25 Aug Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to medication administration.
For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.
Communication in the health care environment consists of an information-sharing experience whether through oral or written messages (Chard & Makary, 2015). As health care organizations and nurses strive to create a culture of safety and quality care, the importance of interprofessional collaboration, the development of tool kits, and the use of wikis become more relevant and vital. In addition to the dissemination of information and evidence-based findings and the development of tool kits, continuous support for and availability of such resources are critical. Among the most popular methods to promote ongoing dialogue and information sharing are blogs, wikis, websites, and social media. Nurses know how to support people in time of need or crisis and how to support one another in the workplace; wikis in particular enable nurses to continue that support beyond the work environment. Here they can be free to share their unique perspectives, educate others, and promote health care wellness at local and global levels (Kaminski, 2016).
Using Google Sites, assemble an online resource tool kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed.
It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative pertaining to medication administration. For example, for an initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues.
Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on safety with medication administration. Each resource listing should include the following:
An APA-formatted citation of the resource with a working link.
A description of the information, skills, or tools provided by the resource.
A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to medication administration.
A description of how nurses can use this resource and when its use may be appropriate.
Remember that you must make your site ‘public’ so that your faculty can access it. Check out the Google Sites resources for more information.
Here is an example entry:
Merret, A., Thomas, P., Stephens, A., Moghabghab, R., & Gruneir, M. (2011). A collaborative approach to fall prevention. Canadian Nurse, 107(8), 24–29.
This article presents the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project. It shows how a collaborative nurse lead project can be implemented and used to improve collaboration and interdisciplinary teamwork, as well as improve the delivery of health care services. This resource is likely more useful to nurses as a resource for strategies and models for assembling and participating in an interdisciplinary team than for specific fall-prevention strategies. It is suggested that this resource be reviewed prior to creating an interdisciplinary team for a collaborative project in a health care setting.
Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.
Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to medication administration.
Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on medication administration.
Analyze the value of resources to reduce patient safety risk related to medication administration.
Present reasons and relevant situations for use of resource tool kit by its target audience.
Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting
APA formatting: References and citations are formatted according to current APA style
Requirements:
1 Root-Cause Analysis and Safety Improvement Plan Cristal Batista School of Nursing and Health Sciences, Capella University NURS4020: Improving Quality of Care and Patient Safety Ginah Haynes July 2023
2 Root-Cause Analysis and Safety Improvement Plan The root-cause analysis (RCA) will be exploring the multifaceted issues associated with polypharmacy, a prevalent problem in healthcare that arises when patients are prescribed multiple medications concurrently. Polypharmacy can lead to adverse drug interactions, medication errors, decreased medication adherence, increased healthcare costs, and potential harm to patients. The RCA aims to identify the underlying factors contributing to polypharmacy, such as inadequate medication reconciliation, fragmented healthcare systems, lack of communication among healthcare providers, patient factors, and prescribing practices. By delving into these root causes, the RCA seeks to develop targeted interventions and strategies to mitigate the risks associated with polypharmacy and improve patient safety and overall healthcare outcomes. . Analysis of the Root Cause One of the significant concerns with polypharmacy in hospitals is the increased risk of adverse drug reactions. When patients are prescribed multiple medications, the potential for drug interactions and side effects rises, leading to undesirable health outcomes. The complexity of managing multiple medications can increase the likelihood of medication errors. Confusion regarding dosages, drug names, or administration schedules can result in the wrong medication being given or at incorrect doses, compromising patient safety. Patients may struggle to adhere to a complex medication regimen, especially if they have difficulty managing multiple medications
