NURS FPX 6016 Assessment 2
[Student Name]
Capella University
[Prof. Name]
September 2025
NURS FPX 6016 Assessment 2: Quality Improvement Initiative Evaluation
Individuals who are beginning their professions in medicine are human beings with imperfections. Unfortunately, medical errors are unfortunately one of the most common causes of patient death. One of the top five medical blunders that negatively affect patients is the delivery of medication. In order to evaluate quality improvement activities, the proposed study will investigate and evaluating quality improvement initiatives in the context of pharmaceutical errors. Additionally, it examines the two-person verification as a quality improvement report program
Present-day QI project
We are also worried about doubling and substituting fire walls, because we already have so many cases of medical errors that caused harm to patients every month over the years and despite that, surgical staff gave them the wrong prescription as discussed in NURS FPX 6016 Assessment 2. The double check is usually provided at the time of introducing medicine since errors may happen at that stage (Mcmullan et al., 2023). Barcode medicine scanning with a twofold confirmation option would limit the errors that might occur in the process of its administration. The nurse will also administer medication during this process as she adheres to the five rights. Another nurse will then assure that all is safe and suitable to deliver at this moment. In order to prevent severe injuries, the facility resorts to prescription medications, narcotic drips, insulin treatment drips, sedative drips, vesicant drugs, TPN/PPN, and blood transfusions.
The second health professional inserts his/her logins into the EMR system and confirms that all is well and that the administration of the drug is safe. This is referred to
as the two-person check which is a form of supplementary check. According to studies of this process aimed at avoiding unwanted outcomes and errors, distractions remain a significant cause of errors and uncertainty concerning the pharmaceutical labeling (Koyama et al., 2020). The need for analytics for program evaluation and quality improvement is highlighted by study, nurses tend to enter their credentials due to lack of time, their trust in the other nurse, and fear of reporting an error to a clinical supervisor (Pfeiffer et al., 2020).
Developing Benchmarks and Outcome Measures
An estimated 7,000 to 9,000 deaths are attributed to pharmaceutical errors in the United States alone each year, and the country spends over $40 billion annually on treating medication error victims (Justinia et al., 2021). It was 100/100 in the spring of 2024, 93.42/100 on average, and 25/100 on average if we exclude the Leapfrog hospital’s safety grade on medication delivery. According to Leapfrog’s research, medication errors are considerably reduced when barcode technology is utilized appropriately, as it makes it harder for nurses to make mistakes (Hospital Safety Grade, n.d.).
NURS FPX 6016 Assessment 2: Inter professional Perspective
As noted in NURS FPX 6016 Assessment 2, recent research has shown that permitting interprofessional teams to work together can enhance treatment quality and results. Physicians, nurses, clinical managers, psychologists, pharmacists, and other healthcare professionals would fall under this category. Among many other actions in the drug process, prescription, transcription, medicine distribution and administration are some of the steps that errors can be prevented through the optimization of
interprofessional team communication. In the stages, error may occur at any point in time, and the role of the doctor, pharmacist, and nurse is to identify them before the patient incurs the outcomes. The last defensive mechanism is a nurse (Irajpour et al., 2019). When implementing inter-professional collaboration, we may encounter obstacles such as inadequate data, a high workload, a lack of time, a lack of comprehension, and subpar leadership.
Talking with my coworkers about the two-person medication check technique taught me about its benefits and drawbacks. The supervisor thinks it’s a terrific technique to ensure that high-risk medicine administration is done correctly and to increase patient satisfaction. The bedside nurses, however, stated that it was both a helpful strategy to prevent negative outcomes and a barrier to providing high-quality care in the critical care unit. Care may be delayed if another nurse takes a long time to check off and sign a medication, particularly if the patient is very sick. Since they are dealing with a specific patient to attend to and may not have the time to take a break in their work to call someone to confirm whether we have taken our medications, these types of barriers are what make us find that in more than one research monograph that nurses only believe they have a signature, or that they believe their other nurses have a signature. A quality improvement plan is necessary since it places one patient’s care in a better position than the other and puts obstacles in the way of nurses.
