Improvement Plan In-Service Presentation

Hello, my name is Adriel. I would like to present the in-service Improvement plan where medication administration errors, plans, strategies, and implementation will be discussed to enhance patient safety. 

Medication Errors

Medication errors can create a huge chaotic environment for the organization and lead to serious disasters. That is why, in the in-service training session for nurses, the importance of medication errors and reasons will be discussed to make them understand what they need to do and do not. The in-service training session will involve medical professionals, baccalaureate-prepared nurses, stakeholders, and practicing professionals. These sessions will be educational-based to improve the quality measures and safety improvement intervention. This in-service training session will guide the cause and its impact, plus how to reduce its impact using effective strategies. Understanding medication error is necessary because we cannot abolish it from the root without a proper understanding of this term. That is why here is a complete review of medication errors and how they can prevent in the organization to improve patient safety.  

What is Medication Error?

A medication error is a blunder that intentionally or unintentionally happens and causes serious impacts such as losing one’s life or making it critical to living. The medication errors probably occurred due to mismanagement, unawareness of roles and duties, and lack of focus. Similarly, St. Luke’s Magic Valley also faces a medication blunder, which causes the organization big penalties. The in-service training session will provide enough knowledge and understanding of these terms to advance nursing practitioners to avoid it as much as possible. The designing and planning of in-service training sessions will include knowledge enhancement and awareness of responsibilities. Plus, engaging them as a team to perform teamwork and improve the stakeholder’s involvement to bring safe environmental changes (J. Weaver et al., 2018).   

 The medication administration should monitor the functions where medication malpractice chances are high such as prescribing the drug, inaccurate order transcription, failing to attain disease history, incomplete order checking, poor professional communications, and unavailability of patient information. 

Safe Medication Administration

After thoroughly understanding medication errors, it is essential to know why it is crucial to administer safe medication. It is essential to understand the guidelines for implementing safe medication administration, such as double-checking the doses and high-alert medication frequencies, performing open communication with medical professionals if any doubt or confusion occurs, do not assign medication if writing is not understandable, rechecking the time of administrating doses to ensure that patient will get sufficient treatment, and rechecking the patient name and their information before prescribing or administrating (Koyama et al., 2019). 

Elements of Good Quality Care

Every organization imposes some guidelines and policies for providing good quality care; however, with time, it gets a little old-fashioned, and nurses forget to read them and applied in their daily duties. That is why; in-service sessions will provide them with awareness to recheck the policies with time to concern the health and quality of patients. We will also elaborate on the elements of good quality care that should include; people-centered, integrated, effective, equitable, timely, and efficient. These elements were prescribed by World Health Organization (WHO) to increase the quality of care (World Health Organization, 2021). 

People-centered: prioritize the people and respond to their preferences, values, and needs. 

Timely: healthcare demand proper scheduling to provide care on time 

Equitable: refer to that healthcare must not be judged based on gender, demographics, locations, socioeconomic statuses, and ethnicity.

Integrated: it defines that offering the complete package of healthcare throughout a patient’s treatment course (World Health Organization, 2021)

Some medication errors are still essential to learn and penetrate for safe medication administration.  

Types of Medication Errors

Medication errors have a broad list, so medication administration must alert their staff during in-service sessions. The types include 

• Omission
• Unauthorized drugs
• Inadequate dose prescription/preparation
• Monitoring errors 
• Administration errors (Tariq & Scherbak, 2021)
• Compliance errors  

Need and Process to Improve Patient Safety

After understanding medication errors, their types, safe medication administration, and elements of good care, we will analyze the need and process to improve patient safety with implementation strategies. In this session, we scrutinized the reason for medication errors and where they occur. For this purpose, we will have to put ourselves as workers to understand the pressure of working and how these errors occur.   

Major Medication Administration Errors

Prescribing is a significant medication administration error because some unskilled and inexperienced nurses who get the wrong abbreviation of medicine can infuse the wrong medication into patients. The other major error includes monitoring errors where some professionals fail to monitor patient reports authentically, such as not figuring out the allergy type or what medication would be best suited for such conditions. These activities cause the patient to face serious consequences, such as an impact on his life. 

Furthermore, the cause of these medication errors includes: 

• Expired products
• Incorrect preparation 
• Incorrect rates
• Incorrect dose 
• Unethical patient action 
• Known allergen (Tariq & Scherbak, 2021)

Improvement Plan

As we have discussed in assessments 1 and 2, in the St. Luke’s Magic Valley medical center case where the infant died due to wrong administered medication, the improvement plan we have built to reduce the probability of such events in the medical center.  

