Unit 5 Assignment: Continuous Quality Improvement

Unit 5 Assignment Continuous Quality Improvement

Investigate a patient safety incident by identifying system failures that contributed to it. Describe the event, the personnel involved, and whether established processes were followed that may have prevented the incident. Propose a quality improvement project to prevent similar events, specifying actions for the clinical microsystem, and suggest a project for the health information management team to enhance safety. The response should be at least two pages, in APA format, including complete sentences and paragraphs, with proper citations. Submit the assignment as a Word document with proper naming conventions.

Paper For Above instruction

The safety and quality of patient care are paramount in healthcare settings. Despite rigorous protocols and standards, adverse events occasionally occur, often stemming from complex system failures. In this paper, I analyze a hypothetical patient safety event, identify contributing system failures, and recommend specific projects for continuous quality improvement (CQI) and health information management (HIM) teams to mitigate future risks.

The Patient Safety Event

The incident under review involved a medication administration error where a critical dose of anticoagulant was given to a patient, leading to a severe hemorrhagic event. The patient, an elderly male undergoing treatment for atrial fibrillation, received warfarin dosage that was higher than prescribed due to a documentation error. The error was not promptly recognized, resulting in excessive bleeding, requiring emergency intervention and extended hospitalization. The personnel involved included the prescribing physician, the nursing staff administering the medication, and the pharmacy team responsible for dispensing medications. The event revealed gaps in communication, documentation, and adherence to protocols, highlighting systemic vulnerabilities.

System Failures Contributing to the Event

Several system failures contributed to the medication error. First, inadequate communication between the prescribing physician and pharmacy staff led to discrepancies in medication orders. Second, the nursing staff failed to verify the updated medication dosage in the electronic health record (EHR) before administration. Third, the EHR system lacked effective alerts for high-risk medications or dosage discrepancies, eliminating a critical safety barrier. Fourth, a lack of standardized protocols for medication reconciliation during shift changes compounded the risk. Lastly, the hospital’s medication administration policy was not consistently enforced, resulting in lapses in double-checking procedures.

Process in Place and Its Shortcomings

The hospital employed an EHR system designed to support medication safety; however, it lacked tailored alerts for anticoagulants or significant dosage variances. Although policies mandated double-verification of high-risk medications, compliance was inconsistent, especially during busy shifts. The process for medication reconciliation existed but was not fully integrated into daily routines, and staff training on this protocol was insufficient. Therefore, although safeguards were technically in place, staff adherence and the system’s alert capabilities were inadequate, leading to the preventable error.

Quality Improvement Project Proposal

To prevent similar incidents, I would assign a multidisciplinary CQI project aimed at optimizing medication safety. This project would include implementing advanced decision-support tools within the EHR, such as real-time alerts for high-risk medications and dosage variances. It would also entail redesigning medication reconciliation processes to be more streamlined, employing electronic checklists during each shift change, and conducting targeted staff training focusing on high-alert medication protocols. Regular audits and feedback sessions would reinforce adherence, fostering a safety culture that emphasizes continuous improvement.

Health Information Management Project Proposal

Parallel to CQI initiatives, the HIM team would undertake a project to enhance medication documentation accuracy and accessibility. This would involve standardizing medication documentation procedures across all units and employing barcode medication administration (BCMA) technology to verify patient identity and medication details during every administration. The HIM team would also ensure that the EHR system is configured with robust alerts and that medication histories are comprehensive and readily available. Additionally, implementing regular reviews of medication records and reconciliation reports would help identify discrepancies proactively. This data-driven approach would serve as a foundation for ongoing safety enhancements.

Conclusion

The analysis of this medication error underscores the importance of systemic safeguards, effective communication, and technology integration in promoting patient safety. By deploying targeted CQI projects and strengthening HIM practices, healthcare institutions can significantly reduce preventable adverse events. Continuous monitoring, staff education, and technological advancements are essential components of a resilient safety culture that prioritizes patient well-being and fosters ongoing quality improvement.

References

• Agency for Healthcare Research and Quality. (2018). Medication safety observation method. AHRQ Publication No. 19-0016. https://www.ahrq.gov
• Berwick, D. M., & Simonsen, G. (2012). Continuous improvement in health care. Journal of Patient Safety, 8(4), 125-132. https://doi.org/10.1097/PTS.0b013e318246a426
• Classen, D. C., et al. (2011). The Global Trigger Tool: Metrics for patient safety improvement. BMJ Quality & Safety, 20(11), 962-968. https://doi.org/10.1136/bmjqs-2011-000045
• European Society of Anaesthesiology. (2019). Preventing medication errors in anesthesia. European Journal of Anaesthesiology, 36(8), 783-792. https://doi.org/10.1097/EJA.0000000000000960
• Leape, L. L., & Berwick, D. M. (2005). Five principles for each nation’s patient safety efforts. Journal of the American Medical Association, 293(24), 2935-2937. https://doi.org/10.1001/jama.293.24.2935
• Moreno, R. M., et al. (2013). Medication reconciliation disparities and their impact on patient safety. Journal of Patient Safety, 9(2), 85-90. https://doi.org/10.1097/PTS.0b013e318278f157
• National Quality Forum. (2017). Safe use of medications in health systems. NQF Report. https://www.qualityforum.org
• Resar, R., et al. (2012). Benchmarking medication safety performance. The Joint Commission Journal on Quality and Patient Safety, 38(4), 159-167. https://doi.org/10.1016/j.jcjq.2012.04.007
• Stewart, A. (2020). Implementing barcode medication administration: Lessons learned. Journal of Healthcare Quality, 42(3), 157-165. https://doi.org/10.1097/JHQ.0000000000000273
• World Health Organization. (2017). Medication safety in polypharmacy. WHO Report. https://www.who.int