NURS FPX 6016 Assessment 2: Additional Indicators & Protocols
Temecula Valley Hospital has been designing and reinventing the patient experience in the past eleven years. To improve patient safety and care quality, they have improved their delivery techniques and repeatedly examined their strategy,
protocols, and standardized treatment. Possible markers and actions that might be implemented in conjunction with pharmacists and at monthly team meetings to ensure that all prescriptions for medications are promptly reconciled. Discharging patients with heart attacks or strokes has been addressed by creating an order set of patients who should be automatically entered for release. For patients with new stents, 81 mg of aspirin, brilinta, and PGY2 inhibitors are crucial drugs to maintain their arteries open and avoid blockages. The staff will be in a position to enter the order set quickly and provide the patient and his family members with time to collect their medication, which is in line with the hospital policy that states that patients cannot leave the hospital without collecting and delivering their medication to the nursing staff. Compared to handwritten scripts, inadequate communication, and incorrect dosage and consumption instructions, computerized transmission of the medication to the pharmacy lowers pharmaceutical errors. Additionally, it reduces the likelihood of misunderstandings and providing the patient with incorrect instructions prior to their release. As an example of a quality improvement plan example, it would also ensure that the established orders are already in the EMR, lessen the workload for the physicians, and free up more time to interact with the nursing staff to prevent medication errors at the facility.
The nursing staff will be provided with a silent medicine spot so that it assists them in avoiding errors, as declared in NURS FPX 6016 Assessment 2. Preparation of medications and their collection would be secure in a quiet and restricted-access space where nursing personnel would not be distracted by noise. According to recent studies, the facilities that gave their nursing staff a secure space to prepare and collect their drugs did not interrupt showed a strong reduction in the rate of medication errors
(Berdot et al., 2021). This is difficult to implement successfully because of inaccessibilities and scarce spaces and because of integrating the pyxis and drug counter with supplies.
References
Koyama, A. K., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ quality & safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552
Temecula Valley Hospital. CA – Hospital Safety Grade. (n.d.). https://www.hospitalsafetygrade.org/h/temecula-valley hospital?findBy=hospital&hospital=Temecula%2BValley%2BHospital&rPos= &rSort=grade
Irajpour, A., Farzi, S., Saghaei, M., & Ravaghi, H. (2019). Effect of inter professional education of medication safety program on the medication error of physicians and nurses in the intensive care units. Journal of education and health promotion, 8, 196. https://doi.org/10.4103/jehp.jehp_200_19
McMullan, R. D., Urwin, R., Wiggins, M., & Westbrook, J. I. (2023). Are two-person checks more effective than one-person checks for safety critical tasks in high-consequence
industries outside of healthcare? A systematic review. Applied ergonomics, 106, 103906. https://doi.org/10.1016/j.apergo.2022.103906
Pfeiffer, Y., Zimmermann, C., & Schwappach, D. L. B. (2020). What are we doing when we double check? BMJ quality & safety, 29(7), 536–540. https://doi.org/10.1136/bmjqs- 2019-009680
Justinia, T., Qattan, W., Almenhali, A., Abo-Khatwa, A., Alharbi, O., & Alharbi, T. (2021). Medication errors and patient safety: Evaluation of physicians’ responses to medication-related alert overrides in clinical decision support systems. Acta informatica medica : AIM : Journal of the society for medical informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH, 29(4), 248–252. https://doi.org/10.5455/aim.2021.29.248-252
Berdot, S., Vilfaillot, A., Bezie, Y., Perrin, G., Berge, M., Corny, J., Thi, T. T., Depoisson, M., Guihaire, C., Valin, N., Decelle, C., Karras, A., Durieux, P., Lê, L. M., & Sabatier, B. (2021). Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: A multi center cluster randomized controlled trial. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00671-7
