, and Opportunities
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Capella University
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Prof Name
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FEB 10, 2024

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Key Findings and Opportunities for Improvement
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In this preliminary report, attention is directed towards outcome measures and

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opportunities for improvement, encompassing a change model strategy aimed at

evaluating all facets of patient care. Annually, preventable medication errors result in
44,000 to 98,000 fatalities within U.S. healthcare institutions. Statistics reveal that out of
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every 100 hospital admissions, 6.5 patients encounter adverse events related to
medication errors (Carver et al., 2019). Various types of medication errors occur,
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including those during prescription, transcription, administration, and monitoring, each

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impacting patient health and leading to adverse outcomes such as disabilities, paralysis,
comorbidities, and even mortality. Hence, it is imperative to identify performance
challenges, assess outcomes, measures, and opportunities to address these issues,
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facilitating prospective enhancements in medication safety.

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Functions, Processes, and Practices in Exemplary Organizations
High-performing healthcare entities continually strive for enhancement and identify

avenues for betterment. To mitigate medication errors, such organizations implement
training and educational initiatives to ensure that healthcare personnel are well-versed
in medication safety and the associated risks. They develop and execute various plans
and strategies, including incident reporting systems and technology-driven medication
management, to ensure safe medication administration and monitoring. Additionally,
these organizations advocate for medication reconciliation during care transitions and
admission, leveraging technological tools such as computerized physician order entry
(CPOE), clinical decision support systems (CDSS), electronic health records (EHR),
and barcode medication administration (BCMA) (Carver et al., 2019). These practices
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aid healthcare professionals in minimizing medication errors across prescription,
transcription, administration, and monitoring phases.
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Promoting a Supportive Environment
Exemplary organizations cultivate a blame-free culture to encourage immediate
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reporting of medication errors through incident reporting systems. They also ensure
adequate staffing levels to mitigate staff burnout, which can contribute to the occurrence
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of medication errors (Kwon et al., 2021). Effective communication among team leads
and staff members regarding medication management and safe administration is
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encouraged, fostering a culture of leadership within the organization (Ledlow et al.,
2023). However, there remains uncertainty regarding how these organizations sustain
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these functions and processes during resource constraints and economic downturns.
Additionally, addressing nurse shortages and elevated turnover rates while preventing
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medication errors necessitates further exploration to enhance analysis.

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Impact of Organizational Functions on Outcomes
The functions, processes, and behaviors of healthcare organizations concerning

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medication errors and their prevention significantly influence outcome measures, both
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positively and negatively, directly affecting patient safety. Organizations with robust
leadership and governance prioritize medication safety by providing effective guidelines,
allocating adequate resources, and delivering comprehensive training, thereby reducing
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medication errors and improving patient outcomes. Conversely, a lack of leadership,

interprofessional collaboration, and transparent communication on medication
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management negatively impacts health outcomes, leading to increased

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medication-associated mortality rates. It is presumed that implementing preventive
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measures such as technology utilization, leadership enhancement, and accountability
governance fosters safe medication administration, while promoting interprofessional
collaboration, hands-off communication, and technology-driven medication
management helps mitigate medication errors.
Quality and Safety Outcomes with Relevant Measures
Medication errors encompass various types, each associated with quality and safety
outcomes that directly impact patient well-being. Prescription errors, dispensing errors,
and administration errors contribute to patient harm, mortality rates, and reduced patient
satisfaction. Preventive measures include implementing communication strategies,
utilizing technology for medication management, involving interprofessional teams, and
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promoting double-check procedures to minimize errors and enhance patient
satisfaction.
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Identifying Performance Issues and Opportunities
Healthcare organizations encounter several performance challenges and opportunities
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related to medication error prevention. These include communication breakdowns
among interprofessional teams, insufficient staff training on medication administration
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technologies, documentation issues, and staff burnout leading to rushed medication
administration and increased error rates. Addressing these challenges requires
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fostering interdisciplinary collaboration, enhancing communication, providing
comprehensive training on technology usage, and implementing strategies to alleviate
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staff burnout.
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Outlining a Strategy: DMAIC Model
To address medication error issues effectively, the DMAIC model (Define, Measure,
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Analyze, Improve, and Control) can be employed. This methodology entails:

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● Define: Clearly delineating types of medication errors and setting specific goals
for improvement.
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● Measure: Collecting data on medication errors and establishing baseline rates.

● Analyze: Conducting root-cause analysis to identify improvement opportunities.
● Improve: Collaboratively devising improvement plans and implementing
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changes.
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● Control: Monitoring and evaluating the effectiveness of implemented changes,

standardizing procedures, and revising policies as needed.
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Conclusion
This report underscores the importance of recognizing outcome measures, performance

issues, and improvement opportunities to mitigate medication errors in healthcare
settings. It highlights the impact of organizational functions on outcome measures and
outlines a strategy utilizing the DMAIC model to ensure comprehensive patient care and
knowledge sharing among staff.
References
● Carver, N., Hipskind, J. E., & Gupta, V. (2019). Medical error. StatPearls
Publishing.
● Kwon, C.-Y., Lee, B., Kwon, O-Jin., Kim, M.-S., Sim, K.-L., & Choi, Y.-H. (2021).
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Emotional labor, burnout, medical error, and turnover intention among South
Korean nursing staff in a university hospital setting. International Journal of
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Environmental Research and Public Health, 18(19), 10111.
● Ledlow, G. R., Ledlow, J. R. R. R., Bosworth, M., & Maryon, T. (2023).
Leadership for health professionals: Theory, skills, and applications. Jones &
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Bartlett Learning.
● Mulac, A., Mathiesen, L., Taxis, K., & Gerd Granås, A. (2021). Barcode
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medication administration technology use in hospital practice: A mixed-methods
observational study of policy deviations. BMJ Quality & Safety, 30(12),
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1021–1030.
● Musharyanti, L., Claramita, M., Haryanti, F., & Dwiprahasto, I. (2019). Why do
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nursing students make medication errors? A qualitative study in Indonesia.

Journal of Taibah University Medical Sciences, 14(3), 282–288.
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FEB 10, 2024

In this preliminary report, attention is directed towards outcome measures and

opportunities for improvement, encompassing a change model strategy aimed at

including those during prescription, transcription, administration, and monitoring, each

facilitating prospective enhancements in medication safety.

High-performing healthcare entities continually strive for enhancement and identify

Exemplary organizations cultivate a blame-free culture to encourage immediate

medication errors necessitates further exploration to enhance analysis.

Impact of Organizational Functions on Outcomes

The functions, processes, and behaviors of healthcare organizations concerning

medication errors and improving patient outcomes. Conversely, a lack of leadership,

management negatively impacts health outcomes, leading to increased

medication-associated mortality rates. It is presumed that implementing preventive

Quality and Safety Outcomes with Relevant Measures

Healthcare organizations encounter several performance challenges and opportunities

Outlining a Strategy: DMAIC Model

Analyze, Improve, and Control) can be employed. This methodology entails:

● Measure: Collecting data on medication errors and establishing baseline rates.

● Control: Monitoring and evaluating the effectiveness of implemented changes,

This report underscores the importance of recognizing outcome measures, performance

nursing students make medication errors? A qualitative study in Indonesia.

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