After analyzing the scenario, we will define the improvement plan leading us towards patient safety measures. To mitigate the medication error impact, a few strategies, such as effective communication, team engagement, and technology involvement with the assured and improved quality by quality measured approaches such as Six Sigma (Trakulsunti & Antony, 2018).  This approach will make our established plan more efficient and successful as it will lead the medical center towards betterment and confirmed technological quality. 

Leadership strategies must improve teamwork and engagement and provide a safe environment where they feel encouraged and motivated. In-service sessions, the awareness, and importance of accomplishing duties with sincerity will be discussed to help the organization achieve its established goals. 

Moreover, implementing open communication, we suggested introducing a platform where all the staff can be connected and address their duties and tasks. This will reduce medication errors, especially due to incorrect pronunciation and prescribing issues. Any application will be worked with restricted internet access where all the staff and nurses will define their tasks and duties, and the supervisors can address their daily duties and chores. 

However, the Barcode administration Medication System (BCMA) (Zheng et al., 2020) will be introduced among staff to make them adopt the change and apply it effectively. The total quality management system will be used to implement technology to assure the system’s quality. The quality assurance assistance will supervise the system’s quality. 

Furthermore, the staffing shortage will be directed to the HR department to recruit more staff to reduce the pressure from nurses and balance the workload. In-service sessions will explain to the Human Resource department how well-skilled and experienced people should be hired to improve the quality and patient safety measures. A responsible and adequate person is more reliable than a non-serious behavioral person; that is why HR must ensure their skills, experience, behavior, and dedication to serving in the organization. 

These safety measures will lead us to reduce medication errors and enhance the capability of the system to provide efficient patient safety care to their people. Furthermore, this improvement plan will ensure the organization’s success because this plan will also emphasize staff engagement and team building through open communication among nurses and professionals. 

Role of Nurses 

The audience includes staff, nurses, and medical professionals who are the real assets and resources of the organization because their dedicated participation can lead the firm to attain its goals. Every participant is associated with certain duties they should not neglect, such as nurses being responsible for monitoring, assessing, delivering the drugs, recording the doses, and communicating with the patient and their families. All these responsibilities are crucial, so disrupting any of them might impact the whole working position (BU Mueller et al., 2022). 

Nurses also help provide detailed plans to doctors in which medication information, patient history details, and current conditions are mentioned so that doctors can prescribe them medication according to their needs. Furthermore, nurses are responsible for monitoring and documenting it carefully so that doctors administer medication properly. Nurses also interpret the results, take lab tests, and take patients’ vitals. Making all the staff comfortable and aware of their tasks will be the main theme of this in-service session and reducing medication errors. The self-assessment will also be initiated and explain the importance of it as it will make the staff activate their skills and expertise to analyze the data and interpret it carefully (Di Simone et al., 2018). 

The in-service session explains the issues, its reasons, causes, and plan for improving the work quality. If anyone has any queries regarding the session, they can ask personally or read the guidance templates we provided in this session. Moreover, frequent sessions will be initiated with the staff where they can practice and ask questions about developing new skills and processes (Fisher & Kiernan, 2019).     

Resources and Activities 

Resources and assets are the main lead in any plan implementation; however, in our plan, few matters do not need proper cash resources, such as team building and engagement that can only be obtained through leadership skills implementation by people like us. The involvement and participation of nurses and leaders will enhance the capability of an organization to attain its mission and vision. Our in-service session will engage the staff and all nurses to work together, and template guidelines will be provided to resolve their questions and ambiguities. 

Humans are the major resource of any organization, which is why we will cherish their existence and make them able to reduce the negativity in the workplace regarding medication errors. The session will broaden their instincts and make them more responsible for their duties. Besides these human resources, the other resources can be accomplished by utilizing staff’s phones. The application can be run on cell phones via internet services, so providing them with separate equipment will not be necessary for this implementation. Furthermore, every company owns the HR, IT, QA, and risk departments, but with time, their capabilities get reduced, and they neglect their duties which causes the organization more trouble. Making them aware of their responsibilities will resolve half of the problems. After the in-service session, all the departments will work together to bring prosperity and quality work (He et al., 2019).   

