Student name

Capella University

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

Professor’s Name

Submission Date

Data Analysis and Quality Improvement Initiative Proposal

Slide 1

Hello all. My name is ______. I am a nurse at the Riverside Community Hospital. I’d like to take this opportunity to talk about a new proposed Quality Improvement (QI) initiative that I have spearheaded to minimize the occurrence of insulin-related medication errors at my facility. The initiative is a direct product of the analysis of our hospital dashboard data. The dashboard data demonstrated the existence of several near-miss medication events in the pharmacy reports. The aim of this Quality Improvement initiative is to utilize evidence-based communication along with the integration of bar-coded medication administration (BCMA) technology and interprofessional teamwork. The primary focus of this initiative is the ongoing refinement of the safety of the systems used to deliver medication and to improve the overall quality of care that is provided to our patients.

Slide 2

• Summary of Riverside Community Hospital Dashboard Data

According to Table 01, for the Riverside Community Hospital Quality Management Department, dashboards for 2024 have been prepared using National Data Benchmarks generated by The Joint Commission (2023) and the Institute for Safe Medication Practices (ISMP) (2022).

• Table 01

Insulin Medication Safety Dashboard Data

Table 1 shows that while all indicators improved from 2022 to 2024, the indicators were still below the national benchmarks. The error rate for insulin as a medication had decreased from 3.2 to 2.1 for every 1000 doses. The national goal for this category is to have a rate of less than or equal to 1 for every 1000 doses. The compliance rate for the Bar Code Medication Administration (BCMA) policy increased from 74% to 88%, with a benchmark of 95% still unmet. Compliance with the SBAR (Situation, Background, Assessment, Recommendation) policy increased from 61% to 79%, with a benchmark of 90% unfulfilled. The rate of hypoglycaemia decreased from 9.4% to 6.8%, with a goal of less than or equal to 5%. Near Miss reporting increased from 42% to 58%, with a benchmark goal of 80% unfulfilled. The remaining gaps demonstrate that a more structured and enhanced quality improvement initiative is needed to reduce the gap between the hospital’s national benchmarks and performance.

Slide 3

• Identified Issues in Riverside Community Hospital

Our dashboard findings indicate that the ordering, administering, and transferring of insulin among staff members is among the highest patient safety risks. The majority of identified patient safety risks can be attributed to: (1) the administration of the incorrect medication to the patient among the numerous interactions that comprise the administration of the medication, and (2) failure to communicate during the transfer of care among the various interactions that comprise the nurse-to-nurse handover. The failure to effectively communicate and the numerous near misses, almost exclusively attributed to the staff responsible for patient safety, suggest that there are not only communication issues, but a culture and a pronounced lack of safety among the staff of the organization (Ferreira et al., 2025). Furthermore, the evidence collected from the Dashboard Analyses is consistent with the Joint Commission Standards and the Health Canada National Patient Safety Goals- Safe Medication Administration.

• Evaluation of the Quality of Data

The analysis of data quality uncovered strengths and weaknesses of dashboard data. Of the metrics, the eHealth record and trend data corroborated the dashboard data, which validated the internal quality management records. Currently, near-miss reporting shows 58%. This means that the actual errors that occurred are probably much less than what has been reported. Underreporting has been consistently identified by hospitals as a patient safety problem. This could be attributed to an employee being scared of retaliation in the form of punitive measures or the lack of an effective reporting system (Braiki et al., 2024). This does suggest that the reported insulin error rate is likely a gross underestimate, and corroborates the case for immediate and sustained QI initiatives.

Slide 4

• Outline a Quality Initiative Proposal

The insulin safety bundle QI initiative contains combined QI effort data from the dashboard, as well as root cause analysis data from a near-miss incident. The specific objectives of this initiative are:

1. To reduce the rate of insulin medication errors to ≤ 1.0 errors per 1,000 doses.
2. To achieve an increase in BCMA compliance to ≥ 95%
3. To achieve an increase in compliance with the SBAR handoff standard to ≥ 90% in the next 12 months.

QI initiative is consistent with the Joint Commission and ISMP standards.

