NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Quality Improvement Initiative Evaluation

Student name

Capella University

NURS-FPX 6016

Professor’s Name

Submission Date

Systematic efforts to enhance patient safety and clinical outcomes while improving the overall efficiency of healthcare systems are known as quality improvement initiatives. Following the near-miss of insulin administration (Estahbanati et al, 2022), the organization decided to put in place an extensive program to improve the safety of the organization’s medication. Using this analysis, improved verification processes and the efficiency of the barcode medication administration system are evaluated. The analysis incorporates familiar benchmarks, interprofessional views, outcome metrics, and proposes innovation opportunities for the initiative to evaluate its success of the initiative.

Analysis of Quality Improvement Initiative

In response to the near miss when Mr. Daniel Carter was administered insulin, Riverside Community Hospital (RCH) built a medication safety quality improvement (QI) intervention for high-alert medications, focusing primarily on insulin. This program made bar code medication administration (BCMA) mandatory, supported the use of an independent double-check for the administration of insulin, SBAR handoff during a shift report, as well as staff training by way of simulations (Kuitunen et al. 2025).

The primary focus of this intervention was on reducing the number of insulin-related medication errors, enhancing communication, and ensuring the safety of the patient while transitioning between the inpatient units, as well as improving the appropriateness of the unit to the patient. This is a systems-based approach rather than an approach focused on individuals (Almutairi et al. 2024). The hospital instituted that the near-miss deficiencies that were inherent could be mitigated by improving verification, communication, and technology. Preliminary internal documents show that there is an improvement in compliance with the bar-code scanning procedures and an increased awareness of high-risk medications among the nursing staff.

Strengths of the Initiative

A strength of the initiative is the ability to adapt to the national patient safety priorities. The evidence of protective measures such as BCMA and independent checks being evidence-based and best practice suggestions shows the urgent need for this high-risk medicine. Two major stakeholders of MNC have the same substantial experience of shifts with SBAR improving the handover. It is now transformed to eliminate the need for the communicator to have to rely on his/her memory or be present to report verbally. The collaborative approach fosters a culture of safety and a shared accountability for patient outcomes.

Knowledge Gaps and Areas of Uncertainty

While the medication safety initiative has plenty of positive aspects, some limitations have made it difficult to determine success or failure. Additionally, there has been limited longitudinal data for the analysis and evaluation of insulin-related errors, and trends for decreasing errors are unknown. Though known to be compliant with barcode and double-check usage, inconsistency and lack of standardization remain. Usage of BCMA and alerts, and their effect on nurse staffing efficiency and workflow during periods of high work demand, is also unknown. Moreover, near-miss reporting does not give an accurate depiction of actual error reporting, as it does not account for under-reporting and better reporting (Lew et al., 2022). Finally, the assessment of patient safety and care measures and the patient’s understanding and confidence in their care have made it difficult to measure the systems used in this program and the overall effect of this program.

Evaluation of the Initiative Using Recognized Benchmarks

To evaluate the medication safety quality improvement (QI) program, we can look at program outcomes versus established national standards and benchmarks. Insulin is classified as a high-risk medication by the Joint Commission and ISMP. Kuitunen et al. (2025) discuss the critical role of BCMA, independent checks, and conventional handoff communication. The initiatives at this hospital align with the national patient safety goals focused on the safe identification of the patient, safe medication administration, and the safe communication of information during a handoff.

A significant decrease in medication errors, particularly those involving insulin, during the subsequent 1,000 patient days, will serve as a key assessment metric. Hypoglycemic and near-miss events associated with wrong dosing will be assessed to measure the impact of BCMA and SBAR on the medication safety culture. Additionally, a barcode scanning compliance rate of greater than 95% will be considered a positive indicator of the program (Estahbanati et al., 2022). The outcomes of an internal audit will show compliance with the double-check policy. If, after a few months, the post-initiative data show a sustained improvement, then the metrics will reflect that the initiative has positively influenced the safety of medication practices and the overall quality of care.

Adverse drug events and hospital-acquired complications are also important metrics in state and federal quality reporting programs for patient safety. It is expected that there would be some alignment with the more general regulatory and reimbursement requirements by reducing the number of preventable occurrences of hypoglycemia and adverse events caused by insulin (Lawson et al., 2021). In addition, addressing those survey items would likely improve the survey scores for the safety and culture of safety surveys, and would indicate the organization’s efforts on accreditation and the development of a safety culture focused on reporting.

The anticipated outcome measures of the QI initiative would include a decrease in the number of insulin-related medication errors, an increase in compliance with the BCMA policy, an increase in compliance with the independent double check policy, an increase in the use of the SBAR communication tool during handoffs, and a decrease in the number of insulin-related near-miss reports. Assuming that these measures reflect positive, incremental changes over time in comparison with the baseline data that is collected prior to the near-miss medication event, the measures would be considered to positively impact the safety of medication (Kuitunen et al., 2025). It would also be critical that a sustained benefit be achieved beyond the heightened focus.