3 or experience side effects. Non-adherence can result in suboptimal treatment outcomes. Polypharmacy can lead to higher healthcare costs due to the need for multiple prescriptions, frequent medication adjustments, and increased hospitalizations or emergency room visits resulting from drug-related issues. Patients on multiple medications may experience delayed recovery or complications, leading to extended hospital stays, which can strain healthcare resources and impact bed availability.Patients are directly affected by polypharmacy as they bear the burden of managing multiple medications, potentially leading to adverse drug reactions, medication errors, reduced adherence, and compromised health outcomes. Healthcare providers face challenges in managing patients on multiple medications, which may lead to increased workload, difficulties in medication reconciliation, and heightened vigilance for potential drug interactions and side effects. Hospital administrators may experience increased healthcare costs due to the need for more medications, longer hospital stays, and managing complications arising from polypharmacy. Polypharmacy places strain on the overall healthcare system, including resources and time spent on medication management, adverse event management, and readmissions due to medication-related issues. The ideal scenario for managing polypharmacy involves a comprehensive approach to medication management in which patients are prescribed the appropriate medications, at the right doses, and with close monitoring for potential drug interactions and adverse effects. The goal is to optimize therapeutic outcomes while minimizing the risks associated with multiple medications. One potential issue is the lack of regular and thorough medication review by healthcare providers. In a busy hospital setting, clinicians may not have sufficient time to conduct comprehensive reviews of a patient’s medication history, leading to overlooked interactions or contraindications. Deprescribing, the process of discontinuing unnecessary
4 medications, might not occur as frequently as necessary. Prescribers may be hesitant to deprescribe due to concerns about patient resistance or lack of time to discuss the rationale for discontinuing medications. Workload and time constraints in hospital settings can influence medication management practices. High patient volumes and time pressure may lead to shortcuts in medication review or inadequate communication among healthcare providers. Patient complexity and the presence of multiple comorbidities may limit the simplicity of medication management, making polypharmacy more likely. Additionally, patient preferences and resistance to deprescribing can be uncontrollable factors influencing medication regimens. Access to comprehensive electronic health records and medication databases can influence medication decision-making. Limited access to up-to-date medication information may impact prescribers’ ability to identify potential drug interactions. The presence of clinical pharmacists in the healthcare team can contribute to medication reviews and deprescribing efforts. The availability of clinical pharmacists may vary across hospitals, affecting the level of medication management support. A recent study stated that few interventions have provided electronic decision support to doctors in their own practice. (Cochrane Library 2018) Human errors, such as illegible handwriting or incorrect transcription of medication orders, can lead to medication errors, especially when patients are on multiple medications. Miscommunication among healthcare providers, such as incomplete handoffs or unclear medication instructions, can result in improper prescribing or administration of medications. In a hospital setting, various healthcare providers may be involved in a patient’s care, resulting in fragmented communication. Inadequate sharing of medication information between different specialties can lead to polypharmacy-related issues.: Insufficient patient education and communication about medications can impact patient adherence and understanding of their treatment regimens, leading to potential non-adherence or misunderstandings.
5 Application of Evidence-Based Strategies Since it is most prevalent in older adults, there is an urgent need to introduce effective strategies to prevent and manage the problem in this age group. (Kurczewska-Michalak et al., 2021). Some evidence- based strategies that can be applied include conducting regular medication reviews for patients on multiple medications to assess the appropriateness of each medication and identify opportunities for deprescribing unnecessary or potentially harmful drugs. This strategy involves evaluating the patient’s current medical condition, medication history, and considering their preferences and goals of care. Fostering collaboration among healthcare providers, including physicians, pharmacists, nurses, and other specialists, to ensure comprehensive medication management. Utilizing interdisciplinary rounds or meetings to discuss complex cases, share information, and make informed decisions about medication regimens. Implementing robust medication reconciliation processes during transitions of care, such as admission, transfer, and discharge. Ensuring accurate and up-to-date medication lists to minimize the risk of duplications, omissions, or errors during care transitions. Providing thorough patient education about their medications, including their purpose, dosages, potential side effects, and the importance of adherence. Engaging patients in shared decision-making about their treatment plans to enhance their understanding and involvement in managing their medications. Implementing standardized order sets or guidelines for common medical conditions to promote evidence-based prescribing practices and reduce variability in medication management. Monitoring patients’ responses to medications regularly and adjusting treatment plans as needed. Regular follow-ups and patient reassessments can identify issues early on and facilitate necessary changes in medication regimens.
