NURS FPX 4020 FNU Medication Administration Safety Improvement Presentation

Develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel & Wright, 2018).As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.You are encouraged to explore the AONE Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONE Nurse Executive Competencies—especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Analyze the elements of a successful quality improvement initiative.
  • Explain the need and process to improve safety outcomes related to medication administration.
  • Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
• Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
  • List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
  • Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
• Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
  • Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
  • Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).
• Reference
  Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic & Neonatal Nursing​, 47(3), s16–s17.Professional Context
  As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group. Preparing to run an in-service may be daunting, as the facilitator must develop his or her message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove him- or herself a valuable resource to others.Scenario
  For this assessment it is suggested you take one of two approaches:

1. Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, or
2. Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.
3. Instructions
   The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.Be sure that your presentation addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

• List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
• Explain the need for and process to improve safety outcomes related to medication administration.
• Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
• Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
• Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.
• There are various ways to structure an in-service session; below is just one example:
• Part 1: Agenda and Outcomes.
  • Explain to your audience what they are going to learn or do, and what they are expected to take away.
• Part 2: Safety Improvement Plan.
  • Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
  • Explain why it is important for the organization to address the current situation.
• Part 3: Audience’s Role and Importance.
  • Discuss how the staff audience will be expected to help implement and drive the improvement plan.
  • Explain why they are critical to the success of the improvement plan focusing on medication administration.
  • Describe how their work could benefit from embracing their role in the plan.
• Part 4: New Process and Skills Practice.
  • Explain new processes or skills.
  • Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
  • In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
• Part 5: Soliciting Feedback.
  • Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
  • Explain how you might integrate this feedback for future improvements.
• Remember to account for activity and discussion time. For tips on developing PowerPoint presentations, refer to:
• Capella University Library: PowerPoint Presentations.
• Guidelines for Effective PowerPoint Presentations [PPTX].

Improvement Plan In-Service Presentation

CAPELLA UNIVERSITY

SCHOOL OF NURSING AND HEALTH SCIENCES

Mar 2021

Content

• Importance of safe medication administration
• Purpose and goals of the in-service session
• Need for safety outcome
• Process of safety outcome
• Role and importance of the audience
• Resources to improve medication administration
• Activities for to skill development and QI plan

This is the content of the presentation. It begins with the importance of safe medication administration. We will look at the project objectives along with purpose and goals of the in-service session to understand what goals needs to achieved. Further, we will see how a team or role of the audience, which is you plays a critical role in this project. Then comes strategies, resources, and activities that will promote the Interprofessional group collaboration, skill development, and understanding process involved in safe medication administration. Further, resources and activities to encourage skill development and process understanding related to a safety improve initiative on medication administration.

Importance of safe medication administration

• Medication administration errors reduce quality care
• Increases threat to patient safety
• Increases burden on nurses
• Increased hospital stay 
• Frequent hospital readmission
• Adverse effects and sentinel events

• Medication administration is a critical process where nurses play a key role. However, stakeholders such as physicians, pharmacists, informatics nurses, and other health care professionals contribute to it as the process includes medication prescription, dosage calculation, medication dispensing, and error monitoring. Error in any of the stages will lead to medication administration errors.
• There are different types of medication errors, which include dosage errors, wrong or improper package information, drug-drug interactions, mismatch in patient’s electronic health records, and poor medication administration (Schmidt et al., 2017). Some of the errors can have an adverse effect on patients and even lead to morbidity and mortality. In their study, Kang et al. (2017) reported that at least five near misses every month, 14.8% of dispensing errors, 4.3% administration errors, and 43.9% prescription errors were from 32 pharmacies. However, only 37.1% prescription errors, 57.4% administration errors, and 43.7% dispensing errors were reported. Salar et al. (2020) highlighted that prevalence of errors varies from 32.1% to 94%. Also, 23%, 38%, and 39% of medication errors were associated with pharmacies, nurses, and general practitioners respectively (Salar et al., 2020).
• Medication errors increase cost, the burden on dispensing, administration, and packaging units. Cumulatively, it leads to work burden on the nurses and reduces patient satisfaction level and trust in health care (Musharyanti et al., 2019).
• Risk factors include mortality, morbidity, and adverse effects. Every year, 7000 to 9000 patients in the US die due to medication errors (Tariq et al., 2021). The errors lead to increased hospital stay cost o $40 billion per year with more than 7 million patients affected by the issue (Thomas et al., 2017). As a result, it is important.

