XQ4001 Assignment Safety & Quality Fundamentals

Nursing Specialty

Medical/ Surgical Nurse in an acute care hospital’s general surgical-medical unit

Chapter

National Patient Safety Goals: Hospital

NPSG 1

Identify Patients Correctly (2025, NPSG.01.01.01)

According to the Joint Commission, NPSG 01.01.01 (Correct Identification of the Patient) is a key concern in 2025. This regulation requires that at least two identifiers, typically two names or the patient’s full name and date of birth, are used before any treatment, medication, or procedure is administered. This effort is key to reducing cases of wrong-patient errors, medication misadministration, and misaligned treatment. The Joint Commission has made it clear that it does not support the use of room numbers as identifiers, and favors the use of some more accurate options such as barcode scanning or wristband verification to ensure that each intervention is the right one for the right person.

NPSG 2

Use Medicines Safely – Medication Reconciliation (2025, NPSG.03.05.01)

NPSG 03.05.01 requires that healthcare providers obtain a complete and accurate list of all medications a patient is taking at admission, transfer, and discharge. Any new or changed medicine orders should be used to help identify and resolve discrepancies with this list. The goal is to place a high priority on medication safety, especially for high-risk medications like anticoagulants and insulin, and to educate patients about their medications. These processes are tight enough to avoid medication omissions, duplications, unwanted interactions, and discrepancies in medication dosing.

NPSG 3

Prevent Mistakes in Surgery – Universal Protocol (2025, UP.01.01.01)

NPSG UP.01.01.01 is one of the Universal Protocol and is comprised of a series of pre-procedure steps to avoid “catastrophic surgical events”. These involve a pre-procedure verification, marking the site, and a “time‑out” pause during which the surgical team verifies the proper patient, procedure planned, and proper site before making the first incision. The three steps (verification, marking, and time-out) have been shown to have a significant impact on reducing wrong-site surgery, wrong-patient surgery, and wrong-procedure surgery, and thereby introducing checkpoints into surgeries (Singh et al., 2024).

NPSG Priority

The most important safety issue I’m concerned with in my acute care organization is Medication Reconciliation (NPSG 03.05.01). Healthcare organizations, particularly those that employ high-risk medications such as insulin or anticoagulants, are still experiencing many preventable instances of medication error. Pharmacists’ involvement in medication reconciliation and patients’ active participation in confirming their medication regimens are supported by robust evidence, with medication inconsistencies during care transitions having a significant impact on reducing medication reconciliation. The involvement of pharmacists in medication reconciliation and active patient participation in confirming medication regimens have strong supporting evidence; medication inconsistencies during care transitions significantly reduce medication reconciliation. Near miss events, like repeated doses of home-prescribed insulin, are just one that we could mitigate on our unit with regular pharmacist reconciliation at admission and discharge and clinical decision support alerts in our electronic health record.

NPSG 03.05.01 calls for a complete and up-to-date list of all drugs a patient takes when admitted to, transferred from, and discharged from the hospital. It should be used to cross-check with the instructions for medicines that have been prescribed or changed to ensure that any discrepancies are identified and resolved, so that medicines are not omitted, duplicated, or given in the incorrect dose.

Moreover, the NPSG03.06.01 pertains directly to the safe use of the administration of “high risk” medications, including those like warfarin and heparin, which can cause serious harm if they are not used wisely. This goal encourages the use of therapeutic level monitoring protocols, patient education, and standard dosing to avoid bleeding complications.

Reflection

Nurses are in the line of duty for patient safety, and a great safety culture is one that we are committed to achieving and adhering to the National Patient Safety Goals. Nurses promote an attitude of teamwork and accountability through practice, such as conducting surgical timeouts, double-checking medication at each medication change, and using two names before any intervention. Employees are motivated to raise concerns if a check is incomplete or anything seems strange because of this second nature of attention to detail (Medvedev et al., 2024). These routine procedures build patient confidence in the confidence of team members and minimize errors, while providing all parties with greater confidence that safety is a part of our institutional culture.

