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Jessica Ramos, BSN, RN

Capella University

NURS-FPX6212: Health Care Quality Safety Management

Dr. Mary Ellen Cockerham

August 14, 2021


Healthcare organizations face an increase in the number of errors committed by practitioners in the line of duty. Medical errors are events that happen to a patient due to the care provider failing to follow the planned care procedure. As a result, these events cause harm to the patient, which compromises the desired Quality of care. As a result, the reputation of the organization can be damaged and lead to litigations. In addition, errors committed by professionals can lead to the loss of jobs. In addition, these events may affect the patient adversely to the extent of causing death. Medical errors have been reported to be among the leading causes of death in the United States, although they are related to other problems such as burnout and work-related stress (Robertson & Long, 2018). This paper analyzes this problem and proposes practice changes that would help alleviate this problem.

Systemic Problems

Medical errors result when a patient is exposed to the wrong medication or by being overdosed or underdosed. Despite the challenges that these issues pose to a healthcare organization, the rate at which they have been happening is alarming, and they are considered to be among the leading causes of death in the United States among patients in a healthcare setting. As turnover rates among nursing professionals increase, the ratio of patient to nurse is also increasing. On the other hand, nurses should balance the Quality of care and at the same time maintain efficiency in care delivery. However, when nurses have a huge workload, it is likely to lead to stress and burnout, which lead to increased chances of committing medical errors. As the ratio of patients to nursing professionals continues to rise, medical errors are becoming rampant, putting the patients’ lives on the line. Therefore, it is important to understand the workload nurses are supposed to deliver and how this leads to increased medical errors (Robertson & Long, 2018). Committing medical errors within a medical unit is so severe that in addition to ruining an organization’s reputation, it leads to legal consequences that affect the organization’s ability to continue operating, affecting the financial abilities of the organization as cases of reimbursements increase.

Proposed Practice Changes

As healthcare organizations face an unprecedented increase in medical errors, they must implement systems that would help them identify possible errors and thus reduce related events, which compromise the Quality of care. Some of the proposed changes in care delivery wo



Executive Summary, Outcome Measures for Medical Errors

Jessica Ramos

Capella University

NURS-FPX6212: Health Care Quality Safety Management

Dr. Mary Ellen Cockerham

September 19, 2021

Executive Summary, Outcome Measures for Medical Errors

Medication errors are prevalent in the healthcare sector, and they pose a potent threat to the quality of care provided to patients. According to Márquez-Hernández (2019), 70% of nurses have made a medication error in the course of their practice. Medication errors may lead to severe injury to patients, longer hospitalization spans, new conditions such as skin rashes and itching or disability. Gorgich et al. (2016) asserted that 30% of patients impacted by medical errors die or develop disabilities lasting over six months. The health conditions caused by medication are a financial burden because they lead to increased medical costs; in the United States, expenses incurred due to medication errors are approximately $6.5 billion (Gorgich et al., 2016).

In the last six months in our facility, there has been an increase in medication errors with three incidents reported. In the first one; a nurse injected a patient with Penicillin, without inquiring if they were allergic to Penicillin, and it led to adverse events including excessing vomiting and diarrhea. In the second one, a patient was wrongly prescribed medication for high blood pressure, yet he had been diagnosed with viral gastroenteritis, therefore, his condition was exacerbated leading to readmission. In the third one, an admitted patient with chronic obstructive pulmonary disease (COPD) was administered extra doses of prednisone 60 mg and methadone dose of 80 mg during the night shift leading to the development of new symptoms. The cases are alarming because they implied that patient safety in the facility was lacking and they hindered the realization of quality medical care in the facility. Therefore, interventions are required to prevent further medication errors from occurring that would damage the facility’s reputation. This executive summary describes the outcome measures to be employed in change implementation efforts and the role of leadership in addressing medication errors in the healthcare organization.

Executive Summary on the Gap

The findings from the undertaken safety gap analysis showed that there is an urgent need to address the prevalent medical errors in the organization. Therefore, investigations on the reported incidents were conducted to determine the factors that led to their occurrence. In the first incident, the nurse did not conduct a thorough assessment on the patient as he believed all the information was in the patient’s file but it was found out that it had not been u


Jessica Ramos

Capella University

NURS-FPX6212: Health Care Quality Safety Management

Dr. Mary Ellen Cockerham

Sep 9, 2021

Outcome Measures, Issues, and Opportunities

The undertaken quality and safety study indicated an urgent need to mitigate medication errors in the healthcare institution. As captured in the executive summary, medication errors adversely impact the quality of care advanced to patients. These adverse effects include exposure to new infections such as skin rashes and itching, severe injury, and prolonged hospitalizations. To healthcare organizations, medication errors erode clients’ trust, damage the organization’s brand equity, and lead to high operational costs due to longer lengths of stays and litigations. Therefore, healthcare organizations need to enact measures to address medication errors. Defining outcome measures is a vital intervention towards providing quality patient care. In this regard, a detailed evaluation of outcome measures, issues, and opportunities are necessary to gain an insightful approach in addressing medication errors. This report describes outcome measures, issues, and opportunities that be considered in mitigating medication errors to improve patient care outcomes and realize effective and efficient healthcare services.

Corporate Processes and Behaviors in Effective Health Care Organizations

The healthcare field deals with human life; hence organizations are mandated to hold the highest possible standards of care. These high standards are realized through organizational excellence. However, high-performing healthcare organizations do not achieve operational efficiency through luck but through deliberate processes and interventions which their leaders have developed. These organizations depict certain functions, processes, and behaviors that enable them to deliver quality healthcare services. These processes and behaviors include effective leadership, strict standardization practices, a favorable error reporting culture, and optimized staffing.

Effective Leadership

In all organizations, leadership is a core determinant in achieving organizational goals. Effective leadership is among the most critical elements that direct an organization to successful outcomes. In high-performing healthcare institutions, effective leadership instills confidence in staff and patients. Additionally, effective leadership in these organizations creates trust, an essential aspect of effective communication in all organizations. Studies indicate a significant correlation between effective leadership styles and high patient satisfaction, reducing the adverse effects experienced by healthcare organizations (Sfantou et al., 2017). Therefore, effective leadership is a crucial element in re


Hospital Adverse Event Data
January February March April May June July August September October November December Total
HOSPITAL READMISSIONS IN < 30 DAYS 12 7 6 4 4 1 3 10 5 3 12 2 69
MEDICATION RELATED DEATHS AND DISABILITIES January February March April May June July August September October November December Total DEATH & DISABILITIES
1 0 2 0 1 0 0 2 1 0 0 1 8
1 1 0 0 0 0 1 0 0 0 0 3 DEATH