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Purpose of the in-service session

The purpose of the in-service session is to educate and prepare the nursing and health care professionals to understand the importance of an QI plan to increase medication administration safety by exploring process of safety outcome, role of health care professionals, resources needed to implement QI plan, and conduct activities to understand the process. 

Objectives and goals

• To highlight need for safety QI plan for medication administration

• To improve knowledge and competency

• To improve communication skills among nursing personnel

• To increase interprofessional collaboration

• Understand strategies to implement QI plan

Objectives and goals

• Understand importance of interprofessional collaboration

• To update knowledge regarding different strategies

• To update knowledge regarding EHRs, bar-code systems, error reporting mechanism, and hospital protocols

• To provide resources and activities related to medication administration

Need for safety outcome

• Nurses and other health care professional are committing medication errors

• Lack of knowledge regarding strategies for interprofessional collaboration 

• Mediation errors increases burden on patients, nurses, and health care

• Every organization aims and individual aim to provide high quality and safer care

• Interprofessional education helps to improve interprofessional collaboration and patient care through the promotion of various professions of health to increase interprofessional collaboration compared to single profession education, which individuals learn in isolation and merely in their profession. Therefore, interprofessional education of medication safety program can reduce medication error and promote patient safety in the ICUs.

• Burnout is common among nurses. As a result, communication and a supportive work environment are critical. Nurses can coordinate with each other during medication administration to handle any interruptions.

• Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy.

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Process of safety outcome

• The first EBP solution is to train and educate nurses to follow guidelines

• Implement a physician order entry system

• Bar-code based medication scanning

• Implement an automated error reporting system 

• Checklists to double check the medication

• The first EBP solution is to train and educate nurses and health care staff to follow the guidelines provided by IOM and QSEN. The guidelines include being vigilant and verify medication with EHRs, check for allergies, assess the medication before administration, diligently calculate dosage (Armstrong, 2019), use memory aids and checklists, avoid workarounds, avoid conversations during administration, consider one patient at a time, clarify an unclear prescription, and avoid abbreviations (Pop & Finocchi, 2016). The process reduces cost as it prevents adverse effects of medication on patients.
• The second EBP is to implement a physician order entry system with medication error reporting and communication system to reduce prescription, dispensing, and administration errors (Thompson et al., 2018). The system is completely electronic where nurses, physicians, and pharmacists are directly connected to compare medication with prescription and EHR to detect any discrepancies.
• Further, implementing technology such as bar-code-based medication administration where each drug has a unique barcode helps in preventing dispensing errors and dosage errors (Thompson et al., 2018).

• The next strategy is to implement an automated error reporting system that includes a patient-specific automated medication system (npsAMS) unit, barcode medication administration (BCMA), and a complex automated medication system (cAMS) with the automated dispensing unit to reduce human errors in communication and decision-making. As the process used an integrated system, the errors were reduced from 0.96 to 0.15 (Risør et al., 2018).

• Koyama et al. (2021) proposed an EBP strategy to double-check medicine through the checklist, implementing hierarchical protocols, and educating interprofessional teams to reduce medication administration errors. The strategy reduced errors as double-checking reduced human errors. Also, recommendations by QSEN and IOM to train health care staff to communicate and collaborate aid in both error prevention and management (Abukhader & Abukhader, 2020).

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Process of safety outcome

• Encourage interprofessional collaboration

• Use of tabards to prevent interruptions

• Implement RCT process to eliminate blame culture

• Create a role-based work culture

• Reduce nurse burnout by increasing nurse-patient ratio

• The imprtant step is to develop a hospital-based protocol and hierarchical response system with a medication error alert system to quickly detect the errors and provide steps taken to report the error along with the responsibilities of different stakeholders (Huckels-Baumgart et al., 2017). This plan aid in solving the first root-cause where the pharmacist sent the wrong product. The outcome of this step is it increases knowledge and competencies along with better communication between the team (Korb-Savoldelli et al., 2018).

• Burnout is common among nurses. As a result, communication and a supportive work environment are critical. Nurses can coordinate with each other during medication administration to handle any interruptions (Hammoudi et al., 2017). For example, a nurse can attend a patient of another nurse or external patient for the time being till the assigned nurse completes his or her administration to reduce mix-ups and confusion. Also, communicating with other nurses to identify allergies in a patient to create a patient-specific medication order prevents adverse effects (Huckels-Baumgart et al., 2017).

