NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

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Capella university

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Change Proposal Summary Report

The main goal of this executive summary report is to suggest a change to Parkview Community Hospital Medical Center’s medication administration error reduction program. This proposal is based on thorough research into medication administration errors and a comparative study of how these errors are addressed in healthcare systems outside of the United States. The purpose of this analysis is to pinpoint practical solutions and strategies that Parkview Community Hospital can adopt to improve patient outcomes by effectively reducing medication administration errors.

Executive Summary

Proposed Change

The decision to emphasize on reducing medication administration errors at Parkview Community Hospital Medical Center arises from the persistent increase of these errors impacting patient safety. While advancements in healthcare technology have been widely adopted, Parkview has not yet fully implemented a comprehensive Barcode Medication Administration (BCMA) system hospital-wide. This partial adoption has led to inconsistencies in medication administration practices, contributing to a higher-than-benchmark rate of medication errors across the organization.

The benchmark for medication errors is recommended to be below 100 incidents for every 10,000 prescriptions/orders processed (ElLithy et al., 2023). However, an annual internal audit at Parkview revealed an error rate of 145 incidents per 10,000 prescriptions/orders processed, significantly exceeding the recommended threshold. This increase in medication errors, along with other harmful events, led to a poor score of hospitals, i.e., 0.96 (Leapfrog Hospital Safety Grade, 2024). These data highlight the urgent need for change at Parkview Community Hospital Medical Center to diminish medication adverse events and enhance patient safety.

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Common errors included incorrect dosage, wrong patient identification, and incomplete documentation. These preventable errors have resulted in adverse drug events, increased patient morbidity, and higher healthcare costs, placing a strain on hospital resources. The causes of these errors in the organization include inadequate staff training, poor communication among healthcare teams, and reliance on outdated systems for patient data management, leading to lapses in safety protocols (Tariq & Scherbak, 2024). Implementing a hospital-wide BCMA system is expected to reduce these errors as demonstrated in similar healthcare institutions (Zheng et al., 2020).

The BCMA system, when fully integrated with the hospital’s electronic health record (EHR) system as mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, will enhance patient safety by making sure that the right medication is injected to the right patient at the right time (Owens et al., 2020). Additionally, the BCMA system will create a digital audit trail, improving accountability and helping the hospital meet regulatory compliance standards (Mulac, 2021).

By reducing the medication error rate to align with or fall below the industry benchmark, Parkview can not only enhance patient outcomes but also realize significant cost savings. These savings will result from fewer adverse events, reduced lengths of hospital stays, and a decrease in litigation related to medication errors. The overall improvement in operational efficiency will allow healthcare professionals to emphasize direct patient care, further enhancing the quality of care delivered at Parkview (Stolic et al., 2022).

Desired Outcomes

One desirable outcome of implementing a Barcode Medication Administration (BCMA) system at Parkview Community Hospital Medical Center is a significant reduction in medication administration errors. This outcome is critical because medication errors can lead to serious adverse drug events, which compromise patient safety and result in more extended hospital stays, increased healthcare costs, and, in severe cases, patient mortality. By reducing these errors, the hospital can improve patient outcomes, enhance the quality of care, and lower the overall cost of treatment (Zheng et al., 2020).

The financial burden of implementing and maintaining the BCMA system will primarily fall on the hospital’s budget, which long-term cost savings and improved patient outcomes may offset. However, third-party payers, such as insurance companies and government programs, will indirectly benefit from the reduced costs associated with fewer complications and readmissions. The hospital will need to explore grants or subsidies aimed at improving patient safety to help fund the initial implementation (Mulac, 2021).

However, limiting factors could impede the achievement of these desirable outcomes. The first is the financial constraint of the initial investment required to implement the BCMA system, including the cost of technology, training, and integration with existing electronic health records. The second limiting factor is the potential resistance to change among healthcare staff, who may be reluctant to adopt new technology or alter established workflows. Effective change management strategies, including thorough training and ongoing support, will be essential to overcoming this resistance and ensuring the successful implementation of the BCMA system (Ho & Burger, 2020).

