Quality and Sustainability Paper Part Two - Identifying Opportunities to Reduce Medication Error Rates by Nursing Staff As reported previously, medication errors can occur in virtually any treatment setting, including patients’ homes, but the problem is especially pronounced in hospitals where the adverse reactions caused by medication errors can result in extended inpatient stays or even death. As also reported previously, nurses account for the largest percentage of medication errors, and these errors affect more than 7 million patients, cost nearly $21 billion and cause more than one million emergency room visits and three-and-a-half million visits to doctors’ offices each year. The purpose of part two of this study is to provide an overview of a selected nationwide health care organization and a description of its successes and failures in reducing medication error rates. In addition, this part of the study identifies a quality area in which nursing science can have a significant positive impact and the variables that should be used to evaluate its effectiveness. Finally, a discussion concerning potential obstacles that may hinder the implementation of the quality or safety measure and those groups or leadership roles within the entity with whom collaboration will be needed is followed by a summary of the research and important findings concerning the role of nursing staff in reducing medication errors in the conclusion.

Review and Discussion

1. Identification of a health care entity

The real-world organization of interest, hereinafter referred to alternatively as the “XYZ Health Care Organization” or just “XYZ,” operates the nation’s largest health care network. Established in 1930 in response to the growing demand for health care services for those individual who served in the United States armed forces, the XYZ Health Care Organization is a Cabinet-level federal agency that is responsible for the provision of the entire range of modern medical care services for eligible patients. At present, XYZ employs more than 377,000 health care workers, operates a network of 170 tertiary health care facilities and more than 1,240 outpatient clinics that provide services...

The formal mission statement for XYZ was taken directly from President Lincoln’s Second Inaugural Address wherein he called for the organization “to care for him who shall have borne the battle and for his widow, and his orphan” (The origin of the XYZ motto, 2018, p. 1). Given the enormous number of patients treated each year in the XYZ Health Care Organization’s facilities, it is not surprising that errors in medication administration occur, and these issues are discussed further below.
2. Using defined quality outcomes and/or patient safety measures, describe the health care entity's successes and failures. Include identified criteria and data that demonstrate why this entity is successful and in what areas.

The quality outcomes related to the reduction of medication errors by XYZ focus on identifying when, where, who, and why they were made to identify opportunities for improvement. The current criteria used by XYZ for patient incident reporting are as follows:

· Suicide

· Suicide Attempt

· Sexual Assault

· Homicide

· Patient Abuse

· Alleged

· Proven

· Fall

· Transfusion Error

· Medication Error

· Injury Not Otherwise Listed

· Fire, Patient Involved in

· Assault, Patient to Patient

· Assault, Patient/Staff

· Death

· Operating Room

· Recovery Room

· During Induction of Anesthesia

· Within 48 Hours of Surgery

· Conjunction with a Procedure

· Cases accepted by the Medical Examiner

· Equipment Malfunction

· On Medical Center Grounds

· Failure to Diagnose or Treat

· Other

· Missing Patient

· Informed Consent, Failure to Obtain (Incident reporting, 2015).

In addition, institution-specific ad hoc criteria are also used by…