NURS-FPX6016

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal
Capella University, MSN, NURS-FPX6016

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

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NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal 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 Metric National Benchmark 2022 Rate 2024 Rate Insulin Medication Error Rate ≤ 1.0 per 1,000 doses 3.2 per 1,000 doses 2.1 per 1,000 doses BCMA Compliance Rate ≥ 95% 74% 88% SBAR Handoff Adherence ≥ 90% 61% 79% Hypoglycemia Incident Rate < 5% inpatients 9.4% 6.8% Near-Miss Reporting Rate ≥ 80% 42% 58%   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: To reduce the rate of insulin medication errors to ≤ 1.0 errors per 1,000 doses. To achieve an increase in BCMA compliance to ≥ 95% 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. 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). 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. The electronic

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation
Capella University, MSN, NURS-FPX6016

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

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NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation Student name Capella University NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation Professor’s Name Submission Date   Quality Improvement Initiative Evaluation The Barcoded Medication Administration (BCMA) system was implemented at Conway Medical Center as part of the quality improvement initiative to help staff better manage medications in a safer way. This was triggered by an incident that occurred when one of the staff was administering insulin to a patient named Sarah. It was then realized that there is a critical flaw in the system of medication administration at the hospital. The BCMA system is designed to improve the process of verifying medications. However, there are challenges, including alert fatigue, inadequate staff training, and challenges in the use of technology (Mulac et al., 2021). The purpose of this paper is to analyze the process of implementing BCMA and to describe the gaps in the process that will help to advance the system to improve medication safety. Analysis of Quality Improvement Initiative Conway Medical Center initiated the BCMA project when their organization nearly experienced a patient getting the wrong insulin due to several medication safety issues, a lack of proper labeling, and insufficient training of float nurses. Saleem (2023) states that the BCMA system is a technological advancement to provide the correct medication that is intended to be delivered at the right dose, at the right time. A BCMA system is an acute care system that utilizes bar coding to verify the right patient, the right drug, the right dose, the right route, and the right time. The BCMA system used in conjunction with an electronic health record (EHR) system minimizes the documentation burden and enhances real-time activity. The barcode medication administration (BCMA) system is focused on medication delivery verification; however, inadequate training, poor medication storage, and alert fatigue diminished the system’s effectiveness. The system faces challenges such as employees resisting and interfering with the system’s existing workflow. Aside from the aforementioned, novel issues arose in the course of the BCMA initiative’s implementation. Challenges arose when scanning acoustic barcodes due to older medication packaging, and placement of barcodes was often incorrect (Barakat & Franklin, 2020). During the implementation of BCMA, it was also revealed that there was a lack of communication among the nursing, pharmacy, and IT departments, and that some of the departments did not respond to concerns in an appropriate manner. This illustrates that simply applying a technological solution to a particular issue is not adequate. For BCMA, it was evident that the staff had an overreliance on the system as a safety barrier to prevent the occurrence of medication errors, thereby assuming the system provides absolute safety (Grailey et al., 2023). This necessitates the same approach to be combined with color enhancement labeling and improved commitment to interdepartmental collaboration. Knowledge Gaps and Areas of Uncertainty There exist many areas lacking understanding in analyzing the QI initiative. One example is the incomplete assessment of how efficient the BCMA system is for multiple products and/or services. This is especially true when incorporating more complex cases and when some areas are characterized by high employee turnover. Because of these knowledge gaps, the impact of the continuous training of float nurses on the system’s success cannot be determined either. There is also a problem of alert deaths associated with the alert’s cause itself (Saleem, 2023). Inadequate interaction of BCMA with other hospital technologies, like EHRs and automated dispensing technology, can lead to a lack of evidence about possible system integration issues. Missing are subgroup and sensitivity analyses for further enhancement of BCMA and the use of the compound in the management of patients like Sarah. Success of Current Quality Improvement Initiative             Quality Improvement (QI) Projects at Conway Medical Center aim to enhance safety within hospital systems that manage the logistics of medication. Bar Code Medication Administration (BCMA) systems represent one of the innovations in this field. One of the BCMA system assessments looks at The Joint Commission’s National Patient Safety Goals and evaluates the safety and quality of the hospital’s services concerning those standards. To assess the efficacy of the BCMA systems, the hospital examines the rate of medication administration errors, the time taken to respond to alerts, and the number of adverse drug events. The safety and quality of the hospital’s services concerning those standards are also advocated for at the national and state levels. Analyzed using The Joint Commission’s (2025) and The Leapfrog Group’s frameworks and the Centers for Medicare & Medicaid Services (CMS) guidelines, the focus of BCMA systems in the safe administration of hospital medications has been evaluated. One of the primary benchmarks was The Leapfrog Group’s safe medication administration score pertaining to BCMA systems. Scoring 100, Conway Medical Center ranked in the top hospitals nationally, far exceeding the average benchmark of 80.51. (Hospital Safety Grade, 2024). The outcome measures are the interception of medication errors, the compliance rate with the medication safety scanning requirement, and the safety check compliance outcome of staff and storage audits. The Initiative has made patient safety better and decreased the rate of errors in the administration of medication. Also, the development of simulation-based training for staff has increased the confidence and skills of staff in using BCMA (Chen et al., 2025). This has led to better adherence to protocols and increased correct medication administration. From the outcome achieved, improved internal quality and the alignment of external accreditation standards in the outlined initiative of the healthcare service delivery in the institution are justified appropriately. There has also been a decline in the rate of unplanned medication-related readmissions, an increased rate of compliance with the scanning, and an increase in the level of trust and safety in the healthcare services offered to the patients, which all denote the success of the initiative. All the stated achievements have shown that the medication safety initiative has developed and maintained a standard of excellence in the safe administration of medication practices in the acute care setting