Real-World Example

Case: Joe Massa, age 2, died at Northern Beaches Hospital in Australia (Chung, 2025)

What happened: Why he went: Joe Massa went to the ED with a history of vomiting overnight, being dehydrated, and having clinical deterioration including an elevated heart rate, a red flag for shock. Despite these “red flags,” he was considered a Category 3 emergency (30-minute treatment) and waited over 2 hours before seeing a doctor. Staff were not monitoring or escalating, mis-triaged, ignored parents’ concerns, and missed key indicators. Staff did not monitor or escalate the care in response to the major vital signs, for example a very high heart rate (tachycardia), signs of dehydration (from repeated vomiting) and poor perfusion. In spite of these clinical warning signs, the triage level was not changed, and the prompt intervention was not started.

The result: Joe’s mother became increasingly worried about the situation, and requested intravenous fluids, noting that more and more Joe was deteriorating each minute. Staff ignored her warning, did not re-flag his triage level, and did not take timely action. Subsequently, a Serious Adverse Event Review revealed that professionals missed the opportunity to see the parents involved as well as physiological warning signs at an important time..

Lessons:

· Escalation procedures should be started by early warning signs.

· Concerns raised by families are important data points.

· Procedures for emergency triage must be transparent, auditable, and followed.

Safety Grade

Name of facility: Sibley Memorial Hospital

Overall facility safety grade?

Grade C for Fall 2024

What areas have been identified as needing improvement? Please list the top three areas.

1. Hand Hygiene: Sibley’s hand hygiene scores were below average, suggesting a lack of basic infection control practices. This is particularly troublesome in high-risk patients and post-operative areas, as unclean hands are known to be a source of spread of disease-causing organisms.

2. The institution was given a poor grade for 2. Communication with patients about medicines – during their hospital stay and when they left the hospital. Poor communication can lead to confusion, drug misuse, and readmissions (Cam et al., 2023).

3. The hospital experienced below-average performance in the area of Prevention of Health Care-Associated Infections (HAIs) for the occurrence of both catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs). These diseases are preventable and can be harmful, especially to elderly or immunocompromised people.

Evidence-Based Interventions

1. Multimodal Hand Hygiene Program (WHO 5 Moments Model): Adopting the The “Five Moments of Hand Hygiene (WHO 5 Moments Model)” is one of the most effective strategies to increase the commitment of healthcare professionals to hand hygiene. This model highlights the following areas of focus: before contact with the patient, before aseptic/clean procedures, after exposure to bodily fluids, after patient contact, and after exposure to the patient’s environment. This paradigm is effective in healthcare settings to promote good hand hygiene practice. Compliance is very high when using multimodal treatments such as education campaigns, visual signals, performance feedback, and leadership engagement. Combining real-time feedback and visual reminders, for example, led to improved compliance with hand hygiene, as demonstrated by Seferi et al. (2023). Leadership visibility and role modeling also help to foster a culture of safety and hand hygiene as a normed clinical practice. Standard auditing,

2. Pharmacist-Led Medication Reconciliation at Transitions of Care: An evidence-based strategy to lower medication mistakes is a med rec process that is pharmacist-directed, particularly when transitioning between care settings such as hospital admission, intrahospital transfer, and discharge. To address all potential concerns about the patient’s drug regimen, the clinical pharmacist and/or nurse educator must be able to systematically review the patient’s actual medication list, identify discrepancies, and correct them. Ensuring patient/caregiver understanding of any changes in prescription using patient education resources, including teach-back methods, is an important component in this process (Marks et al., 2022). These types of programs significantly affect patient satisfaction and the rate of adverse medication events, research by The Joint Commission and Institute for Healthcare Improvement (IHI) reveals. In a study by Stuijt et al. (2022), the pharmacists had a direct role in reconciliation, which was associated with a 15% decrease in medication errors in 6 hospitals. This not only enhances patient safety but also helps prevent unnecessary rehospitalizations and supports better continuity of care by ensuring precise and clear orders for medications.

3. CLABSI and CAUTI Reduction Bundles: Standard care bundles are employed to help prevent infections associated with healthcare, including central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). These bundles may include evidence-based practices like strict aseptic technique when inserting the line/inserting a catheter, chlorhexidine skin antisepsis, and daily assessment of the line/catheter’s true need. Staff are also encouraged to remove the devices as soon as they are no longer required, and to keep a regular and consistent record of catheter care. The implementation of care bundles has been associated with a decrease in infection rates in a variety of healthcare settings (Centers for Disease Control and Prevention, 2024). This strategy underlies the principles of accountability culture and interprofessional care as well as clinical protocols. A properly implemented CLABSI or CAUTI bundle can lead to decreased complications, antibiotic use, length of stay, and patient outcomes.