Improvement Plan Tool Kit

Healthcare requires complete and proper quality care systems to assure patients’ safety. However, medication errors often happen in every US healthcare system, which impacts patient quality care. As a part of healthcare, the in-service training sessions and improvement plans have been initiated, yet making these practices possible and sustainable for the system requires more encouragement and the presence of any online tool kid or resource repository that guides the in-service’s audience to understand the research behind the safety improvement plan regarding the medication administration. 

Annotated Bibliography

Analyzing Successful Quality Improvement Initiative for Medication Administration

Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., Bower, P., Campbell, S., Haneef, R., Avery, A. J., & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, 366, l4185. https://doi.org/10.1136/bmj.l4185

This article focuses on preventing medication errors because of increasing morbidity and mortality. This article aims to articulate the prevalence, nature of preventable medication errors, and severity of incidents among healthcare centers worldwide. This article defines the pressure and burdens that healthcare faces due to excessiveness in patient harm in developed countries like the US. These incidents also impact the firm’s financial structure because they deal with these crises and save themselves from public opinions. It has become so common that these factors have become the policy priority internationally for effective healthcare systems. However, this article also emphasized the unavoidable clinical practices which might cause patient harm, such as drug reaction probabilities; otherwise, the survival rate of Patients would be extremely low. Still, these are optional cases for referring the medication errors and preventable patient harm. The major causes of medication errors also explained in this article include poor actions of medical professionals, healthcare system failures, or patient stubbornness. However, qualitative observation has been implemented where cross-sectional studies of different geographical areas were published from 2000 onwards. The outcomes define the reasons, such as the primary outcome based on the prevalence of preventable patient harm because of identifiable and modifiable causes. The secondary outcome defines the severity in three types such as mild, moderate, and severe because of the drug, diagnostics, healthcare-acquired infections, and medical procedures. This study analysis shows that 12% of harm was severe, leading to death. However, private and advanced hospitals have more chances to prevent patient harm than general hospitals. Hence, this study’s analysis provides knowledge regarding the prevalence of patient care and the severity of the impact on the nurses.

Bates, D. W., & Singh, H. (2018). Two Decades Since To Err Is Human: An Assessment of Progress And Emerging Priorities In Patient Safety. Health Affairs, 37(11), 1736–1743. https://doi.org/10.1377/hlthaff.2018.0738

This article was published to represent the watershed US healthcare system moments because of dramatically reported safety risks from the past two decades. After reporting diagnostic errors, medication risks, and administrative errors, the healthcare systems boost their levels and implement the interventions using information technology and scientific policies. However, medication errors cannot be mitigated from the roots, but with the help of strategies and team building, they can be reduced, which happened after it. The frequency of risks and errors is reduced, increasing the determining capacity to prevent harm. The technology helps measure the frequency level and provides testing methods to improve the quality of patient safety in healthcare systems. Furthermore, IT involvement also helps in predicting the errors chances and diagnosis impact on the patients, which acknowledges the professionals to make alternatives for uncertain situations and prevent harm. Hence, these articles also teach nurses about the use and implementation of technology in the healthcare systems to reduce the impact of medication errors and increase patient safety.     

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open, 8(8). https://doi.org/10.1136/bmjopen-2018-022202

This article discusses successful quality improvement initiatives by promoting the communication and patient hand-off tool SBAR for patient safety. This study can help nurses figure out the importance of communication and improve their communication skills for these matters. The SBAR tool, which refers to Situation, Background, Assessment, and Recommendation, helps increase the quality of professional actions and patient safety. This article summarizes the impact of the SBAR tool through systematic reviews in the setting of primary and secondary care, nursing, and clinical homes. The outcomes measure the occurrence and incidence of adverse events, and for this purpose, three controlled clinical trials were performed on multiple clinical criteria. However, this study promotes the team communication impact and improvement of hand-off communication on mobile phones from nurses to professionals. To check the significance of the communication tool total of 26 patient outcomes were measured, of which eight significantly improved and eleven improved with no further statistical tests found. Lastly, the six outcomes did not report any change. Hence, the study defines that the SABR tool can enhance the communication structure and implementation of practices by reducing the gap between nurses and medical professionals.  

For example, a nurse with improved communication skills with the SABR communication tool can lead others in a better and more effective way and pave the way for professionals to directly prescribe medication to patients without hesitation because nurses already make up their minds with their effective communication skills. On the other side, the nurses who lack communication skills and expertise in consoling the patients and their families or making them agree on medication treatment brought many dramas and hassles for the physicians and impacted the organization’s sustainability. 

