Medication Error Quality Improvement Initiative Paper

rite a 5–7-page a comprehensive analysis on an adverse event or near miss from your professional nursing experience. Integrate research and data on the event and use as a basis to propose a quality improvement (QI) initiative in your current organization. The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Nurses and other health professionals with specializations and/or interest in the condition, disease, or the selected issue are your target audience. QUESTIONS TO CONSIDER As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment. Reflect on quality improvement (QI) initiatives in your workplace: • • •Medication Error Quality Improvement Initiative Paper

What makes a QI initiative a success? What elements must be incorporated? What opportunities are there for interprofessional collaboration on a QI initiative in your workplace? Proficiency in interpretation of data is critical to understanding and communicating QI outcome measures. What can be done to improve data literacy across interprofessional teams? Preparation Instruction Prepare a comprehensive analysis on an adverse event or near-miss from your professional nursing experience that you or a peer experienced. Integrate research and data on the event and use as a basis to propose a Quality Improvement (QI) initiative in your current organization. The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Adverse Event or Near-miss Analysis addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion. 1. Analyze the missed steps or protocol deviations related to an adverse event or near miss. • Describe how the event resulted from a patient’s medical management rather than from the underlying condition. • Identify and evaluate the missed steps or protocol deviations that led to the event. • Discuss the extent to which the incident was preventable. • Research the impact of the same type of adverse event or near miss in other facilities. 2. Analyze the implications of the adverse event or near miss for all stakeholders. • Evaluate both short-term and long-term effects on the stakeholders (patient, family, interprofessional team, facility, community). Analyze how it was managed and who was involved. • Analyze the responsibilities and actions of the interprofessional team. Explain what measures should have been taken and identify the responsible parties or roles. • Describe any change to process or protocol implemented after the incident.

3. Evaluate quality improvement technologies related to the event that are required to reduce risk and increase patient safety. • Analyze the quality improvement technologies that were put in place to increase patient safety and prevent a repeat of similar events. • Determine whether the technologies are being utilized appropriately. • Explore how other institutions integrated solutions to prevent these types of events. 4. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement. • Identify the salient data that is associated with the adverse event or near miss that is generated from the facility’s dashboard. (By dashboard, we mean the data that is generated from the information technology platform that provides integrated operational, financial, clinical, and patient safety data for health care management.) • Analyze what the relevant metrics show. • Explain research or data related to the adverse event or near miss that is available outside of your institution. Compare internal data to external data. 5. Outline a quality improvement initiative to prevent a future adverse event or near miss. • Explain how the process or protocol is now managed and monitored in your facility. • Evaluate how other institutions addressed similar incidents or events.

• Analyze QI initiatives developed to prevent similar incidents, and explain why they are successful. Provide evidence of their success. • Propose solutions for your selected institution that can be implemented to prevent future adverse events or near-miss incidents. 6. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. 7. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style. Submission Requirements • • • Length of submission: A minimum of five but no more than seven double-spaced, typed pages. Number of references: Cite a minimum of three sources (no older than seven years, unless seminal work) of scholarly or professional evidence that support your evaluation, recommendations, and plans. APA formatting: Resources and citations are formatted according to current APA style and formatting. Required Resources MSN Program Journey The following is a useful map that will guide you as you continue your MSN program. This map gives you an overview of all the steps required to prepare for your practicum and to complete your degree. It also outlines the support that will be available to you along the way. • MSN Program Journey | Transcript. Suggested Resources The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The Nursing Masters (MSN) Research Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you. Capella Resources Capella provides a thorough selection of online resources to help you understand APA style and use it effectively. • APA Module. Adverse Events and Reporting These resources explore how cultures focused on safety learn from adverse events. • • Rafter, N., Hickey, A., Condell, S., Conroy, R., O’Connor, P., Vaughan, D., & Williams, D. (2014).Medication Error Quality Improvement Initiative Paper