The QI initiative will be guided by the Plan-Do-Study-Act (PDSA) model. The PDSA model is the most utilized iterative testing process model prior to the full-scale adoption of an intervention. The reason for the popularity of this model is the small “test of change” that is suggested, which allows the organization to evaluate the data and make informed changes in the organization as a result of what is learned (Albaadani et al., 2024). This initiative will be implemented in the two hospital units over a 30-day planning and training phase, and will continue to be tested for the 90-day PDSA cycle, followed by a six-month implementation with continuous data collection.

The bundle strategies will utilize evidence-based methods to improve insulin safety.

1. All shift changes will standardize communication using SBAR, along with an insulin-specific checklist for all insulin patients. Multiple studies suggest SBAR communicates clinically with a 77-100% handoff accuracy rate (Hidalgo-Tapia et al., 2025).
2. As a no-exception rule, the independent double-check of insulin delivered by two licensed nurses will remain in place for the administration of all insulin doses.
3. The electronic health record contains integrated systems of clinical support to assist with the administration of insulin by addressing discrepancies and providing recommendations at the point of administration. Previous studies show that clinical decision support systems within EHRs brought about enhanced safety with the management of inpatients’ glucose and sustained a reduction in the usage of clinical judgment (Gerwer et al., 2022).
4. In an effort to develop communication skills in conjunction with meeting established guidelines and adding value to patient care, all staff will be required to participate in at least one full cycle of the interprofessional debriefs that accompany the simulation-based training.

This initiative seeks to address the rate of insulin medication errors, hypoglycemic episodes, BCMA compliance, SBAR compliance, and near-miss reporting, among other metrics that capture the quality of care provided to the patients. The initiative aims to achieve the quality of care by implementing a feedback system that allows for real-time and continuous adjustments based on the observations made (Salik & Paige, 2021). Knowledge gaps and unknowns still exist related to staff compliance with the BCMA protocol in the presence of case-level saturation and the variable participation of pharmacists in bedside rounding when there is a staffing deficit. All of these should be observed during the process of implementation.

Slide 5

• Knowledge Gaps and Areas of Uncertainty

There are many unknowns with the involvement of the quality improvement initiative. The near-miss medication error reporting rate of 58% (Braiki, 2024), it indicates there are probably many more undetected insulin medication errors, therefore preventing the hospital from assessing the full extent of this issue. Furthermore, the workflow pressures, problems with technology, and staff attitudes toward change remain unknown factors with the low compliance rate with the barcode medication administration system (Grailey et al. 2024). There is limited literature on the retention of theoretical knowledge improvement, but research has shown that simulation improves safety and communication. The assumption of this initiative is that the EHR and BCMA systems will perform the same in all inpatient units. Measuring and monitoring, along with supportive leaders and a focus on improvement and safety, will be the only way the unknowns can be addressed.

Slide 6

• Quality Enhancement from an Interprofessional Perspective

Successful implementation of the Insulin Safety Bundle relies on the collaboration of the entire team, including the nurse, doctor, pharmacist, IT specialist, and QI personnel, among others (Alhur et al., 2024). Each of these roles helps to construct a safe environment for the patient, reduces the risk of medication error, and builds better inter-professional communication for personnel managing high-alert medications. The nurse, alongside the nursing leadership, will direct and/or support the building of protocols for BCMA, insulin double checks, and SBAR Handoff nursing. The American Nurses Association (2023) supports open communications and states that nurses can and should construct and reinforce safety culture in their practice. Riverside Community Hospital pharmacists will conduct the first review of all insulin orders. They will perform dose review and assist with the clinical decision support (CDS) system along with the consulting pharmacist.

Clinical decision support alerts that operate through the electronic health record (EHR) assist physicians and advanced practice providers in the accurate prescribing of insulin. IT specialists who manage the Bar Coded Medication Administration (BCMA) system and configure safety alerts in the EHR monitor compliance dashboards. Quality improvement specialists and nurse educators will lead the analysis of near-miss data and define the goals of the Plan-Do-Study-Act (PDSA) cycle, as well as provide the simulation training. It is expected that avoiding insulin-related medication errors will improve the overall safety and quality of patient care and decrease the cost of care associated with avoidable complications. It is further expected that the safety and quality of care will improve, and stress during shift changes and the medication administration process will be reduced.