Factors Leading to Patient Safety Risks with Specific Examples

Wright, J., Lawton, R., O’Hara, J., Armitage, G., Sheard, L., Marsh, C., Grange, A., McEachan, R. R., Cocks, K., Hrisos, S., Thomson, R., Jha, V., Thorp, L., Conway, M., Gulab, A., Walsh, P., & Watt, I. (2018). Assessing risk: a systematic review of factors contributing to patient safety incidents in hospital settings. In www.ncbi.nlm.nih.gov. NIHR Journals Library. https://www.ncbi.nlm.nih.gov/books/NBK390649/

This article was based on a systematic review of factors contributing to hospital patient safety incidents. A total of five contributing factors were scrutinized that frequently happened, such as active failures, individual factors, communication systems, management of staff and setting levels, and equipment and supplies. Among these, the active failures in which lapses, deviations from policy, slips, and mistakes are included, and individual factors were prominent because of frequently happened in the healthcare systems. This article can be helpful for the systematic collection of data regarding factors involved in patient safety incidents (PSIs) because 1502 total articles were scrutinized, and 1676 contribution factors were found, from which five major factors were separated and named major factors. Understanding these contributing factors will help the hospital settings improve the identification and prevention of patient harm. 

Chaneliere, M., Koehler, D., Morlan, T., Berra, J., Colin, C., Dupie, I., & Michel, P. (2018). Factors contributing to patient safety incidents in primary care: a descriptive analysis of patient safety incidents in a French study using CADYA (categorizing errors in primary care). BMC Family Practice, 19(1). https://doi.org/10.1186/s12875-018-0803-9

Patient safety incidents (PSIs) have become a major concern of healthcare systems. This article leads the nurses to determine the patient safety risk factors to improve their knowledge and care settings. The CADYA (Categorization of Errors in Primary Care) method is utilized. However, this study also discussed human behaviors and attitudes to determine the impact of human behavior on patient safety measures. The study identified the 590 contribution factors from the 482 PSIs were 482 based on MDs and 178 on SDs. The completion percentage was based on four processes; care process (35%), human factors (30%), healthcare environment (22%), and technical factors (13%). This study helps improve the human factors with GPs and patient involvement in the processes. The nurses can find these articles and resources to determine the human factors involved and errors in the healthcare centers. 

For example, these articles will provide scenarios to nurses to determine the impact of these contributing factors on patient safety risks and enhance their knowledge for dealing with situations where these factors’ involvement occurs. 

Garcia, C., Abreu, L., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicine, 55(9), 553. https://doi.org/10.3390/medicina55090553

This article indicates burnout’s influence on patient safety because stress can lead to negative results such as ineffective teamwork, physical and psychological workload, failed organization process, and poor communication. These all are risk factors that impact patient safety, and this article is based on a systematic review with meta-analysis using PubMed and the web of Science Database. The main studies were patient safety, organizational culture and professional burnout, and patient safety and burnout safety and safety management. These factors also impact the physician and nurse relationships, so this article defines the importance and significance of these two methods’ relationships. 

Organizational Interventions to Promote Patient safety

Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019). Impact of the World Health Organization Surgical Safety Checklist on Patient Safety. Anesthesiology, 131(2), 1. https://doi.org/10.1097/aln.0000000000002674

This article discusses the WHO organization’s surgical safety checklist’s impact on patient safety. Despite evolvement worldwide, surgical complications remain unchanged because of many factors’ contributions. However, this article articulates that the World Health Organization (WHO) presented surgical safety checklists to enhance anesthesia and surgery safety. Furthermore, these checklists also help reduce complications and mortality by implementing communication, teamwork, engagement, and consistency in care. This article provides knowledge to nurses regarding the advantages and disadvantages of using surgical safety checklists because it provokes the development, possible clinical positive effects, and implementation to achieve quality health work.

Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. H. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(1). https://doi.org/10.1186/s12960-019-0411-3

In this article, team effectiveness improvement is emphasized because this contribution contributes to achieving high results in the healthcare system. The systematic review analyzed the overall scientific study’s focus and used interventions. The identification of evidence-based research was the goal of this study to improve the team’s effectiveness and understand interventions that can be used in different scenarios. From 2008 to July 2018, published articles were considered, in which 6025 studies were included, and 297 studies were based on the criteria. A total of three types of intervention were considered, including training, tools like SABR, and the organizational design in which structure designing and team possess included.   

Gray, P., Senabe, S., Naicker, N., Kgalamono, S., Yassi, A., & Spiegel, J. M. (2019). Workplace-Based Organizational Interventions Promoting Mental Health and Happiness among Healthcare Workers: A Realist Review. International Journal of Environmental Research and Public Health, 16(22), 4396. https://doi.org/10.3390/ijerph16224396

This article defines workplace organizational interventions because the workplace environment causes many impacts, both ways negative and positive. The congested environment can cause the workers to burn out, have a mental illness, or stress, which can impact their working structures. For this purpose, three premier health-related databases were scrutinized, where 1290 articles discuss workplace interventions, mental health, and healthcare workers. Furthermore, 46 articles were selected as the main lead and listed the context, mechanisms, and outcomes analysis. However, organizational interventions include skills, leadership development, team building, time management, knowledge development, communication, and workload management. All these aspects lead the organization towards smooth collaboration. 

