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 medical care advanced to the patients. Márquez-Hernández (2019) states that 70% of nurses have made a medication error in the course of their practice. The costs incurred due to medication errors surpass billions of dollars. In the United States, expenses incurred due to medication errors are approximately $6.5 billion (Gorgich et al., 2016). Besides losses of revenue, medication errors result in severe injury to patients, longer hospitalization spans, new conditions such as skin rashes and itching. Additionally, medication errors can cause disability or death. Gorgich et al. (2016) assert that 30% of impacted medical errors die or develop disabilities lasting over six months. Therefore, medication errors have a significant impact on patient safety, hindering the realization of quality medical care. The health institution’s quality and safety gap analysis indicated a high prevalence of medication errors, which need an intervention to mitigate them. 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. Comment by Dr. Cockerham: This is a good introduction

Executive Summary on the Gap

The findings from the undertaken safety gap analysis have shown an urgent need to address the prevalent medical errors in the organization. Medical errors present a significant challenge towards achieving quality medical care. Prescribing drugs is one of the most complex and vital aspects of nursing care hence requires a high level of quality control to realize quality healthcare services. From the safety gap analysis in the healthcare institution, medication errors resulted in adverse consequences such as increased hospitalization costs, increased length of stays, distrust from the patients and other clients, severe injury, and death. In the organization, medical errors have been increasing for the last two years, posing a dangerous trend that poses the above-named adverse effects to the organization and its clients. Hence, there is a need to craft effective interventions to address this issue.

Quality and Safety Outcomes

This is where I want to hear about YOUR organization. Remember this is an executive summary. Your leaders are wanting to hear about your organiziaotns problems. Perhaps you would inform the leaders that a gap analysix showed that in your organization there is a problem with medication errors. Then describe your findings. Leader do not want to read “general statements” an executive summary is about YOUR organization and your problems compared to best practice.

Death and Disability Rates

Various specific outcome measures can be employed to assess the role of medication errors in affecting the quality of medical care. One of the outcome measures is mortality and disability rates related to medication errors. As aforementioned, medication errors can cause severe disabilities and even death to patients. In this regard, it is vital to evaluate the number of deaths or disabilities emanating from medication errors, enabling the healthcare organization to realize the prevalence of medication errors in its context.

Hospital Readmissions

In the modern healthcare context, healthcare institutions are using hospital readmissions to measure the quality of care. Previous studies indicate that 21% of all the patients discharged from hospitals seek readmissions, with 21% of the cases resulting from medication issues (Uitvlugt, 2021). In this regard, evaluating the number of hospital readmissions is vital in realizing the efficiency of medication procedures.

Organizational Culture on Error Reporting

Healthcare institutions’ healthy error reporting culture ensures that healthcare professionals feel free to report errors early. Healthcare professionals equate mistakes to failure. In this regard, they experience significant psychological effects such as depression, anger, and guilt. These psychological effects arise due to the fear of punishments, making them reluctant to report errors. Failure to report medication errors has profound impacts on the quality of care advanced to the patients. Therefore, having an organizational culture that perceives medical errors as a challenge and an avenue of improvement creates trust, which is essential in reporting medication and other errors.

Relationship Between Systemic Problem and Outcomes

Inform the leader what you problem is….. what is the systemic problem in your organization and how does it impact quality. For example you might note that the mediaication administration process is manual and that leader so multiple work arounds and errros.

Role of the Quality Outcome Measures

Based on your organizations problems estiabligh outcome measures. Lets say your medication error rate is 30%. Your goal is to reduce it to 15% by implementing….. education, a new system, etc….

Quality outcome measures on care in nursing are tools used to weigh or quantify processes and outcomes in the healthcare sector. These outcomes are essential as they help understand the patients’ perception of the care they are receiving. Through the outcomes, we can understand the organizational functions and structure and check whether it can provide high-quality care and meet the organizational goals and objectives. The outcomes are measured to help in bridging the gap that has been identified. Through measuring the outcomes, we can improve the entire nursing practice in terms of quality care, patient safety, patient experience, and future healthcare expected outcomes (Sim et al., 2019). Data on outcomes in nursing indicates that the patients’ results depend on how sensitive the nurse is on issues such as pressure and ulcers. It also depends on the relationship established between nursing and patient that builds on trust.

