MHA FPX 5020 Assessment 2 Capstone Proposal

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SOURCE (APA format required)

RELEVANCE STATEMENT

1

Alcalá, P. J., Garau, A. D., Fernández, M. J. S., Reina, C. C., Pernas, P. D., Hernández, A. A., & Marrodán, B. R. (2023). Safe handoff practices and improvement of communication in different paediatric settings. Anales de Pediatría, 99(3), 185–194. https://doi.org/10.1016/j.anpede.2023.08.008

This article provides evidence that a lack of information management during handoff contributes to adverse events in care, as well as standardized handoff tools and guidelines on how to prevent medication errors during handover in different care settings.

2

Atinga, R. A., Gmaligan, M. N., Ayawine, A., & Yambah, J. K. (2024). “It’s the patient that suffers from poor communication”: Analysing communication gaps and associated consequences in handover events from nurses’ experiences. SSM – Qualitative Research in Health, 6(100482). https://doi.org/10.1016/j.ssmqr.2024.100482

In this paper, we will be talking about the reasons behind poor communication between the two shift teams and how this directly contributes to errors of diagnosis, treatment, and eventual prolonged stay, including poor documentation, absence of handover structure, and interpersonal conflict.

3

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10), 1–12. https://doi.org/10.7759/cureus.47731

The overall findings shown in this big picture review lead to the understanding that efficient practices in the administration of a hospital are necessary to improve patient safety, satisfaction, and outcomes overall in health care institutions, including the importance of measurement for data and using an interdisciplinary team.

4

Guntschnig, S., Barbosa, R., Jenzer, H., Greening, M., Hayde, J., Heery, H., Serrano, M. C., Lajtmanová, K., Rossin, E., Peceva, S., Kohl, S., & Mulac, A. (2025). Tackling medication errors: How a systems approach improves patient safety. European Journal of Hospital Pharmacy, 23(3), e04533. https://doi.org/10.1136/ejhpharm-2025-004533

This paper uses a systems approach to evaluate medication errors that occur in about 1 out of 30 patients and determines governance gaps, lack of consistent application of legal standards, understaffing, and lack of technical infrastructure to be major contributors to avoidable medication-related damage.

5

Hammour, K. A., Farha, R. A., Ya’acoub, R., Salman, Z., & Basheti, I. (2022). Impact of pharmacist-directed medication reconciliation in reducing medication discrepancies: A randomized controlled trial. Canadian Journal of Hospital Pharmacy, 75(3), 191–199. https://doi.org/10.4212/cjhp.3143

The study is a randomized controlled trial, which demonstrated that using medication reconciliation by the pharmacist significantly reduced the number of unintentional medication discrepancies, particularly omission and duplication of doses, during admission and discharge of surgical wards, and also reduced adverse effect which might occur to a patient.

6

Kumah, A. (2025). Poor quality care in healthcare settings: An overlooked epidemic. Frontiers in Public Health, 13(13), e172. https://doi.org/10.3389/fpubh.2025.1504172

This research shows that, in high-income countries, between 10-12% of all hospitalized patients every year experience adverse events (Figure 2, which the WHO estimates to be 134 million global adverse events and 2.6 million deaths annually, with systemic issues in the provision of healthcare and in safety standards.

7

Latimer, S., Hewitt, J., de Wet, C., Teasdale, T., & Gillespie, B. M. (2022). Medication reconciliation at hospital discharge: A qualitative exploration of acute care nurses’ perceptions of their roles and responsibilities. Journal of Clinical Nursing, 32(7-8), 1276–1285. https://doi.org/10.1111/jocn.16275

The paper is a qualitative study about the perception of nurses about the role of medication reconciliation at discharge, barriers to implementation of the medication reconciliation role, such as lack of clinical guidance in practice, lack of specialized training, and the importance of standardized interprofessional practices to improve patient safety and prevent delays during discharge.

8

Moges, T. A., Akalu, T. Y., & Sema, F. D. (2022). Unintended medication discrepancies and associated factors upon patient admission to the internal medicine wards: Identified through medication reconciliation. BioMed Central Health Services Research, 22(1), e1090. https://doi.org/10.1186/s12913-022-08628-5

The prospective study demonstrated that on admission, 39.1% of patients had one or more UMDs, with omission and wrong dose identified as the commoner UMDs, and that before and after the medication reconciliation by Pharmacists, advanced age, poor adherence, and polypharmacy were the risk factors for UMDs.

9

Ocaña, M. J. R., Morales, C. T., Pichardo, J. D. R., & Hernández, M. A. (2023). Barriers and facilitators of communication in the medication reconciliation process during hospital discharge: Primary healthcare professionals’ perspectives. Healthcare, 11(10), e1495. https://doi.org/10.3390/healthcare11101495

The barriers to effective communication in reconciling medications during discharge are identified as a lack of technological tools, a shortage of employees and time to reconcile medication, and a lack of collaboration between the patient and caregivers, and the facilitators are computerisation of medical history and collaboration among the members of the interdisciplinary team.

10

Ramesh, B., Singh, P., & Unni, V. (2025). Connecting the dots: Communication’s role in reducing medication errors—A systematic review. Sarvodaya International Journal of Medicine, 1(2), 40–45. https://doi.org/10.4103/sijm.sijm_8_25

The findings in this review paper validate the fact that the common areas where medication errors occur are those where there is a communication gap in providing medical information at the handover time points of care, and that the areas most in need of focused communication training interventions are communication failures between healthcare professionals, lack of active listening, and poor handover practices.

