BHA FPX 3004 Assessment 1 Executive Summary on a Patient Safety Issue

Executive Summary on a Patient Safety Issue

Student Name

Capella University

BHA-FPX 3004

Instructor’s Name

Submission Date

Issue Identified in the Vila Health Simulation

The Medication Administration Error is one of the most common and preventable causes of patient harm in acute care hospitals and is highlighted in the Vila Health simulation as one of the healthcare field’s concerns regarding patient safety. Although technology is developing, the process of prescribing, transcribing, dispensing and administration is flawed and endangers patients. The answer to this problem is directly tied to patient safety issues in our country and our strategic goal of becoming a high-reliability organization.

Importance of Patient Safety in Healthcare

The event was on a medical ward in a 68-year-old who had been admitted for A-fib with rapid ventricular response. He was treated with diltiazem IV for his heart rate. One evening, a nurse was administering a 25 mg IV dose of metoprolol to a patient. When she was in a hurry, she gave an overdose of metoprolol 25 mg IV instead of diltiazem IV. This occurred because the nurse picked up the wrong medication from the automated dispensing unit because of similar labels and packaging of similar drugs.

Although the bar code medication administration technology was available, it was not used because the bar code did not scan properly during previous medication administrations during the shift. Later, the patient had onset of symptomatic bradycardia and hypotension and was moved to the ICU for monitoring. Eventually, the patient’s condition stabilized, and there were no long-term effects due to the medication error. This is an ADE that could have been prevented.

The safety motivation for health care systems is that they should design systems to predict human error and reduce it for patient safety. This is because healthcare organizations now know that it is not enough to be vigilant to guard against human error; it is necessary to design systems that can anticipate human error and mitigate it. This is particularly after the Institute of Medicine’s publication “To Err is Human. This is because it is known that most medical errors are not caused by faulty healthcare providers and also not by careless people, but as a result of faulty systems and processes.

This is because it is known that most medical errors are not caused by careless healthcare providers and not as a result of careless people, but as a result of faulty systems and processes. This is especially relevant in medication errors because it is recognized that preventable harm is caused by medication errors. This is particularly significant in this instance as there were other drugs that were stored in a similar manner with no obvious distinguishing characteristics on the automated dispensing unit. Furthermore, the use of the barcode technology was not enforced because it was not working well in the previous administration of medication during the shift. There is also a financial cost associated with medical errors due to longer hospital stays, more treatment, and legal costs.

The Joint Commission, as a regulatory body, keeps an eye on the implementation of medication safety standards and National Patient Safety Goals. There are several consequences if the standards are not met. Consequences of repeated infractions include accreditation and reimbursement consequences. Occupational safety (OSHA standards) is one of the aspects of the regulatory process, particularly for systems that may be distressing to employees and create an environment that is not sanitary (The Joint Commission, 2026). In cases of medication-related mistakes, the mediation of trust will be at issue. The study has shown that ADEs may result in increased mortality rates and healthcare expenses (Jiang et al., 2022).

Risks to Patients, Employees, and the Organization

Patient, employee, and organizational risks associated with attendance. Patient, employee, and organizational risks related to attendance. High-alert medications like anticoagulants, insulin, beta-blockers, and opioids have high risks of adverse effects in cases of dosing errors. For example, some beta-blockers can lead to cardiovascular instability. Subsequent use of the wrong drug will lead to a huge disaster in the future. The risks to the employees will be moral distress, burnout, and disciplinary risks. The second victim phenomenon (Tariq et al., 2024) will also occur with feelings of guilt, anxiety, and loss of confidence among the nurses in the event of a medication error.

The organizations will have to deal with greater liability for malpractice and increased operating expenses. In cases of medication errors, there will be higher costs of operations because of the need for extended hospital stays. In addition, there will be the need for repeated treatments. The National Patient Safety Goals for medication safety are not optional, but rather required for safe operations (The Joint Commission, 2026). The healthcare safety mandate calls for proactive risk mitigation using culturally sensitive technologies, policies, and practices.

Role of the Patient Safety Officers

The role of patient safety officers is clearly defined in the intersection of strategy and operations and is geared towards advancing quality and safety. This involves giving full support to the concept of root cause analysis (RCA) and tackling identified root causes of failure modes and effects analysis (FMEA) results, incident reporting, and applying the regulatory requirement to policy and converting it into action and relevance (Kuitunen et al., 2024).

First, for a scenario as presented, I would undertake a formal RCA, which will include nursing leadership and management, pharmacy, biomedical engineering, and information technology. The RCA will include the review of factors like medication storage, barcode scanner function, staffing levels, how new nurses are introduced to the staff, and communication breakdowns.

The findings of the RCA will be communicated to the nursing team for them to work with the pharmacy leaders in addressing medication storage in automated dispensing systems and to include designing spaces for high-alert and look-alike medications that are clearly separated and labelled with tall-man lettering. The team will also be expected to work with the information technology and biomedical engineering teams to ensure the barcode scanning is working properly and that the users do not have to find other alternative ways that are not included in the barcode medication administration system (Ravi et al., 2022).

Moreover, teaching will take place on the five rights of medication administration and on the need for psychological safety in reporting near misses. Research has demonstrated that implementing a barcode medication administration system will lead to a 30-50% decrease in medication errors and, therefore, is a sign of high reliability and effective leadership monitoring (Williams et al., 2025).

Evidence-Based Strategies to Reduce Medication Errors

The leadership style has been recognized as a variable that affects the degree of compliance with medication safety practices among employees. The most recent systematic review reveals that transformational, ethical, and situational leadership styles have been linked to better medication safety outcomes, including higher reporting of medication errors and better medication administration practices (Dirik et al., 2026). On the other hand, passive leadership is correlated with a rise in the frequency of medication errors.

Key lesson learned: healthcare organization leaders actively support staff to follow medication safety procedures. Transformational leadership is a leadership style that is effective in fostering a safety culture in the healthcare sector because of its ability to empower employees, promote group teamwork, and hold all employees accountable. Medication safety initiatives in healthcare organizations can be enhanced by leadership development programs on transformational and ethical leadership, which help to decrease medication safety errors.

To reduce medication errors is necessary to reinforce barcode medication administration. The use of BCMA is known to substantially reduce medication errors by various studies if used strictly. Goal: Barcode verification of patient and meds to be performed 100% of the time – real-time audit – alert if not performed. But effective leadership is essential to ensure that all staff are held accountable, and that they are using the equipment and medication safety processes effectively (Williams et al., 2025). Another essential leadership strategy is to implement leadership safety rounds, along with competency-based education.

Safety rounds provide opportunities for leaders and other clinical leaders to communicate with staff and patients, and to show their leadership by example in promoting a culture of safety. A survey reveals that effective leadership rounds play a significant role in enhancing communication and collaboration, and empowering employees to raise safety issues (Bornman & Louw, 2023). Moreover, competencies-based education plays a crucial role in providing the competencies that health care professionals need to effectively perform their functions in medication administration.

Conclusion

This patient safety risk is avoidable and apparent and is a typical medication error. Using the case of a 68-year-old patient on a medical/surgery floor, it is seen that the failure of equipment, its design, timing, and culture all converged and led to a med error. The issue with us making revolution does not necessarily lie in accusing any person of anything but looking at the systems that we employ and devising means of bettering them. The five-point plan that unites the best practices can help us establish an atmosphere of safety that fulfills our patient safety and quality care promise.