These measures significantly impact patient care, where the effect can either be positive or negative. The steps evaluate and examine the communication between team members among healthcare providers concerned about patient care. If the transmission is effective, then the results on patient care would also be positive and vice versa. The implication on a culture of quality and safety depends on whether the organization embraces the safety and quality of all staff, which will impact patient quality care and protection. When the staff’s well-being has been catered for, leading to job satisfaction, and reducing burnout, then the safety of the patients will also be favorable. It is vital to continue measuring these outcomes to try and improve both quality and safety for patients and even healthcare providers. If the consequences are not counted, it would negatively impact the patient results. The reason for saying that is that no gap would be identified. Together with other executive leaders, nursing leaders would not know the areas that need improvement or what the patients think about the treatment (Pappas, 2016).

Role of Nursing Leaders in Supporting Quality Outcome Measures

Strategic planning in organizations dealing with healthcare is very crucial as it involves stating the steps that need to be taken to achieve specific goals set. Through strategic planning, an organization can ensure that all activities are directed towards the mission and vision of the organization. Healthcare organization has created a competent strategic planning team to ensure they set goals that are SMART and measurable, and at the same time develop strategies to meet these goals. There is a relationship between outcome measures and strategic planning. To improve quality and safety through strategic planning, we need to measure the outcomes of strategic plans to examine whether they were a success or not. These measures ensure that the organizational culture on safety and quality is well preserved and improved where need be. Through these measures’ outcomes, variances can be detected and corrected immediately before the impact on quality and safety is adverse (Schaffner, 2017).

Nursing leaders should be ready to adapt to any change in the practice before their juniors do. They are supposed to lead by example. What an you add here?? What can the leaders do to support your interventions that you will list above? Support education efforts, not have a culture of blame, etc…All nurses and other healthcare providers should adapt to the changes affecting specific outcomes to ensure effectiveness. The following steps should be taken to ensure the adoption process is successful. It is essential first to communicate the transition to other nurses to become aware of it. After communication, they need to be involved in the entire process to avoid resistance that could lead to failure of the adoption process. The need for change in the specific outcome should be communicated, and then they are given a chance to air their views on whether the difference is vital and whether it will impact patient care, which is the main focal point of the practice setting as a whole. Later, the strategic plans to adopt the proposed change are communicated to ensure that every nurse and other practitioner makes the adoption and implementation process successful. And lasting the proposed change will be implemented without any resistance from any staff. The approach will be practical as it will help reduce the cost implication of change adoption and implementation (Baloh, Zhu & Ward, 2018). Comment by Dr. Cockerham: Good what else

Conclusion

In conclusion, medication errors adversely impact the quality of medical care. In this regard, it is essential to develop interventions for measuring outcomes in nursing practice, aiming to improve the quality of medical care rendered to the patients. However, measuring methods should also be critically evaluated to ensure they are correlated to better medical services, as the evaluation process is costly to healthcare institutions. Without measuring its performance and outcomes, no organization can succeed after a specific duration specified in its strategic plan. Lack of measuring tools would only mean that the organization has goals and mission written or stated only to fulfill an unquestionable requirement for the law and not to guide their operations in both the short and long run.

References

Baloh, J., Zhu, X., & Ward, M. M. (2018). Implementing team huddles in small rural hospitals: How does the Kotter model of change apply?. Journal of Nursing Management, 26(5), 571-578.

Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Global Journal of Health Science, 8(8), 220.

Márquez-Hernández, V. V., Fuentes-Colmenero, A. L., Cañadas-Núñez, F., Di Muzio, M., Giannetta, N., & Gutiérrez-Puertas, L. (2019). Factors related to medication errors in the preparation and administration of intravenous medication in the hospital environment. PloS one, 14(7), e0220001.

Pappas, S. H. (2016). Value, a nursing outcome. Nursing Administration Quarterly, 37(2), 122- 128.

Schaffner, J. (2017). Roadmap for success: the 10-step nursing strategic plan. JONA: The Journal of Nursing Administration, 39(4), 152-155.

Sim, J., Joyce‐McCoach, J., Gordon, R., & Kobel, C. (2019). Development of a data registry to evaluate the quality and safety of nursing practice. Journal of Advanced Nursing, 75(9), 1877-1888.

Uitvlugt, E. B., Janssen, M. J., Siegert, C. E., Kneepkens, E. L., Van den Bemt, B. J., Van den Bemt, P. M., & Karapinar-Çarkit, F. (2021). Medication-related hospital readmissions within 30 days of discharge: Prevalence, preventability, type of medication errors and risk factors. Frontiers in Pharmacology, 12.