Adverse events in healthcare: Learning from mistakes. QJM: Monthly Journal of the Association of Physicians, 108(4), 273–277. Retrieved from https://academic.oup.com/qjmed/article-lookup/doi/10.1093/qjmed/hcu145 Skinner, L., Tripp, T. R., Scouler, D., & Pechacek, J. M. (2015). Partnerships with aviation: Promoting a culture of safety in health care. Creative Nursing; Minneapolis, 21(3), 179–185. The following resources explore the benefits and challenges of incident reporting systems. • Harrison, R., Lawton, R., & Stewart, K. (2014). Doctors’ experiences of adverse events in secondary care: The professional and personal impact. Clinical Medicine, 14(6), 585– 590. • Crane, S., Sloane, P. D., Elder, N., Cohen, L., Laughtenschlaeger, N., Walsh, K., & Zimmerman, S. (2015). Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes. Journal of the American Board of Family Medicine, 28(4), 452–460. Retrieved from http://www.jabfm.org/content/28/4/452 This resource examines organizational factors that lead to adverse events and near-miss incidents. • Patterson, M. E., & Pace, H. A. (2016) A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists. Journal of Patient Safety, 12(2), 114–117. Reporting Systems These resources provide comprehensive event reporting systems data and performance assessment information: • The Joint Commission. (2017). National patient safety goals. Retrieved from https://www.jointcommission.org/standards_information/npsgs.aspx • U.S. Food & Drug Administration. (2017). FDA adverse event reporting system (FAERS). Retrieved from http://www.fda.gov/Drugs/InformationOnDrugs/ucm135151.htm • Hospital Consumer Assessment of Healthcare Providers and Systems. (2017). CAHPS hospital survey. Retrieved from http://hcahpsonline.org/ This resource provides examples of adverse events and near-miss incidents: • Agency for Healthcare Research and Quality. (2016). WebM&M cases & commentaries. Retrieved from https://psnet.ahrq.gov/webmm Adverse Event or Near Miss Analysis Scoring Guide CRITERIA Analyze the missed steps or protocol deviations related to an adverse event or near miss. NONPERFORMANCE Does not list the missed steps or protocol deviations related to an BASIC PROFICIENT DISTINGUISHED Lists the missed steps or protocol deviations related to an adverse event or near Analyzes the missed steps or protocol deviations related to an adverse event or near miss. Analyzes the missed steps or protocol deviations related to an adverse event or near miss,Medication Error Quality Improvement Initiative Paper

CRITERIA NONPERFORMANCE BASIC PROFICIENT DISTINGUISHED adverse event or near miss. miss, but fails to analyze how they led to the adverse event or near miss. and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty (where further information could improve the analysis). Analyze the implications of the adverse event or near miss for all stakeholders. Does not list the implications of the adverse event or near miss for all stakeholders. Lists possible impacts of the adverse event or near miss for stakeholders, but fails to analyze their short- or long-term implications for the stakeholders. Analyzes the implications of the adverse event or near miss for all stakeholders. Analyzes the implications of the adverse event or near miss for all stakeholders, and identifies assumptions on which the analysis is based. Evaluate quality improvement technologies related to the event that are required to reduce Does not list quality improvement technologies related to the event that are required to reduce risk Lists quality improvement technologies related to the event that could reduce risk or increase patient Evaluates quality improvement technologies related to the event that are required to reduce risk Evaluates quality improvement technologies related to the event that are required to reduce risk and increase CRITERIA NONPERFORMANCE BASIC PROFICIENT DISTINGUISHED risk and increase patient safety. and increase patient safety. safety, but fails to evaluate how those technologies were used, or how they could be more usefully employed. and increase patient safety. patient safety, and identifies criteria that can be used to evaluate the technologies. Incorporate relevant metrics of the adverse event or near miss incident to support need for improvement. Does not identify relevant metrics of the adverse event or near miss incident to support need for improvement. Attempts to identify some metrics relevant to the adverse event or near miss incident, but omits some relevant data or fails to meaningfully show how metrics relate to the event or incident. Incorporates relevant metrics of the adverse event or near miss incident to support need for improvement. Incorporates relevant metrics of the adverse event or near miss incident to support need for improvement, and evaluates the quality of the data. Outline a quality improvement initiative to prevent a future adverse event or near miss. Does not outline a quality improvement initiative to prevent a future adverse Attempts to outline a quality improvement initiative to prevent a future adverse event or near Outlines a quality improvement initiative to prevent a future adverse event or near miss. Outlines a quality improvement initiative to prevent a future adverse event or near miss, and impartially

CRITERIA NONPERFORMANCE BASIC PROFICIENT DISTINGUISHED event or near miss. miss, but it is not clear that QI suggestions are based on research or best practices. considers conflicting data and other perspectives. Communicate analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Does not communicate analysis and proposed initiative in a professional and effective manner; does not write content clearly and logically with correct use of grammar, punctuation, and spelling. Attempts to communicate analysis and proposed initiative in a professional and effective manner, but content is not consistently clear and logical, or errors in use of grammar, punctuation, or spelling distract from the message. Communicates analysis and proposed initiative in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Communicates analysis and proposed initiative in a professional and effective manner. Content is clear, logical, and persuasive; grammar, punctuation, and spelling are without errors. Integrate relevant sources to support arguments, correctly formatting citations and Does not integrate relevant sources to support arguments; does not correctly format Sources lack relevance or are poorly integrated, or citations or references are Integrates relevant sources to support arguments, correctly formatting citations and references Integrates relevant sources to support assertions, correctly formatting citations and references CRITERIA references using current APA style. NONPERFORMANCE citations and references using current APA style. BASIC incorrectly formatted. PROFICIENT using current APA style. DISTINGUISHED using current APA style. Citations are free from all errors. .Medication Error Quality Improvement Initiative Paper