Enhancing Quality and Safety Essay

Enhancing Quality and Safety Essay

Enhancing Quality and Safety

Despite the commitment to providing optimal care, health care settings are high-risk areas where a patient’s health can worsen due to adverse events. Medication errors are common causes of adverse events. Such errors result from wrong prescription, administering medication through the wrong route, incorrect dosage, and wrong time medication administration, among others. Due to the severe impacts of medication errors on costs, care quality, and patient safety, health care organizations must adopt evidence-based and best practice strategies to prevent such them. The purpose of this paper is to assess factors leading to a risk related to medication administration, solutions, nurse coordination to increase patient safety, and stakeholder roles.


Factors Leading to a Medication Administration Risk

Case Study

In everyday practice, nurses come across issues related to medication administration with far-reaching effects on a patient’s health. To better understand the connection between medication administration and safety, the case study is a scenario where a baby in a neonatal intensive care unit received insulin infusion instead of heparin. After six hours of Total Parental Nutrition (TPN) infusion, the pediatrician nurse noticed that the baby’s glucose levels did not change as expected. A comprehensive analysis of the events leading to the medication dispensing error revealed that the dispensing nurse did not confirm the drug before administration. Heparin and insulin were also stored in similar dosages and bottles. They were also stored close to each other, further increasing the chances of confusion.

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Specific Factors Triggering the Medication Error

Medication errors can occur in any step of the medication administration pathway. Incorrect dosages, poor communication, incorrect diagnosis, and prescription errors are the leading causes (AMCP, 2019). The leading cause of the heparin-insulin confusion in the case study was the lack of drug confirmation. Regardless of the practice area and the patients that health care providers handle, drug confirmation should be standard practice. Confirmation ensures that the drug being administered is the one prescribed. It enhances accuracy, vital in preventing health complications, among other adverse outcomes. Shrestha and Prajapati (2019) also noted that medication errors ruin patients’ trust in their health care providers. As a result, drug confirmation should be a norm in all health units. In a cross-sectional study of medication errors in tertiary health care institutions, it emerged that medication errors extend hospital stays, increase the chances of severe body harm, disability, and can cause death (Wondmieneh et al., 2022). Causes of errors included inadequate nurses’ knowledge on safe medication administration and lack of a medication administration guideline for nurses to follow (Wondmieneh et al., 2022). The severe impacts indicate that medication errors are a severe patient safety issue that requires maximum attention.

The other factor behind the insulin-heparin confusion was poor storage practices. Drugs that should be stored in refrigerated containers should be stored specifically in such containers to maintain efficacy. Besides, drugs should be stored under appropriate temperatures and correctly labeled. In the case study, poor storage is demonstrated by keeping drugs that look alike close to each other. Such closeness increases the chances of erring.

Medication errors are multifaceted, implying that their causes vary according to the situation. A single issue or a combination of factors can cause medication errors. Besides poor storage practices and the lack of drug confirmation, ineffective medication administration protocols also triggered the error when dispensing the medication. New nurses should be watched closely and assisted in handling all roles, particularly when working in high-risk areas such as intensive care units. They should not conduct drug-related activities alone until they are adequately familiar with all workplace policies, regulations, and guidelines. Delegating sensitive tasks to new nurses in the facility increases their chances of committing errors.

Evidence-Based and Best-Practice Solutions

Medication dispensing errors have huge implications on a patient’s health and health care costs and should be avoided in all ways possible. One of the most effective evidence-based solutions to improve patient safety by preventing such errors is electronic drug confirmation. In this case, all drugs must be confirmed and re-confirmed before administering them to patients. Naidu and Alicia (2019) recommended barcode technology in drug confirmation as an effective strategy of promoting the five rights of medication administration. Barcode scanning ensures that the right patient takes the right drug at the right time, dose, and route. Baiden (2018) found that barcode scanning can reduce errors by 50%-70% margins. In this case, it can reduce costs associated with care for patients with concerns related to such errors by the same margin. Tariq et al. (2018) found that health care spending related to medication errors is up to $40 billion annually in the United States. Using technologies that reduce errors would reduce such costs significantly.

The other evidence-based solution is appropriate storage and labeling. As earlier mentioned in the case study, chances of erring were increased by keeping unrelated but easily-confused drugs close to each other. Each drug should be stored in a separate cabinet and labeled correctly. Labeling should consider different colors, mainly where medications come in bottles of the same size and shape. Furthermore, labeling should provide adequate information besides a drug’s name (Vlieland et al., 2018). It should provide details regarding active ingredients, uses, and crucial warnings. Labeling should also be legible in font size, type, and color. Reducing errors by proper medications storage and labeling practices would further reduce health care costs.

Best practices include nurse education and promoting a culture of reporting. In every health care unit, nurses and other health care providers should be adequately informed on workplace policies, issues, and administrative protocols. They should also adapt to change as situations prompt. Nurse education should focus on technology to empower nurses to use technologies effectively to reduce safety issues. Empowered nurses are also motivated to comprehensively apply best practices to address patient needs. A culture of reporting is crucial to promote proactive management of issues related to medication administration. Such a culture encourages nurses to report workplace issues and adverse events when they occur without primarily holding nurses answerable (Paradiso & Sweeney, 2019). Reporting ensures that problems are better understood and appropriate measures are adopted to prevent future occurrences. It also helps to respond to issues promptly to mitigate their damage potential.