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis
Capella University, MSN, NURS-FPX6016

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis

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NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis Student name  Capella University NURS-FPX6016 Quality Improvement of Interprofessional Care Professor’s Name Submission Date Adverse Event or Near-Miss Analysis Although safety is a priority in healthcare settings and advances in technology, systems, and training have been instituted, adverse events and near misses have not been eliminated. Errors in medication are the most prevalent type of avoidable harm and can occur at multiple points in the medication process, from the prescribing through to the drug administration (Tariq et al., 2024). Analysis of these events can identify significant and constructive systemic weaknesses and challenges to quality improvement (QI). This review focuses on a near miss of an insulin administration event in American hospitals and considers the impact of this on the stakeholders, performs a root cause analysis and considers QI and associated technology, and proposes an evidence-based QI initiative to prevent similar events. Case Scenario St. Mary’s Medical Center almost experienced a serious incident with Mr. Robert Hall, a post-operative diabetic patient who had a knee replacement. During a busy day, the night nurse verbally told the patient (during the blood glucose reading) to give a target blood glucose reading of 410 mg/dL (instead of the correct 140 mg/dL). The day nurse was going to give the patient 20 units of insulin (instead of the correct 4 units). While this was happening, one of the student nurses was going through the patient’s electronic health record and was able to intervene and verify the order before it was administered. In line with the most recent literature, the incident was a close call with no patient harm, as it gave the health care system an opportunity to realize some of the vulnerabilities that exist in the system regarding handoff communication, compliance with the protocols, and verification, as well as the gaps that exist in the current system to address high-alert medication errors. The introduction of technology in a more structured, facilitated, and integrated manner would help establish double checks in the system that could strengthen patient safety. Impact and Analysis of Near Miss The near-miss incident involving insulin at St. Mary’s Medical Center impacts a wide range of stakeholders. The immediate effects on Mr. Hall, the patient involved, included the potential for hypoglycemia and the development of anxiety, while he may experience longer-term effects of developing a mistrust of the entire healthcare system and of the safety of his prescribed medications. The patient’s family became increasingly more vigilant and active in the patient’s care. The interprofessional team became aware of deficiencies in their communication and in their checking of and adherence to procedures, as well as in the handoff of care. This undoubtedly resulted in a great deal of thought and reflection as to the issues surrounding handoff of care and the medical teams’ responsibility. Haliq and AlShammari. (2025) cited significant communication issues when a paramedic and a nurse complete a handover in emergency medical care. The organization also has the potential to lose its business, and its safety culture becomes not only a priority but a necessity. The case illustrates that every healthcare organization should invest in safer systems that minimize the risk of medication errors and safeguard their patients. Responsibilities The nursing, medical, pharmaceutical, and clinical teaching professions all have responsibilities in avoiding these incidents. The collaborative practice teams have been the best in delivering person-centered care and in improving the outcomes of the patients and the system (McLaney et al., 2022). It is the role of the nurse to carry out an assessment and report, as well as conduct a drug check for the high-risk medications. It is the role of the doctor to order and report for the patient. The pharmacist is responsible for checking the dose and for the safety alert. It is a requirement for all the team members to avoid injury to the patient by collaborating and communicating effectively and efficiently during handoffs and while reporting abnormalities. Preventive Measures The prevention of errors during the handoff of high-risk medications from one healthcare professional to another requires the use of SBAR as well as the two-check approach. The use of the electronic health record system with the dose alert differentiations also serves as a prevention measure. It has been proven that the use of SBAR and mind mapping reduces the occurrence of errors and adverse events and boosts satisfaction in nursing (Haliq and AlShammari, 2025). There is an imperative need to create educational programs focused on the safe administration of insulin and the management of fatigue, as well as interprofessional communication. The management of the nursing unit and the quality improvement committee are tasked with the responsibility of creating policies, enhancing compliance, and evaluating the reporting of near-misses to improve practices focused on patient safety. Assumptions In this analysis, we assume that personnel have clinical competencies, but issues related to high-volume workloads, environmental challenges, and inconsistent handoff procedures created barriers. It assumes that the nursing student was the first and only line of defense to recognize and capture the near miss, and that it was not the result of an automated system fail-safe. Errors and near misses predominantly occurred as students failed to check for patient identification and allergy status, and apply the rights of medication administration (Silvestre & Spector, 2023). Blame for the near misses and errors is placed on the system, and not the individual staff. It is assumed the incident will result in practice changes for the staff that will incorporate additional verification, enhanced documentation, and stricter adherence to interprofessional communication standards. Root Cause Analysis of the Sequence of Events The incident at St. Mary Medical Center reveals a much larger failure of the medical system as a whole, rather than being the simple case of a patient with diabetes. The blood glucose level of Mr. The was at a normal level of 140 mg/dl. This incident was triggered by a series of events that began with a verbal handoff during the start of

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