Composition of safety team

• Decision-making
  • Nurse leaders
  • Nurse managers
  • Chief of unit (pharma, residents, surgeons, and others

• Team members
  • Nurses
  • Physicians
  • Pharmacist
  • Informatics nurse
  • IT professionals

• Decision-making team includes nurse leaders, managers, and unit chiefs as they draft the policies and take decisions whenever there is an issue. Also, they monitor the resources and finances involved in the units. However, other members such as nurses and physicians provide their input in medication administration activities.
• Medication administration includes nurses as they administer drugs, match the drug by comparing with EHRs, and report any errors. It also includes physicians as they prescribe drugs and dosage. Pharmacist dispenses the medication by checking the order against prescription. Informatics nurses handles EHRs and other tools. IT professional help in troubleshooting any issues in system and devices.

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Interprofessional collaboration strategies

• Team building activities
• Encourage open communication
• Enable knowledge-sharing
• Integrate shared decision-making
• Reward and recognize
• Setting common goals and platform to discuss

• Team building activities are one of the great ways to bring the employees closer as it allows the team members to understand each other’s perspectives, ideas, and thoughts (Zhang & Cui, 2018).
• Encourage open communication: open communication allows everyone to express their views effectively. this increases in-flow of information and critical analysis (Truglio-Londrigan & Slyer, 2018)
• Enable knowledge-sharing: the group members can share their knowledge to others to highlight certain points and also it helps in gaining knowledge as others have something to share too
• Reward and recognize: incentive-based approach or reward and recognize motivates the workers to work towards common goal to achieve desired productivity (Zhang & Cui, 2018).
• Integrate shared decision-making: this reduces autocratic leadership and promotes democratic leadership as input from everyone is important. It is crucial in increasing diversity.
• Setting common goals and platform to discuss – this drives all the focus towards set of goals instead of individual goals (Truglio-Londrigan & Slyer, 2018)

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Role of the audience

• Research and understand the issues
• Understand strategies, policies, and guidelines
• Educate peers through collaboration
• Work towards achieving safety goals 
• Communicate and coordinate with hospital staff
• Report and address adverse and sentinel events

Importance of the audience

• Nurses are important as they administer medicines

• Physicians prescribe the orders

• Pharmacist dispenses the order

• Informatics nurses maintain EHRs 

• Technician troubleshoot issues in EHRs 

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

Resources to improve medication administration

• Improving Medication Safety by ACOG

• Guidelines by QSEN and IOM

• Literature and protocol manuals provided by health care

• EBP research articles and strategies

QSEN Competencies useful for practice improvement of Vaccine Safety, Medication Errors, Polypharmacy, Communication Breakdowns, Test Result Follow up, HER Errors & Diagnostic Errors

1. Patient Centered Care
   1. Knowledge
      1. Discuss principles of effective communication
      2. Describe principles of consensus building and conflict resolution

• Examine how the safety, quality & cost effectiveness of health care can be improved through involvement of patients/families

1. Equity issues-culture-language
2. Skills:
   2. Communicate care provided & needed at each transition in care
3. Attitude
   2. Value the patient’s expertise with own health and symptoms
   3. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care
4. Teamwork & Collaboration
   2. Knowledge
      2. Describe strategies for ID & managing overlaps in team member roles & accountabilities
      3. Analyze differences in communication style preferences & impact on others

• Discuss effective strategies for communicating & resolving conflict

1. ID system barriers for effective team function
2. Skills
   3. Participate in designing system that support team work
   4. Follow communication practices that minimize risks associate with handoffs among providers & across transitions in care
3. Attitudes
   3. Appreciate risk associated with handoff & transitions in care
4. Evidence Based Practice
   3. Knowledge
      3. Explain the role of evidence in determining best clinical practice
      4. Describe reliable sources for locating evidence reports & clinical practice guidelines
   4. Skills
      3. Locate evidence reports related to clinical practice topics & guidelines
      4. Question rational for routine approaches to care that result in less-than desired outcomes or adverse events
   5. Attitudes
      3. Value the need for continuous improvement
      4. Appreciate the risks associated with handoffs among providers and across transitions in care