Health Care System Comparative Analysis

To gain deeper insights and identify a better strategy, we conducted a comparative analysis of how two healthcare systems outside the United States prevent and reduce medication errors. The National Health Service (NHS) in the United Kingdom addresses medication administration errors through the widespread implementation of electronic prescribing and medicines administration (ePMA) systems. These systems are integrated into hospital workflows and provide real-time decision support, including automated alerts for potential drug interactions and incorrect dosages (Mohsin, 2020).

The NHS has also invested heavily in training healthcare providers to use these systems effectively, ensuring a high level of compliance and accuracy. The NHS has seen a significant reduction in medication administration errors since implementing ePMA systems. The system also improves communication among healthcare providers, which further reduces the likelihood of errors. This approach has led to safer patient care and has minimized the costs associated with medication errors (Mohsin, 2020).

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Australia’s healthcare system has adopted a Barcoding at the Point of Care (BPOC) approach, similar to BCMA but with additional features tailored to the specific needs of Australian hospitals. The BPOC system includes a comprehensive inventory management module that ensures medications are tracked from the pharmacy to the patient’s bedside. This system also integrates with electronic health records (EHRs) and utilizes real-time data analytics to identify potential errors before they reach the patient (Kalke & Mundhe, 2020). The added inventory management feature has also led to more efficient use of resources and reduced wastage.

The integration of real-time analytics has allowed healthcare providers to address potential issues, further enhancing patient safety quickly. The BPOC system has improved overall patient outcomes and has been a cost-effective solution for hospitals (The Society of Hospital Pharmacists of Australia, n.d.). At Parkview Community Hospital Medical Center, the current system for medication administration relies heavily on manual checks and basic electronic health record (EHR) integration, with no widespread use of advanced technologies like BCMA or ePMA. As a result, medication errors remain a significant concern, with error rates higher than those observed in the UK and Australia.

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Lessons from the NHS and Australia’s healthcare systems underscore the importance of integrating advanced technologies and ensuring thorough staff training to reduce medication errors. The NHS’s use of ePMA systems highlights the potential for decision support and automated alerts to prevent mistakes. In contrast, Australia’s BPOC system demonstrates the benefits of comprehensive barcode scanning and real-time data analytics. At Parkview, adopting a BCMA system with these features, along with rigorous staff training and ongoing education, could significantly improve the accuracy and efficiency of medication administration, ultimately enhancing patient safety.

Rationale for the Proposed Change

The implementation of a Barcode Medication Administration (BCMA) system at Parkview Community Hospital Medical Center is expected to lead to several key improvements in outcomes. These include a substantial reduction in medication administration errors, enhanced patient safety, and increased operational efficiency. By ensuring that the correct medication is administered to the right patient at the right time, the BCMA system can significantly decrease the incidence of errors, which are a major source of preventable harm in healthcare (Ho & Burger, 2020).

This, in turn, will reduce adverse drug events, lower the need for corrective treatments, and shorten hospital stays, ultimately leading to better patient outcomes and cost savings for the hospital. One landmark study demonstrated that the implementation of BCMA systems in hospitals led to a 74.2 % reduction in medication administration errors and a 50.8% reduction in potential adverse drug events (Owens et al., 2020).

The study concluded that BCMA technology is efficacious in improving patient safety by significantly reducing medication administration errors. Given the existing structure and resources at Parkview Community Hospital, these expectations are reasonable. The hospital can leverage its existing electronic health records (EHR) system as a foundation for integrating BCMA technology. While initial investment and training are required, the long-term benefits of reduced errors, improved patient outcomes, and cost savings make this a feasible and beneficial change within the current healthcare system.

Financial and Health Implications

Implementing a Barcode Medication Administration (BCMA) system at Parkview Community Hospital will involve substantial upfront costs, including purchasing the technology, integrating it with existing systems, and training staff. However, these initial expenses are expected to be offset by significant long-term financial benefits.

Reducing medication errors will decrease the frequency of adverse drug events, which in turn will lower the costs associated with corrective treatments, prolonged hospital stays, and potential legal liabilities. Additionally, the improved patient safety resulting from BCMA implementation can enhance the hospital’s reputation, attracting more patients and increasing revenue. Over time, the financial savings and potential revenue growth from adopting BCMA are likely to outweigh the initial investment, offering a strong return on investment (Berg et al., 2024).