Nurse’s Role in Coordinating Care

Schroeder, K., & Lorenz, K. (2018). Nursing and the future of palliative care. Asia-Pacific Journal of Oncology Nursing, 5(1), 4–8. https://doi.org/10.4103/apjon.apjon_43_17

Nurses are participants in the healthcare system who spend more time with patients to provide effective care. In this article, the different nurse’s roles were distinguished, such as registered nurses,  advanced practice registered nurses, and palliative care nurses. All these types must include special skills such as effective communication, compassion, and human vulnerability. This article helps define the duties of nurses’ current roles in which primary or generalist palliative care and specialist palliative care were considered. However, this article also focused on sole practitioners, transitions in health care, and nurses supporting community practice models in which home visits were also focused on better explaining their roles. All these nurses’ roles help improve coordinating care and treatment effectiveness.   

Cornick, R., Picken, S., Wattrus, C., Awotiwon, A., Carkeek, E., Hannington, J., Spiller, P., Bateman, E., Doherty, T., Zwarenstein, M., & Fairall, L. (2018). The Practical Approach to Care Kit (PACK) guide: developing a clinical decision support tool to simplify, standardize and strengthen primary healthcare delivery. BMJ Global Health, 3(Suppl 5), e000962. https://doi.org/10.1136/bmjgh-2018-000962

In this guide, the evidence-based reviews were considered for the best practices toolkit for nursing to improve the effectiveness and care coordination. The PACK kit helps in clinical decision making for developing clicinal systems. This tool kit is reserved for nurses or professionals and for the patients to learn about their disease and its impact. The tool kit also involves the stakeholders of all stages to improve the decision-making and generate evidence-based databases. Hence, these articles help improve the original work and citation credits to provide efficient healthcare systems. The tool kit will also include the code of ethics and human behavior factors to improve the nurse’s role in coordinating care. 

Havens, D. S., Gittell, J. H., & Vasey, J. (2018). Impact of Relational Coordination on Nurse Job Satisfaction, Work Engagement, and Burnout. JONA: The Journal of Nursing Administration, 48(3), 132–140. https://doi.org/10.1097/nna.0000000000000587

This article explores the relational coordination that supports the quality enhancement and patient safety outcomes. It directly refers to the nurse and professional behaviors such as work engagement, team efficiency, burnout, job satisfaction, and other major factors that improve the experience of providing care. In this article, survey methods used on nurses and other providers in five acute care community hospitals were also included to get the significant impacts on job satisfaction, work engagement, and to reduce burnout. This relational coordination helps the nurses perform efficiently and gain job satisfaction, improving their performance. 

References 

Bates, D. W., & Singh, H. (2018). Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging Priorities In Patient Safety. Health Affairs, 37(11), 1736–1743. https://doi.org/10.1377/hlthaff.2018.0738

Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. H. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(1). https://doi.org/10.1186/s12960-019-0411-3

Chaneliere, M., Koehler, D., Morlan, T., Berra, J., Colin, C., Dupie, I., & Michel, P. (2018). Factors contributing to patient safety incidents in primary care: a descriptive analysis of patient safety incidents in a French study using CADYA (categorization of errors in primary care). BMC Family Practice, 19(1). https://doi.org/10.1186/s12875-018-0803-9

Cornick, R., Picken, S., Wattrus, C., Awotiwon, A., Carkeek, E., Hannington, J., Spiller, P., Bateman, E., Doherty, T., Zwarenstein, M., & Fairall, L. (2018). The Practical Approach to Care Kit (PACK) guide: developing a clinical decision support tool to simplify, standardise and strengthen primary healthcare delivery. BMJ Global Health, 3(Suppl 5), e000962. https://doi.org/10.1136/bmjgh-2018-000962

Delawska-Elliott, B. (2022). LibGuides: Evidence-Based Practice Toolkit for Nursing: Resources. Oregon Health & Science University. https://libguides.ohsu.edu/ebptoolkit/Resources

Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019). Impact of the World Health Organization Surgical Safety Checklist on Patient Safety. Anesthesiology, 131(2), 1. https://doi.org/10.1097/aln.0000000000002674

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open, 8(8). https://doi.org/10.1136/bmjopen-2018-022202

Panagioti, M., Khan, K., Keers, R. N., Abuzour, A., Phipps, D., Kontopantelis, E., Bower, P., Campbell, S., Haneef, R., Avery, A. J., & Ashcroft, D. M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ, 366, l4185. https://doi.org/10.1136/bmj.l4185

Schroeder, K., & Lorenz, K. (2018). Nursing and the future of palliative care. Asia-Pacific Journal of Oncology Nursing, 5(1), 4–8. https://doi.org/10.4103/apjon.apjon_43_17

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 1–15. https://doi.org/10.3390/ijerph17062028

Wright, J., Lawton, R., O’Hara, J., Armitage, G., Sheard, L., Marsh, C., Grange, A., McEachan, R. R., Cocks, K., Hrisos, S., Thomson, R., Jha, V., Thorp, L., Conway, M., Gulab, A., Walsh, P., & Watt, I. (2016). Assessing risk: a systematic review of factors contributing to patient safety incidents in hospital settings. In www.ncbi.nlm.nih.gov. NIHR Journals Library. https://www.ncbi.nlm.nih.gov/books/NBK390649/