Coordinating Care to Increase Patient Safety

Nurses can play a critical role in increasing patient safety through coordinated care. Such care is characterized by nurses working as a team and collaborating with other health practitioners where necessary. As Rodziewicz et al. (2021) observed, medication errors are a system-wide issue requiring the teams involved in medication administration to be involved in streamlining processes. In this case, medication personnel, including physicians, pharmacists, and nurses, must liaise and follow procedures that each understands in detail. Furthermore, they must communicate and guide each other on matters specific to their roles.

Besides teamwork, nurses can also promote care coordination by sharing knowledge and helping with care transitions. Typically, nurses differ in knowledge and experience, affecting how they perceive, interpret, and respond to issues. A suitable way of sharing knowledge is supporting new colleagues and ensuring that they are adequately conversant with all workplace policies and norms. During care transitions, nurses guide the ones taking over and ensure that they have adequate details regarding the patient’s condition and needs. Nurses should be further available for consultation by their colleagues. Such a collaborative practice ensures that nurses achieve a common goal. It also minimizes issues likely to hamper patient outcomes.

Nurses should educate their peers and participate in quality improvement initiatives too. Educating peers implies improving their knowledge regarding medication administration, error sources, and prevention techniques. Abukhader and Abukhader (2020) found education programs to improve nurses’ knowledge by 92.3%. Enhanced knowledge would be pivotal in preventing medication dispensing errors and related costs by similar margins. Serving in quality improvement teams provides nurses with a unique opportunity to propose evidence-based practices to streamline processes based on the issues they observe in everyday practice. Coordinating care requires nurses to be more committed to serving other roles besides primary patient care.

Stakeholders for Coordination

Like other critical issues in health practice, medication administration challenges would be best addressed by a coordinated practice. Nurses should work with the appropriate stakeholders to identify medication administration issues and adopt evidence-based interventions. Among many stakeholders in health care delivery, the management and nurse leaders are the most required stakeholders to drive safety enhancements with medication administration. The management supports evidence-based initiatives that nurses propose. In evidence-based practices, the organizational leadership provides resources necessary to promote practice change (Li et al., 2018). For instance, adopting technologies such as barcode scanning cannot succeed without nurse-management coordination. Nurse leaders influence nursing teams and guide them to adopt best practices. They also guide them on interprofessional collaboration and dealing with workplace issues.

Besides the management and nurse leaders, nurses should coordinate with the information technology (IT) department. As earlier mentioned, medication dispensing errors would be best addressed through technologies such as barcode scanning. The IT department is responsible for technology and information systems integration into everyday processes in health care organizations (Balgrosky, 2019). The IT staff is the best positioned to understand the current versions of scanners and other technologies essential in improving medication administration, such as computerized provider order entry (CPOE). The IT personnel’s role cannot be underestimated when adopting technologies to improve care coordination and patient safety.


Health care organizations must always be committed to providing care that meets the required quality, safety, and timeliness standards. To achieve this goal, issues hampering quality and safety must be avoided and effectively addressed when they occur. This discussion explored medication administration problems, primarily focusing on medication dispensing errors. It provided a case study of insulin-heparin confusion to exemplify how medication dispensing errors occur. Central to preventing such errors to enhance quality and safety is care coordination. Best practices and evidence-based solutions include adopting technologies such as barcode scanning. Above all, teamwork is crucial to supporting each other and achieving a shared goal.



Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal of Biosciences and Medicines8(06), 135-137. https://doi.org/10.4236/jbm.2020.86013

AMCP. (2019). Medication errors. https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors

Baiden, D. (2018). Factors affecting the impact of barcode medication administration technology in reducing medication administration errors by nurses. Canadian Journal of Nursing Informatics13(1). https://cjni.net/journal/?p=5368

Balgrosky, J. A. (2019). Understanding health information systems for the health professions. Jones & Bartlett Learning.

Li, S. A., Jeffs, L., Barwick, M., & Stevens, B. (2018). Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Systematic Reviews7(1), 1-19. https://doi.org/10.1186/s13643-018-0734-5

Naidu, M., & Alicia, Y. L. Y. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. Health11(05), 511-526. https://doi.org/10.4236/health.2019.115044

Paradiso, L., & Sweeney, N. (2019). Just culture: It’s more than policy. Nursing Management50(6), 38-45. doi: 10.1097/01.NUMA.0000558482.07815.ae

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Shrestha, R., & Prajapati, S. (2019). Assessment of prescription pattern and prescription error in outpatient Department at Tertiary Care District Hospital, Central Nepal. Journal of Pharmaceutical Policy and Practice12(1), 1-9. https://doi.org/10.1186/s40545-019-0177-y

Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2018). Medication dispensing errors and prevention.StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519065/

Vlieland, N. D., van Den Bemt, B. J., Bekker, C. L., Bouvy, M. L., Egberts, T. C., & Gardarsdottir, H. (2018). Older patients’ compliance with drug storage recommendations. Drugs & Aging35(3), 233-241. https://doi.org/10.1007/s40266-018-0524-8

Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: A cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing19(1), 1-9. https://doi.org/10.1186/s12912-020-0397-0


The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.
Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.
• Explain factors leading to a specific patient-safety risk focusing on medication administration.
• Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
• Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
• Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.
• Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Additional Requirements
• Length of submission: 3–5 pages, plus title and reference pages.
• Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
• APA formatting: References and citations are formatted according to current APA style.

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