NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Quality Improvement Initiative Evaluation

Quality Improvement (QI) initiatives play a vital role in enhancing patient safety, quality of care, and health system efficiency. Medication errors remain one of the main causes of preventable harm in hospitals and, therefore, the QI work in this regard is particularly essential (Alrabadi et al., 2021). In this paper, an assessment of a QI project at Riverbend Community Hospital is done following an adverse drug event (a patient with a known allergy).

The evaluation will be critical of the initiative implementation, outcome measures, benchmarks, interprofessional engagement, and knowledge deficit. It will also propose changes in protocols and technologies that have the potential to improve the efficacy and long-term value of the initiative on patient safety.

Analysis of the Current Quality Improvement Initiative

The current QI initiative in the Riverbend Community Hospital aims at improving medication safety after a negative incident in which Ivy, an aged patient, was given IV hydromorphone despite having a known morphine allergy. This is a critical mistake, which leads to respiratory depression and transfer to the ICU, which led to the launch of the initiative.

The root cause analysis identified the following major failures: the Barcode Medication Administration (BCMA) system was bypassed due to the malfunction of the scanner, the allergy screening was not performed, and there was poor communication between the interprofessional groups. These insufficiencies reflected the need to increase compliance with the medication verification procedures, the efficiency of the technology used, and the accountability of the staff (Mulac et al., 2021).

• Initiative Challenges Identified

Thus, the hospital had developed a QI project to increase the compliance of BCMA by training how to verify allergies and contingency plans in case of equipment failure. The other aspect of the initiative was the necessity to make the creation of a non-punitive culture a priority that will encourage reporting of incidents and the use of near misses to learn.

It does not matter what interventions were taken; there were still some significant problems. As an example, the faulty equipment did not have an urgent fix agenda, and no written policy was available on escalation in the event of failure of safety technology. The program was also characterized by disorganized post-incidents debriefs and failure to incorporate all stakeholders equally in the review.

The issues created by the initiative itself are the potential delays of the process because of stricter protocol adherence, the unwillingness of the staff to work around, and the heavy workload during drug passes. Lack of uniformity when it comes to technology reliability and the lack of enhancement of accountability strategies were also among the factors that led to the failed initiative.

These obstacles imply that although the project has addressed some of the underlying problems, the project can use betterment and employee involvement in order to succeed in the long run. Knowledge gaps encompass unclear accountability policies in the event the equipment is malfunctioning, a lack of follow-up personnel training, a lack of consistency in integrating allergy alerts, and a lack of clarity about the long-term effects of improved BCMA compliance on patient outcomes (Mulac et al., 2021).

Evaluation of the Success of the Quality Improvement Initiative

Riverbend Community Hospital’s success in the quality improvement program is gauged on several recognized benchmarks and outcome indicators, in line with the national patient safety measures and accreditation standards. The ones that are most vital in terms of performance are the rates of BCMA compliance, the rates of medication errors, the rates of transfers in the ICU as a result of medication administration, and the ratings of patient satisfaction.

The use of technology in medication administration and implementation of safeguards around high-alert medications is emphasized by the Joint Commission and the Centers for Medicare & Medicaid Services (CMS), both of which constitute the target of this effort (TJC, 2020). In the example, the hospital established an objective of 95 percent adherence to BCMA, in line with the nationwide standards of the electronic checking of drugs (Riverbend, n.d.).

• BCMA Compliance Outcomes

Before the initiative, the average compliance levels of BCMA were at 88 percent and went down to 12 overrides in the review month of the adverse event in Ivy, of which three were high-alert medications. Even with the implementation of the initiative, the preliminary internal data revealed that there was a low but significant rise in compliance with BCMA, and more near misses were reported with an indication of greater vigilance and openness. The score of patient satisfaction, which had decreased to 76% after the incident, started to return to normal, which means that patients increased their confidence in safety practices (Leapfrog, 2022).

The most successful part of the initiative was the achievement of awareness and responsibility of the nurses, which led to the reduction of the number of safety system overrides and attendance at the safety huddles. As a result of the continuous data gathering, it is already possible to report that there is a positive shift in the direction of achieving the compliance and construction of the safety culture targets (Hunt and Chakraborty, 2020).

The review is founded on the assumption that the information obtained is trustworthy, is reported regularly, and is appropriate to clinical practice. It also presupposes retraining of the staff to indicate accurate allergy status and the revision of the EHR and BCMA systems to indicate accurate allergy status. In addition, it presupposes the existence of a positive climate in leadership, which promotes adherence to safety measures without any disciplinary measures. These assumptions are needed in the interpretation of trends in outcomes, as well as the ability to measure the effectiveness of the initiative.