11

World Health Organization. (2022). Medication without harm. https://www.who.int/initiatives/medication-without-harm

This WHO international patient safety effort defines unsafe medication practices and medication errors as costly (estimated 42 billion USD a year), and the primary potential causes are weak medication systems and human factors, requiring global involvement to cut severe preventable medication-related harms by half.

12

Agency for Healthcare Research and Quality. (2023). Medication errors and adverse drug events. U.S. Department of Health and Human Services. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

This is an authoritative source of AHRQ that defines the terms of medication errors, adverse drug events, and offers evidence-based approaches to prevent them, and emphasizes the importance of system-level interventions, communication strategies, and safety precautions in preventing preventable medication-associated harm.

FACTOR

CAUSAL OR CONTRIBUTING

UNIT OF MEASUREMENT

SOURCE (APA format)

Handoff Communication Completeness

Causal

% compliance with standardized handoff protocol (e.g., SBAR, I-PASS)

Alcalá, P. J., Garau, A. D., Fernández, M. J. S., Reina, C. C., Pernas, P. D., Hernández, A. A., & Marrodán, B. R. (2023). Safe handoff practices and improvement of communication in different paediatric settings. Anales de Pediatría, 99(3), 185–194. https://doi.org/10.1016/j.anpede.2023.08.008

Medication Reconciliation Accuracy

Causal

% of unintended medication discrepancies per patient admission/discharge

Moges, T. A., Akalu, T. Y., & Sema, F. D. (2022). Unintended medication discrepancies and associated factors upon patient admission to the internal medicine wards: Identified through medication reconciliation. BioMed Central Health Services Research, 22(1), e1090. https://doi.org/10.1186/s12913-022-08628-5

Staff Training and Competency in Handoff Procedures

Contributing

% of nursing staff trained in standardized medication reconciliation and handoff communication protocols

Latimer, S., Hewitt, J., de Wet, C., Teasdale, T., & Gillespie, B. M. (2022). Medication reconciliation at hospital discharge: A qualitative exploration of acute care nurses’ perceptions of their roles and responsibilities. Journal of Clinical Nursing, 32(7-8), 1276–1285. https://doi.org/10.1111/jocn.16275

Data Analysis Method

Root Cause Analysis (RCA) with Trend Analysis

Rationale

 Root Cause Analysis refers to having a methodology to recognize the failure of the system behind the scenes and the contributing factors that cause medication errors when handing patients between nurses. This approach investigates trends in medication discrepancies, communication failures, and process lapses to identify causal associations but not symptoms. The error rates can be measured based on their trend analysis throughout a period of time to determine the effectiveness of the interventions, and what issues are amenable to correction within the system on a regular basis.

Source

(APA format)

Driesen, B. E. J. M., Baartmans, M., Merten, H., Otten, R., Walker, C., Nanayakkara, P. W. B., & Wagner, C. (2021). Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities. Journal of Patient Safety, 18. https://doi.org/10.1097/pts.0000000000000925

Factor #1 Examined

Medication Reconciliation Accuracy at Patient Admission

Precise Unit of Measurement (days, dollars, %…)

% of patients with unintended medication discrepancies (UMD)

Type of Graphic Data Summary (pie chart, bar graph, other)

Bar graph showing the percentage of patients with and without medication discrepancies at admission

Source of Data (APA Format)

Moges, T. A., Akalu, T. Y., & Sema, F. D. (2022). Unintended medication discrepancies and associated factors upon patient admission to the internal medicine wards: Identified through medication reconciliation. BioMed Central Health Services Research, 22(1), e1090. https://doi.org/10.1186/s12913-022-08628-5

Factor #2 Examined

Types of Medication Discrepancies During Care Transitions

Precise Unit of Measurement (days, dollars, %…)

% distribution by type of discrepancy (omission, wrong dose, wrong frequency, duplication)

Type of Graphic Data Summary (pie chart, bar graph, other)

Pie chart showing breakdown of medication discrepancy types: Omission (41.75%), Wrong dose (21.9%), and other categories.

Source of Data (APA Format)

Moges, T. A., Akalu, T. Y., & Sema, F. D. (2022). Unintended medication discrepancies and associated factors upon patient admission to the internal medicine wards: Identified through medication reconciliation. BioMed Central Health Services Research, 22(1), 1090. https://doi.org/10.1186/s12913-022-08628-5

Factor #3 Examined

Impact of Pharmacist-Led Medication Reconciliation on Error Reduction

Precise Unit of Measurement (days, dollars, %…)

Number of medication discrepancies identified (intervention vs. control group)

Type of Graphic Data Summary (pie chart, bar graph, other)

Comparative bar graph showing medication discrepancies in the intervention group (53 discrepancies) versus the control group (33 discrepancies), and the acceptance rate of pharmacist recommendations (38%)

Source of Data (APA Format)

Hammour, K. A., Farha, R. A., Ya’acoub, R., Salman, Z., & Basheti, I. (2022). Impact of pharmacist-directed medication reconciliation in reducing medication discrepancies: A randomized controlled trial. Canadian Journal of Hospital Pharmacy, 75(3), 191–199. https://doi.org/10.4212/cjhp.3143

Name of Practicing Healthcare Provider

Dr. Sarah Mitchell, PharmD, BCPS

Organization Name

Emory Healthcare

Organization Address

1364 Clifton Road NE, Atlanta, GA 30322

Organization Website

https://www.emoryhealthcare.org

Date of Scheduled Feedback Session

In person, Webconference, Phone Meeting?

February 15, 2026

Webconference (Zoom)