Slide 7

• Needed Actions

All the staff groups responsible for the Insulin Safety Bundle (ISB) will be required to collaborate in its implementation. Nurses will be involved in training and education related to the BCMA and SBAR, related to the double-check for insulin, and the near-miss reporting will be required to participate in training and education. These applications will assist in the advancement of safety in the medication delivery process (Mulac et al., 2021). The active roles of pharmacists and physicians in cross-disciplinary ward work and review of medication orders will remain. IT staff will support and maintain the BCMA and EHR systems, while the QI staff will maintain the safety and support culture and leadership.

• Underlying Assumption

This model assumes that healthcare staff will collaborate when provided with the appropriate tools, structure, communication, feedback, and time (Reime et al., 2024). It also assumes that supporting collaboration and enhancing safety will be a continuous effort of the organization’s leadership.

Slide 8

• Effective Communication Strategies

Collaboration across different fields will lead to activities in a profession-specific way. The Insulin Safety Bundle will be applied and maintained as follows. There will be Interprofessional huddles that will take place at the beginning of every shift, every day, within the relevant project units. Daily morning huddles, which will be attended by nurses, pharmacists, and the charge physician, will be used to go over the list of patients currently receiving insulin. The huddles will serve to ensure that the glucose level of every patient receiving insulin has been checked and recorded in the patient’s EHR, reviewed for any pending orders, and to resolve any inconsistent verbal reports. Katantha et al. (2025) say that in developing countries, the main goal of structured interprofessional communication should be to decrease the delays in treatment and lessen the occurrence of medication errors.

All inpatient units will utilize new SBAR handoff forms for patients requiring insulin. Hidalgo-Tapia et al. (2025) state that utilizing an SBAR framework for documentation improves handoff precision and lessens the chances of communication errors within the interface of health care. It will be the responsibility of the nurse on the sending side to extract and document the most recent blood glucose level recorded in the EHR, the most recent order for insulin, the most recent dose of insulin given, and to document any insulin-related abnormal lab results. Prior to assuming responsibility for the patient, the nurse on the receiving side is to conduct a verbal confirmation of the information using a read-back technique.

To assist staff in documenting all instances of seeking help, a near-miss reporting and debriefing protocol will be developed, and we will use the reporting to collect insights from the near-miss event related to insulin. An interprofessional team will gather within twenty-four (24) hours of the documented near-miss event to conduct a debriefing of the insulin near-miss event based on the advocacy and inquiry approach to communication (Salik & Paige, 2021). The use of simulation and debriefing will enhance interprofessional communication, promote adherence to safety practices related to protocols, and improve the overall decision-making process.

All non-urgent communications related to the administration of insulin that involve nursing and pharmacy staff will occur in writing via the EHR system. This system will provide a secure way to send messages and avoid the risk of a verbal message being misinterpreted. Guan et al. (2023) studied the integration of artificial intelligence (AI) into clinical decision support systems embedded in the EHR system and stated that this will provide a dependable tool to help and verify insulin dosing orders for patients with erratic glucose levels. An interprofessional team will conduct QI meetings to examine the compliance data, review near-miss incidents, and evaluate the BCMA scanning rates and the SBAR communication framework (Albaadani et al., 2024). The interprofessional QI team will develop run charts to show the SBAR compliance in the unit as well as shift intervals, and focus on which unit or shift remains non-compliant. QI team members will perform rapid PDSA cycles to evaluate changes in the training content and the system technological configuration based on the continuous feedback provided in the meetings.

• Underlying Assumptions

The first collaboration strategy is based on the assumption that if interdisciplinary healthcare practitioners are provided with open data, well-articulated roles, and sufficient time, they will be able to resolve the challenges together. The second assumption is that effective leadership and the presence of a positive safety culture will facilitate the reporting of near-miss events and will enable adherence to the guidelines.

Slide 9

Conclusion

Data from the Riverside Community Hospital dashboard show that the safety of insulin therapy is compromised due to an elevated medication error rate, failure to use BCMA, low adherence to SBAR, and a lack of reporting near-miss medication incidents. To resolve these gaps, the Insulin Safety Bundle is an evidence-based practice, and an interprofessional design approach is utilized, incorporating standardized communication, the use of BCMA, EHR, and simulation, along with the continuous assessment and improvement of the process. The goal is to strengthen the safety culture and foster interprofessional teamwork to decrease the number of avoidable medication errors and improve patient outcomes. This initiative will help the organization meet and/or improve its performance against the national quality and patient safety standards.