Interprofessional Perspectives and Actions

An interprofessional team is the necessary component of the effectiveness of the QI initiative at Riverbend Community Hospital. The next categories of people, nurses, pharmacists, physicians, IT support, and quality management, will play a critical role in the medication safety and proper utilization of the protocols. Their alternative perspectives make the initiative more operational as they treat safety differently. The nurses are the most active participants in the medication administration sphere and can assist in exposing barriers to BCMA adherence, such as time constraints and scanner malfunctions.

Pharmacists emphasized the role of a more thorough integration of allergy notifications to Electronic Health record (EHR) and more strict high- alert medication review protocols (Fuller et al., 2022). Physicians supported these types of changes and encouraged effective communication between the doctors during the shift handoff to reduce the amount of errors that occurred due to missed allergies.

• Staff Feedback Insights

To gain a clearer insight into the outcomes of the initiative, informal conversations with the nurses, pharmacists, and information technology specialists were conducted. One of the charge nurses gave an explanation on how the safety huddles helped improve communication and group awareness on equipment issues. According to one clinical pharmacist, the mistake in the documentation of allergies was one of the reasons that led to the preventable errors, and suggested a system upgrade that would allow the alerts to be visible and persistent.

An IT specialist has identified the technical defects of the BCMA scanner system and elaborated on the existing approach of software upgrades and equipment replacement (Hunt and Chakraborty, 2020). These discussions revealed not only the similarity of interest in the safety of the patients but also some of the gaps in knowledge and operational limitations in each of the fields.

However, they have doubts. It is not indicated whether there is any reporting of equipment malfunctions and resolution in every shift. Long-term effects of implementation are not well addressed either, such as whether the compliance levels of BCMA improve. Also, it is necessary to learn more regarding the efficiency of staff retraining and the use of patient feedback in quality planning (Alrabadi et al., 2021). The information about these areas would provide a more accurate evaluation of the aggregate impact of the initiative and its sustainability.

Recommended Additional Indicators and Protocols

Besides complementing and expanding the outcomes of the current quality improvement program at Riverbend Community Hospital, there are other protocols and technologies that should be implemented. An obligatory policy would be one such process redesign, which will be a mandatory stop and resolve policy that will avoid medication administration during times when the BCMA technology is failing.

It would compel nurses to report the issue to IT and supervisory staff members without delay, without having to resort to dangerous workarounds, and promote a culture of safety. Additional protocols of checking all high-alert medications that patients should have should also be normalized across the shifts and have to be verified by the second licensed practitioner before the administration (Sloss & Jones, 2021).

• CDSS Implementation Benefits

Installing real-time clinical decision support systems (CDSS) built into the EHR would enhance medication administration quality and safety. These systems can provide active notification of documented drug-drug interactions, allergies, and dose anomalies and reduce reliance on human memory, enhancing the probability of detecting mistakes before they reach the patient (Sloss & Jones, 2021). To strengthen this, automated equipment monitoring and alerting software can be utilized in monitoring the operational status of the BCMA scanners and remind the IT teams in real time when the equipment has failed.

Currently, the program is tracking BCMA compliance and patient satisfaction, but not training retention and incident response-related outcome measures. The use of such metrics would make it possible to monitor the adoption of the protocols by nurses, the effectiveness of retaining training materials in the long term, and the speed at which problems are resolved in case they are discovered (Fuller et al., 2022). The benefits of these recommendations are that there will be increased safety, reduced medication error rates, and more responsibility in the team.

The drawbacks may include increased workload due to a double-verifying process, resistance to the imposed stop procedures early, and expenses due to the enhancement of the technology (Shermock et al., 2023). These are not easy, but the long-term benefits of preventing life-threatening medication errors and a culture of high reliability are much greater than the challenges of the initial implementation, and these recommendations are necessary to maintain continued improvement in patient outcomes.

Conclusion

The Ivy incident at the Riverbend Community Hospital with a medication error showed that there were essential flaws in safety management and the application of technology. The QI program utilized was to enhance BCMA compliance and allergy verification, and interprofessional communication.

Although the first positive results were observed, there are still lapses in the reliability of equipment and its tracking of outcomes. Interprofessional interactions and feedback played a crucial role in determining problems and future interventions. Safety systems also require further improvement and investment in order to maintain patient safety and quality care.

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