6 Improvement Plan with Evidence-Based and Best-Practice Strategies Communication, and teamwork in particular, are pillars of patient safety culture. Conducting regular interdisciplinary medication management rounds where healthcare providers from various specialties discuss complex cases and collaboratively develop medication plans. These rounds will enhance communication, foster teamwork, and facilitate shared decision-making regarding medication regimens. (Approach to improving patient safety: Communication 2021) Establishing a standardized medication reconciliation protocol for all care transitions, including admission, transfer, and discharge. This protocol will ensure accurate and up-to-date medication lists, reduce medication discrepancies, and enhance patient safety during transitions of care. New Processes/Policies can include the use of Electronic Health Record (EHR) Enhancements: Enhancing the EHR system to include clinical decision support alerts for potential drug interactions, allergies, and contraindications. These alerts will prompt healthcare providers to consider potential risks before prescribing medications. (Légat et al., 2018) Existing Organizational Resources Improving the implementation and outcomes of using electronic health records (EHRs) to prevent polypharmacy requires the collaboration of various organizational personnel and the utilization of specific resources. The following existing personnel and resources can be instrumental in this endeavor: • Chief Medical Information Officer (CMIO): The CMIO plays a vital role in overseeing the implementation and optimization of EHR systems in the organization. They can
7 champion the use of EHR functionalities to support medication management, including drug interaction alerts, medication reconciliation, and decision support tools. • Clinical Informaticists: These professionals have expertise in both clinical practice and health information technology. They can work with clinicians and IT staff to configure the EHR to effectively prevent polypharmacy by setting up relevant alerts and ensuring seamless integration of medication-related modules. • Clinical Pharmacists: Pharmacists possess specialized knowledge in medication management and can provide valuable insights during the implementation of EHR functionalities related to polypharmacy prevention. They can collaborate with other healthcare providers in customizing medication profiles, performing medication reviews, and identifying potential drug interactions. • IT Staff and EHR Vendors: The organization’s IT staff and the EHR vendors are essential resources in ensuring the successful integration and customization of the EHR system for polypharmacy prevention. They can assist in developing and optimizing features such as clinical decision support and medication reconciliation tools. • Quality Improvement Team: A quality improvement team can monitor and evaluate the outcomes of using EHRs for polypharmacy prevention. They can analyze data, identify areas for improvement, and implement changes to enhance the effectiveness of EHR-driven interventions. • Interdisciplinary Care Teams: The collaboration and engagement of interdisciplinary care teams, including physicians, nurses, pharmacists, and other healthcare professionals, are crucial for the successful implementation of EHR-based polypharmacy prevention strategies. They can work together to interpret EHR alerts, conduct medication reviews, and communicate with patients effectively.
8 • Continuing Education Resources: Access to continuing education resources related to EHR utilization for polypharmacy prevention can enhance the knowledge and skills of healthcare providers. Webinars, workshops, and online training materials can keep personnel up to date with the latest best practices and developments. • Patient Engagement Tools: Interactive patient portals and educational materials within the EHR can empower patients to actively participate in their medication management. These resources can educate patients about their medications, potential side effects, and the importance of adherence. • Research and Evidence-Based Guidelines: Organizations can utilize existing research and evidence-based guidelines on EHR-driven polypharmacy prevention to inform their implementation strategies. Leveraging credible sources can lead to more effective and evidence-based interventions. By leveraging these existing personnel and resources, healthcare organizations can effectively implement EHR-driven interventions for preventing polypharmacy. This collaborative approach ensures that the right tools, knowledge, and expertise come together to improve patient safety and optimize medication management practices. Conclusion In conclusion, the root cause analysis (RCA) has provided valuable insights into the multifaceted issues associated with polypharmacy in the healthcare setting. The analysis revealed numerous factors contributing to polypharmacy, including inadequate medication review, fragmented healthcare systems, communication gaps, and human errors. Understanding these root causes has paved the way for a comprehensive safety improvement plan to prevent polypharmacy and
9 enhance patient safety. Overall, the root cause analysis and safety improvement plan serve as critical tools in empowering healthcare organizations to prevent polypharmacy and promote safe and effective medication management. By prioritizing patient safety and adopting evidence-based strategies, healthcare providers can enhance patient outcomes, reduce medication-related harm, and foster a culture of continuous improvement and patient-centered care. References Cochrane Library. (n.d.-b). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008165.pub4/full
10 Kurczewska-Michalak, M., Lewek, P., Jankowska-Polańska, B., Giardini, A., Granata, N., Maffoni, M., Costa, E., Midão, L., & Kardas, P. (2021, October 26). Polypharmacy management in the older adults: A scoping review of available interventions. Frontiers. https://www.frontiersin.org/articles/10.3389/fphar.2021.734045/full Approach to improving patient safety: Communication. Patient Safety Network. (n.d.). https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Légat, L., Van Laere, S., Nyssen, M., Steurbaut, S., Dupont, A. G., & Cornu, P. (2018, September 7). Clinical decision support systems for drug allergy checking: Systematic review. Journal of medical Internet research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231757/