Underlying Assumptions

Several assumptions are prevalent in this assessment. First, the assessment assumes that the early mistakes with insulin were accurate for making comparisons. Second, it assumes that the staff continues to use BCMA, along with the verify & check and SBAR guidelines. Third, it assumes that the near-miss reports are valid and that there is no underreporting, and that the reporting culture does not impact the results. Fourth, the assessment also assumes that the recorded incidents of errors decreased due to QI and is not due to other factors like the decrease in staff, patients’ acuity, etc. (Kubáňová et al., 2022). Finally, the assessment assumes that the metrics of patient safety, like barcoding, have improved and that other metrics of patient safety have improved as well.

Interprofessional Perspectives

Nursing staff said that verification procedures added to their workloads during peak shifts and that staffing and procedural support were needed. The immediate notification feature improved collaboration, but sent excessive notifications, which interrupted workflow. Doctors agreed that real-time notifications improved collaboration, but were disruptive. Doctors said that improvements were being made to medication safety, but expressed frustration that the system said that delays in requests were acceptable. Unresolved urgent requests would pose a risk to medication safety. There were also some system support challenges.

IT experts said that the systems needed to be updated and support was required continually. Unit managers said that there were positive changes to the safety culture, and employees felt the environment now supported reporting incidents without the fear of being disciplined. Interprofessional collaboration was a result of the work of a common committee and iterative feedback by quality improvement officers involved in the study. However, the training did not address patient care technicians, who have an important role in the delivery of patient safety. Financial administrators had concerns about the staff overtime and the costs of sustaining the technology. They were also concerned about the time it would take for the technology to “pay for itself.”

Knowledge Gaps and Areas of Uncertainty

Low-level information about the sustainability of the initiative (6 months in implementation). The numbers on how many staff members went on to leave and how many of the new staff were efficient in adjusting to the technology would be good data to present on the training requirements performed (Patel and Mohanty, 2023). Moreover, the study of the effect of the initiative on various groups of patients, especially high-risk groups, requires further research, using more detailed and stratified analysis. A performance comparison with other units/hospitals with similar technologies would also help to identify best practices and the need for improvement.

Additional Indicators and Protocols

Some additional indicators and protocols could be implemented to augment and maintain the impact of the medication safety QI work done at Riverside Community Hospital. Firstly, the integration of smart infusion pumps, which have inbuilt drug libraries of high alert medications, would add safety regarding the manual dosing of the medication. While the technology can help enhance safety for patients and support informed decisions, there are potential challenges as it may come with increased costs of purchasing and maintaining, and requires a commitment to ensuring ongoing staff training and a chance to use the devices in effective ways (Shah and Jani, 2020).

Second, a real-time check of the accuracy of medication orders and recommendations in the challenging cases, by clinical pharmacists, reviewing high-acuity in-hospital units, should be implemented. This strategy will decrease mistakes and enhance interprofessional cooperation; nevertheless, this method would necessitate special staffing and could not be applied to every unit because of the lack of resources.

Fourth, prompt corrective action and root cause analysis by having a rapid response team to investigate near-miss events immediately would help in the timely root cause analysis. This can increase the learning through error, but also be stressful in terms of staffing, and close coordination may be required to avoid delays in the delivery of other sorts of patient care.

Lastly, training on medication safety based on simulation and improved patient and family education regarding medication safety is suggested quarterly. Simulations in teaching practice can help increase the competence of the staff and confidence to operate the high-alerts while also involving patients in learning activities so that they can cooperate to prevent errors (Sessions et al., 2020). The two key constraints are training time and possible opposition to change by staff as a result of workload. However, these standards can help improve medication safety, proactive risk management, and promote a culture of ongoing improvements, alongside addressing issues of resources and workflow management.

Conclusion

QI intervention of medication safety, involving the use of BCMA, the use of quadruple handoff checks, and formalized handoff communications, has enhanced the safety of insulin administration and enhanced interprofessional cooperation at Riverside Community Hospital. There are some encouraging data in early stages, but a lack of understanding of longer-term sustainability, the impact of workflow, and the impact on the patient.

The smart infusion pumps, real-time investigation of pharmacists, predictive analytics, rapid response teams, and training through simulation may also be recommended to improve safety and eliminate errors. In all, it’s a matter of continuously monitoring, continually engaging the staff, and continually re-evaluating the processes – to sustain the improvements and to set up a patient safety culture within the organization.

For the next (3rd) assessment of this class visit: NURS FPX 6016 Assessment 3