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

The health benefits of adopting a BCMA system are considerable. By significantly reducing medication administration errors, the system will enhance patient safety, leading to better health outcomes, such as fewer adverse drug events, reduced morbidity and mortality rates, and higher patient satisfaction (Mulac, 2021). This aligns with Parkview Community Hospital’s commitment to providing high-quality care. Additionally, a safer medication administration process will reduce stress and workload on healthcare providers, contributing to improved job satisfaction and potentially reducing burnout. Conversely, not implementing the BCMA system could result in continued high rates of medication errors, putting patients at risk of preventable harm and undermining the hospital’s ability to deliver safe and effective care (Zheng et al., 2020).

Conclusion

In conclusion, the proposed implementation of a Barcode Medication Administration (BCMA) system at Parkview Community Hospital Medical Center is a strategic and necessary change to enhance patient safety, reduce medication administration errors, and improve overall healthcare quality. The financial investment required for BCMA is justified by the long-term benefits of reduced adverse drug events, cost savings, and improved operational efficiency. By learning from successful healthcare systems like the NHS and Australia, Parkview can integrate advanced technology and ensure comprehensive staff training to achieve better patient outcomes. Ultimately, this initiative aligns with the hospital’s commitment to delivering high-quality care and will contribute significantly to the well-being of patients and the sustainability of the healthcare system.

References

Berg, C., Keefe, G., & Goodman, R. (2024). Case study: improve the safety and compliance of drug preparation and administration with barcode technology. Elsevier EBooks, 411–426. https://doi.org/10.1016/b978-0-12-818381-6.00021-8 

ElLithy, M. H., Salah, H., Abdelghani, L. S., Assar, W., & Corbally, M. (2023). Benchmarking of medication incidents reporting and medication error rates in a JCI accredited university teaching hospital at a GCC country. Saudi Pharmaceutical Journal, 31(9), 101726–101726. https://doi.org/10.1016/j.jsps.2023.101726 

Ho, J., & Burger, D. (2020). Improving medication safety practice at a community hospital: A focus on bar code medication administration scanning and pain reassessment. BMJ Open Quality, 9(3), e000987. https://doi.org/10.1136/bmjoq-2020-000987 

Kalke, P., & Mundhe, D. (2020). Comprehensive study on medication error to improve patient safety. Indian Journal of Forensic Medicine & Toxicology, 14(4). https://pdfs.semanticscholar.org/4937/167f9df076a84b3a3b322ecb77d7fda5b351.pdf

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Leapfrog Hospital Safety Grade. (2024). Parkview Community Hospital Medical Center – CA – hospital safety grade. Hospitalsafetygrade.org. https://www.hospitalsafetygrade.org/h/parkview-community-hospital-medical-center?findBy=hospital&hospital=Parkview+Community+Hospital+Medical+Center&rPos=200&rSort=grade 

Mohsin, S. (2020). The impact of electronic prescribing on pharmacists’ communication in UK inpatient settings: A mixed methods study. https://discovery.ucl.ac.uk/id/eprint/10117798/3/PhD%20Thesis-%20Soomal%20Mohsin-Shaikh.pdf 

Mulac, A. (2021). Barcode medication administration technology use in hospital practice: A mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223 

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing, 46(6), 884–891. https://doi.org/10.1016/j.jen.2020.07.004 

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Stolic, S., Ng, L., & Sheridan, G. (2022). Electronic medication administration records and nursing administration of medications: An integrative review. Collegian, 30(1), 163–189. https://doi.org/10.1016/j.colegn.2022.06.005

Tariq, R. A., & Scherbak, Y. (2024). Medication dispensing errors and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/   

The Society of Hospital Pharmacists of Australia. (n.d.). Closing the loop of medication management in hospitals to improve patient safety with barcoding technology on unit dose packaging . https://shpa.org.au/publicassets/baa132c4-de53-ec11-80dd-005056be03d0/position_statement_-_unit_dose_packaging.pdf 

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), 832–841. https://doi.org/10.1016/j.sapharm.2020.08.001 

Appendix

Table 1: Health Care System Comparative Analysis

(Kalke & Mundhe, 2020; Mohsin, 2020; The Society of Hospital Pharmacists of Australia, n.d.)