4. Safety:
   4. Knowledge
      4. Examine human factors & basic safety design, common unsafe practices
      5. Evaluated safety enhancing technology (barcodes, CPOE)

• Describe how root cause analysis can help us understand when safety event or error occurs

1. Skills
   1. Use of technology & standardized practices that support safety & quality
   2. Strategies to reduce reliance on memory

• Participate in appropriately analyzing errors & design system improvements

1. Engage in RCA when error/near miss occurs
2. Attitudes
   2. Appreciate the cognitive and physical limits of human performance
   3. Value own role in preventing errors
3. Informatics
   2. Knowledge
      1. Describe examples of how technology & information management are related to quality & safety
   3. Skills
      1. Apply technology & information management tools to support safe processes of care
   4. Attitudes
      1. Appreciate the necessity for all health professionals to seek lifelong, continuous learning of information technology skills
      2. Value technologies that support clinical decision-making, error prevention, and care coordination

• Value nurses’ involvement in design, selection, implementation, and evaluation of information technologies to support patient care

6. Quality Improvement
   6. Knowledge
      6. Importance of variation & measurement in assessing quality of care
      7. Described approaches for changing processes of care
   7. Skills
      6. Use quality measures to understand performance
      7. Identify gaps between local & best practice

• P-D-S-A to test change in daily work

1. Use tools helpful for understanding variation
2. Attitude
   1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals
   2. Appreciate the value of what individuals and teams can to do to improve care

Activities for to skill development and QI plan

• Analyzing a medication error case study

• Discussing root-causes in the case study

• Discussing challenges faced by health care professionals

• Analyzing what could have averted the error

• Implementing EBP changes in the future

The patient has been admitted to a 20-bed medical unit for treatment of acute diverticulitis. The provider has ordered Ultram (Tramadol hydrochloride) 50 mg p.o. every 6 hours prn pain. The patient is requesting a pain medication, as it has been 8 hours since his last dose. The nurse selects the individually wrapped medication from the patient’s assigned medication drawer and scans the barcode to determine if it is the correct medication. The scanner is not working again. As she wants to administer the pain medication as soon as possible, she types in the Internal Entry Number (IEN) and the computer indicates the medication is Ultracet 37.5/325 mg but the package says Ultram 50 mg. The nurse calls the pharmacy and the pharmacist says there is only one number different between Ultram and Ultracet and, since the package says Ultram, to administer the medication because she must have typed in the wrong number. The nurse administers the medication, and within 30 minutes the patient shows signs of an allergic reaction. The nurse checks the record and determines the patient is allergic to acetaminophen. The patient is treated for the allergic reaction, and a medication incident form is completed. The nurse manager asks for a Root Cause Analysis (RCA) to be completed for the medication error.

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation

References

• Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal Of Biosciences And Medicines, 08(06), 135-147. https://doi.org/10.4236/jbm.2020.86013
• Hammoudi, B., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal Of Caring Sciences, 32(3), 1038-1046. https://doi.org/10.1111/scs.12546
• Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Quality & Safety, bmjqs-2016-005991. https://doi.org/10.1136/bmjqs-2016-005991
• computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal Of Medical Informatics, 111, 112-122. https://doi.org/10.1016/j.ijmedinf.2017.12.022
• Koyama, A., Maddox, C., Li, L., Bucknall, T., & Westbrook, J. (2021). Effectiveness of double checking to reduce medication administration errors: a systematic review. BJM Quality & Safety, 29(7). https://doi.org/http://dx.doi.org/10.1136/bmjqs-2019-009552
• Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opinion On Drug Safety, 17(3), 259-275. https://doi.org/10.1080/14740338.2018.1424830
• Risør, B., Lisby, M., & Sørensen, J. (2018). Complex automated medication systems reduce medication administration errors in a Danish acute medical unit. International Journal For Quality In Health Care, 30(6), 457-465. https://doi.org/10.1093/intqhc/mzy042
• Tariq, R., Vashisht, V., Sinha, A., & Scherbak, y. (2021). Medication dispensing errors and prevention. Retrieved 17 March 2021, from https://www.ncbi.nlm.nih.gov/books/NBK519065/.
• Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351. https://doi.org/10.1016/j.mayocpiqo.2018.09.001

NURS FPX 4020 Assessment 3: Improvement Plan In-Service Presentation.