For this assessment, you will develop a 3–5 page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.
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Introduction
Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).
The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.
You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.
References
Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academy Press.
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.
Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.
Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.
Scenario
Select one of the safety quality issues presented in the Assessment 01 Supplement: Enhancing Quality and Safety [PDF] Download Assessment 01 Supplement: Enhancing Quality and Safety [PDF] ( PDF is down below) resource and incorporate evidence-based strategies to support communication and ensure safe and effective care.
Instructions
For this assessment, you will analyze a safety quality issue in a health care setting and identify a quality improvement (QI) initiative.
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 that you know what is needed for a distinguished score.
· Explain factors leading to a specific patient-safety risk in a health care setting.
· Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
· Explain how nurses can help coordinate care to increase patient safety and reduce costs.
· Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
· Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
· Length of submission: 3–5 pages, plus title and reference pages.
· Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
· APA formatting: References and citations are formatted according to current APA style.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
· Competency 1: Analyze the elements of a successful quality improvement initiative.
· Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
· Competency 2: Analyze factors that lead to patient safety risks.
· Explain factors leading to a specific patient-safety risk in a health care setting.
· Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
· Explain how nurses can help coordinate care to increase patient safety and reduce costs.
· Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
· Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
· Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
· Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.
Assessment 01 – Enhancing Quality and Safety For this assessment, you will develop a 3–5-page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue. Before you complete the instructions detailed in the courseroom, first select one of the safety quality issues below to analyze for this assessment. After you have selected one of the issues from the list below, return to the detailed instructions in the courseroom to complete your assessment. • Staffing Shortages in Healthcare: The adequacy of staffing in healthcare settings directly impacts the quality of care, safety, and overall functioning of the institution. Here’s why understanding the implications of staffing shortages is crucial: o Patient Safety and Quality of Care: With fewer staff members, each individual is often required to manage a larger number of patients. This increased workload can lead to oversights, missed care, delayed responses to patient needs, and a higher likelihood of errors in medication administration or treatment. o Burnout and Mental Health: Continuously working in understaffed conditions places immense stress on healthcare professionals. The constant pressure, long hours, and emotional toll of not being able to provide optimal care can lead to burnout, depression, and other mental health issues. o Physical Health Risks: Extended shifts and fewer breaks due to staffing shortages can result in physical exhaustion. Over time, this can lead to chronic health issues, increased susceptibility to illnesses, and a higher risk of workplace injuries. o Decreased Patient Satisfaction: Patients are keenly aware when staff are rushed, unavailable, or too busy to attend to their needs. This can lead to feelings of neglect, dissatisfaction, and a lack of trust in the healthcare system. o Increased Turnover: Chronic staffing shortages can lead to a vicious cycle where overwhelmed staff members leave their positions in search of better working conditions, further exacerbating the shortage. This turnover also means a loss of experienced staff, which can impact the quality of care. o Economic Implications: While it might seem counterintuitive, staffing shortages can lead to increased costs for healthcare institutions. Costs associated with hiring and training new staff, overtime pay, and potential lawsuits or penalties due to errors can add up. o Educational and Mentorship Opportunities: For nursing students and new graduates, mentorship from experienced nurses is invaluable. However, in understaffed settings, experienced nurses may not have the time or energy to
2 provide guidance, potentially impacting the quality of training and professional development for newer nurses. o Team Dynamics and Morale: Working in a consistently understaffed environment can strain team dynamics. The constant pressure can lead to tensions, miscommunications, and conflicts, further impacting the quality of care and the workplace environment. • Medication Errors in Healthcare: Medication administration is a fundamental aspect of patient care, and errors in this process can have severe, sometimes life-threatening, consequences. Understanding the gravity and implications of medication errors is essential. Here’s why: o Patient Safety and Well-being: The most immediate concern with medication errors is the potential harm to the patient. Administering the wrong medication, dosage, or route can lead to adverse reactions, exacerbate existing conditions, or introduce new health complications. o Complexity of Modern Medicine: With the advancement of medicine, patients often receive multiple medications, sometimes with intricate dosing schedules. This complexity increases the potential for errors, making vigilance and thorough knowledge essential for healthcare providers. o Loss of Trust: When patients or their families experience or witness a medication error, their trust in the healthcare system and professionals can be severely diminished. This mistrust can hinder therapeutic relationships and make patients hesitant to adhere to future medical advice. o Professional and Legal Implications: Medication errors can have significant repercussions for healthcare professionals. These might include disciplinary actions, loss of licensure, legal consequences, and damage to one’s professional reputation. o Economic Costs: Medication errors can lead to extended hospital stays, additional treatments, and potential lawsuits, all of which result in increased costs for healthcare institutions. o Emotional Toll on Healthcare Providers: Realizing that one has made a medication error can be emotionally devastating for healthcare providers. Guilt, anxiety, and fear of potential consequences can lead to burnout, self-doubt, and even deter some from continuing in the profession. o Systemic Implications: Frequent medication errors can indicate deeper systemic issues within a healthcare institution, such as inadequate training, poor communication, or insufficient checks and balances. Addressing these root causes is crucial for preventing future errors. o Educational Opportunities: Every medication error, while unfortunate, provides an opportunity for learning and improvement. Analyzing the causes of errors can lead to better training programs, improved protocols, and the implementation of safety measures to prevent recurrence.