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NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

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Capella University

NURS-FPX 6016 Quality Improvement of Interprofessional Care

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Quality Improvement Initiative Evaluation

Healthcare facilities face several challenges requiring Quality Improvement (QI) activities to deliver proper care and enhance patient outcomes. The Henry Ford Hospital has launched a Quality Improvement (QI) project focusing on Adverse Drug Events (ADEs) caused by Medication Administration Errors (MAEs). Following an MAE incident involving a patient named Jennifer, the Medical Center’s administration initiated QI action.

ADEs caused by MAEs are serious episodes found in hospitals that result in poor patient outcomes. MAEs develop adverse outcomes in medical settings because they can cause injury, mental distress, extended hospital stays, and deaths (Oura & Sajantila, 2022). The present paper intends to evaluate the QI project, analyze efforts, and explore interdisciplinary perspectives regarding the efficacy of QI actions.

Analyze a Current Quality Improvement Initiative

Analyzing QI initiatives for mitigating ADE is vital to improve patient safety. ADEs occur due to MAEs during patient care. MAEs are a critical medical hazard that jeopardizes patient safety. The World Health Organization (WHO) revealed that MAEs damage 1.3 million people yearly and kill one person in the United States every day. Furthermore, the global cost of MAE errors is estimated to reach $42 billion annually (Naseralallah et al., 2023). Every year, over one million people are treated in medical facilities for ADEs in the US. More than a quarter of these individuals require hospitalization for additional treatment (CDC, 2024a).

It is determined that most of these ADEs are preventable, indicating that there are possibilities to enhance patient safety (Ersulo et al., 2022). This evidence supports the necessity for QI activities to ensure pharmaceutical safety and enhance patient outcomes. The current QI initiative in the medical care setting responds to an adverse event in the Henry Ford Hospital, emphasizing adherence to medication safety protocols.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

The adverse event occurred due to a misinterpretation and lack of medication reconciliation by nurse Amelia. The potential risk posed to Jennifer by the improper drug highlighted the critical need for effective prescription practice and strict compliance with drug safety guidelines. The occurrence of ADE motivated the Interdisciplinary team to evaluate the root cause and consequences of the ADE and take preventative measures to avoid similar events in the future (Liukka et al., 2020). 

The QI initiative deals with crucial areas such as medication reconciliation approaches, comprehensive safe medication guidelines, staff training, and technology adoption initiatives. Bello (2021), stated that adhering to the drug delivery guidelines and recognizing the five rights of drug delivery can improve outcomes during care by reducing MAEs. Moreover, nurses’ compliance with protocols aids in developing an attitude of considering the five rights of drugs before administering medication. Medication safety training and education for nurses evaluate the hazards of ADEs.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Nurses gain understanding and trust in recognizing the situations that cause MAE and utilizing theoretical expertise in practice to resolve ADEs. This strategy reduces the incidence of MAEs, promotes patient satisfaction, and minimizes the expense of additional treatments for ADE-caused harm (Musharyanti et al., 2021). Other measures included efforts to prevent verbal prescribing. Verbal instructions and prescriptions should be avoided wherever possible and utilized only in extreme cases like emergencies (Ambwani et al., 2019).

Furthermore, developing regulations to follow the double-checking and drug reconciliation guidelines will aid in minimizing MAEs and, eventually, ADEs (Stralen et al., 2024). Moreover, Electronic Health Records (EHR), and the Barcode Scanning System (BCMA) play significant roles in reducing ADE during patient care. EHR systems will improve collaboration among interdisciplinary teams. EHR reconciliation functions will guide nurses in avoiding errors. Moreover, BCMA will support nurses in addressing five drug rights and preventing MAEs, improving patient safety (Naseralallah et al., 2023).

Knowledge Gaps and Missing Information

Although the QI initiative covers critical aspects, specific possible issues may remain unresolved. For example, the initiative may need to investigate underlying fundamental problems causing workflow inefficiencies extensively. The QI initiative focuses on developing medication security standards and interventions to establish a safety culture in the Henry Ford Hospital. However, this initiative has a drawback in that it fails to address the problem of ADE insufficient reporting. Furthermore, the endeavor may require a thorough strategy for dealing with misinterpretation or imprecise verbal prescriptions, which may continue to pose hazards to patient safety despite the execution of established protocols.