Expected Outcomes 

After implementing the improvement plan, we will discuss the expected results from the applied activities. The SMART goals can be applied here. They are Specific, Measurable, Attainable, Relevant, and Time-Based. The expected results would be:

• Improved medical staff focusing on their roles and responsibilities to reduce medication errors. 
• Everyone must be aware of their tasks and duties regarding what they should do when in the field and how to overcome the challenges they face during the process
• The nurses must be experts in understanding the medication administration working and offer complete consideration to evaluate the patient health safety 
• The guidelines and policies must be acquired properly by each member, and violation of any can lead them to file penalties (Gates et al., 2019). 
• The prevention of medication errors and violation of terms and regulations must be explained in the session and adopted by every participant 
• The session will provide a sense of making rapid and effective decisions for the betterment of the patients 
• The staff must be aware of technological involvement and adapt to the change in the environment frequently
• The nurses should know how to utilize the technological equipment and discuss the critical points with the professionals to maintain the drug’s effectiveness.
• This session will make the nurses more communicative regarding prescribing, monitoring, and assessing patients with medical professionals.  

Soliciting Feedback/Conclusion

These are some of the expected outcomes from the in-service sessions; however, feedback from the staff on the improvement plan will be conducted through surveys and questionnaire distributions. The distributed questionnaires will explain the thoughts and opinions of each participant regarding the in-service session for patient safety improvement. It will also help us get feedback and further advance the opinions of introverts who hesitate to communicate openly. 

This feedback from participants will help us to enhance our abilities to deliver a more effective improvement plan for the future. All concerns will be gathered, and our team will analyze them thoroughly to conclude the results to broaden our thoughts on the patient improvement plan and deliver positive and potential results.   

References 

World Health Organization. (2021). Quality of care. Www.who.int. https://www.who.int/health-topics/quality-of-care#tab=tab_1

BU Mueller, W Franklin, ERS Fisher, & DR Neuspiel. (2022). Principles of Pediatric Patient Safety: Reducing Harm Due To Medical Care. Aap.org. https://publications.aap.org/pediatrics/article-abstract/143/2/e20183649/37320

1. Weaver, P., Sallie J., Rosen, A. DiazGranados, M., Dietz, D., S. Benishek, A., E. Thompson, L., & Pronovost, D. (2018). APA PsycNet. Psycnet.apa.org. https://psycnet.apa.org/record/2018-23205-011

He, J., Baxter, S. L., Xu, J., Xu, J., Zhou, X., & Zhang, K. (2019). The Practical Implementation of Artificial Intelligence Technologies In Medicine. Nature Medicine, 25(1), 30–36. https://doi.org/10.1038/s41591-018-0307-0

Gates, P. J., Baysari, M. T., Gazarian, M., Raban, M. Z., Meyerson, S., & Westbrook, J. I. (2019). Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis. Drug Safety, 42(11), 1329–1342. https://doi.org/10.1007/s40264-019-00850-1

Fisher, M., & Kiernan, M. (2019). Student Nurses’ Lived Experience of Patient Safety and Raising Concerns. Nurse Education Today, 77. https://doi.org/10.1016/j.nedt.2019.02.015

Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication Errors in The Emergency Department: Knowledge, Attitude, Behavior, and Training Needs of Nurses. Indian Journal of Critical Care Medicine, 22(5), 346–352. https://doi.org/10.4103/ijccm.ijccm_63_18

Koyama, A. K., Claire-Sophie Sheridan Maddox, Li, L., Bucknall, T., & Westbrook, J. I. (2019). Effectiveness of Double Checking to Reduce Medication Administration Errors: a systematic review. BMJ Quality & Safety, 29(7). https://doi.org/10.1136/bmjqs-2019-009552

Tariq, R. A., & Scherbak, Y. (2021). Medication Dispensing Errors and Prevention. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Trakulsunti, Y., & Antony, J. (2018). Can Lean Six Sigma be used to reduce medication errors in the healthcare sector? Emerald.com. https://www.emerald.com/insight/content/doi/10.1108/LHS-09-2017-0055/full/html?fullSc=1

Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2020). The Impact of Introducing Automated Dispensing Cabinets, Barcode Medication Administration, and Closed-Loop Electronic Medication Management Systems on Work Processes and Safety of Controlled Medications in Hospitals: A systematic review. Research in Social and Administrative Pharmacy, 17(5). https://doi.org/10.1016/j.sapharm.2020.08.001