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Quality and Safety Gap Analysis
Introduction
The provision of safe, high-quality patient care is critical in healthcare organizations. However, systemic problems in healthcare systems have contributed to adverse quality and safety outcomes. The purpose of this paper is to identify a systemic problem in a healthcare organization, propose specific practice changes that will improve quality and safety outcomes, prioritize proposed practice changes, determine how proposed practice changes will foster a culture of quality and safety, and justify necessary changes with respect to functions, processes, or behaviors specific to the organization.
Identification of a Systemic Problem
The systemic problem identified is medication errors in a hospital setting. Medication errors are common in hospitals and contribute to adverse patient outcomes such as hospitalization, disability, and death (Goyal et al., 2023). According to the World Health Organization (WHO), medication errors harm millions of people worldwide annually, and they are preventable (WHO, 2012).
Proposed Practice Changes
Several practice changes can be implemented to improve medication safety and quality outcomes in hospitals. The following proposed practice changes are:
1. Use of Electronic Prescribing Systems (EPS): Electronic prescribing systems (EPS) are computer-based systems that allow healthcare providers to prescribe medications electronically. EPS can significantly reduce medication errors by eliminating handwriting errors, dosing errors, and drug interactions (Abdel-Qader et al., 2020).
2. Implementation of Bar Code Medication Administration (BCMA): BCMA is a computerized system that matches a medication with a patient's barcode on their wristband. The system ensures that the right medication is given to the right patient at the right time. BCMA can significantly reduce medication errors (Owens et al., 2020).
3. Medication Reconciliation: Medication reconciliation is a process of comparing a patient's medication orders to all of the medications that the patient is taking. The process ensures that the patient is receiving the correct medication, dosage, and frequency. Medication reconciliation can reduce medication errors and improve patient safety (Koprivnik et al., 2020).
4. Nursing Education and Training: Nursing education and training on medication administration can improve patient safety and quality outcomes. Nurses need to be educated and trained on medication administration, including drug interactions, side effects, and medication administration routes.
5. Communication and Collaboration: Communication and collaboration among healthcare providers can improve medication safety and quality outcomes. Healthcare providers need to communicate effectively and collaborate to ensure that the patient receives the right medication at the right time.
Priority of Proposed Practice Changes
The proposed practice changes can be prioritized based on their potential impact on patient safety and quality outcomes. The following is the priority list:
1. Implementation of BCMA
2. Use of...…to this culture by promoting open communication, collaboration, and a willingness to learn from mistakes.
Justification of Necessary Changes
The proposed practice changes are necessary to improve patient safety and quality outcomes. Medication errors can have serious consequences for patients, and the proposed practice changes can significantly reduce the incidence of medication errors. The use of BCMA and EPS can eliminate many of the common causes of medication errors, such as illegible handwriting and dosing errors. Medication reconciliation can ensure that patients receive the correct medication, dosage, and frequency. Nursing education and training can improve medication administration practices, and communication and collaboration can ensure that patients receive safe and high-quality care.
In conclusion, medication errors are a systemic problem in healthcare organizations that contribute to adverse quality and safety outcomes. The proposed practice changes of using BCMA, EPS, medication reconciliation, nursing education and training, and communication and collaboration can significantly improve patient safety and quality outcomes. The implementation of these changes can foster a culture of quality and safety that promotes patient-centered care, teamwork, and continuous improvement. Healthcare organizations need to prioritize the proposed practice changes based on their potential impact on patient safety and quality outcomes and ensure that they are implemented effectively to achieve the desired performance in the provision…
References
Abdel-Qader, D. H., Al Meslamani, A. Z., El-Shara', A. A., Ismael, N. S., Albassam, A., Lewis,P. J., ... & Mohamed Ibrahim, O. (2020). Investigating prescribing errors in the emergency department of a large governmental hospital in Jordan. Journal of Pharmaceutical Health Services Research, 11(4), 375-382.
Goyal, A., Martin-Doyle, W., & Dalal, A. K. (2023). Diagnostic errors in hospitalizedpatients. JCOM, 30(1).
Koprivnik, S., Albiñana-Pérez, M. S., López-Sandomingo, L., Taboada-López, R. J., &Rodríguez-Penín, I. (2020). Improving patient safety through a pharmacist-led medication reconciliation programme in nursing homes for the elderly in Spain. International journal of clinical pharmacy, 42(2), 805-812.
Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-codemedication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing, 46(6), 884-891.
World Health Organization. (2022). Medication errors. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;sequence=1
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