Furthermore, the QI strategy does not address staff scarcity, a significant risk factor for adverse drug practices (Salar et al., 2023). However, there is a knowledge gap; for better comprehension of MAEs’ background and the implications of the initiatives, there is a need to gather relevant data from the medical databases. Data regarding ADE prevalence and current medical centers’ initiatives to mitigate ADE incidences aid in evaluation before and after the QI actions for ADE prevention (Naseralallah et al., 2023). To analyze the effectiveness of the current QI endeavor, sensitive and reliable outcome metrics must be used.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

These outcome metrics must include lowering MAE, near misses, and ADEs and improving compliance with pharmaceutical safety guidelines. It increases medical staff expertise and evaluates patient satisfaction with pharmaceutical delivery protocols (Musharyanti et al., 2021). By carefully analyzing these outcome metrics, the QI initiative’s impact on patient safety and the quality of care can be measured, and areas for reform can be uncovered. The QI endeavor is a proactive approach to deal with the ADE and improve patient safety at Henry Ford Hospital. Additional information, refinement, or review may be required to guarantee its success and sustainability.

Evaluation of the Success of the Quality Improvement Initiative

To determine the effectiveness of a healthcare QI strategy, it must be monitored and analyzed frequently. The Henry Ford Hospital management examined the QI program implemented in their healthcare setting to avoid ADEs related to MAEs. The Agency for Healthcare Research and Quality (AHRQ) highlighted three areas of analysis for the QI program, including tracking the compliance with the new strategies, assessing the impact of new approaches in providing patient-focused care, and evaluating the enhancements in patient satisfaction and standard of care (Mikhael et al., 2023). 

This evaluation is based on the total number of patients enrolled in a Henry Ford Hospital and the implementation plan’s participants, including physicians, nurses, pharmacists, and patients. This initiative’s Key Performance Indicators (KPIs) include fewer MAEs and adverse events, improved conformity to drug safety guidelines, and increased patient satisfaction with the administration of drug processes. These metrics are critical for meeting accreditation requirements and providing standard patient care (Lima et al., 2019). It is evaluated that the QI initiative’s strategies substantially benefit patient safety outcomes regarding ADEs. Interprofessional education and training result in healthcare professionals’ collaboration to enhance pharmaceutical practices.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

A crucial benchmark set by Centers for Disease Prevention and Control (CDC), for improving success by reducing MAEs. Evidence revealed that caregiver education programs significantly increase medication safety by promoting adherence to drug delivery guidelines (CDC, 2024b).  Training for nurse employees resulted in improved compliance with pharmaceutical safety guidelines, improving patient safety. Adherence to guidelines such as proper prescription, dispensing and the five rights of drug administration paradigm increased significantly.

According to the data collected, healthcare personnel adhering to established criteria increased from 50% to 88% (Owen et al., 2023). Based on the AHRQ information, following the innovative QI procedure enhances the treatment of patients and health outcomes (Mikhael et al., 2023). Medical staff at Henry Ford Hospital adopt standard drug safety guidelines and double-check approaches in their practices to enhance patient safety. According to the Food and Drug Administration (FDA), following the five rights of drug administration significantly reduces the number of MAEs in the healthcare system (FDA, 2019).  The Centers for Medicare & Medicaid Services (CMS) has established a benchmark for measuring success in decreasing MAEs and adverse events.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Recent statistics showed a 20% drop in MAEs, highlighting the initiative’s efficacy in improving patient safety (Bhati et al., 2023). Furthermore, the no-tolerance attitude for medication carelessness encouraged medical personnel to remain cautious throughout the drug administration procedure. This was demonstrated by a decrease in the frequency of drug-related adverse events from 10 to 4 per 100 patients. Furthermore, a survey revealed that 80% of patients reported enhanced experiences regarding the standard of care (Stralen et al., 2024). A significant outcome of this QI initiative is a 25% increase in patient satisfaction levels, obtained through extensive feedback from patients and families. This positive change represents the initiative’s efficient solution to patient concerns, improving the standard of care.

Moreover, the national benchmark data revealed that implementing technologies like BCMA and EHR can significantly reduce the MAEs in health settings. About 50% reduction occurs in MAEs by implementing an EHR system (Eisa & Bah, 2022). It is demonstrated that about 40% of falls in ADE occur in the Henry Ford Hospital through innovative technology. It is assumed that following Medication safety guidelines and technology interventions improves patient safety by reducing the number of medication errors and ADEs. It is assumed that training of nurses raises the quality of treatment. The key assumption of this evaluation is that improvements in medicine safety, adherence to guidelines, and patient satisfaction are significantly linked to the QI initiative’s success. These assumptions drive the development of KPIs and the thorough evaluation of the initiative’s influence on patient care  (Owen et al., 2023).

Interprofessional Perspectives and Actions

A collaborative team must implement a QI program to achieve satisfactory results. The QI plan at Henry Ford Hospital implemented by an interprofessional team that includes nursing staff, nurse managers and educators, the quality control department, and the medical center’s administration and legislators. The Henry Ford Hospital’s QI action focuses on preventing MAEs and ADE incidents. In executing the QI program, nurses, as frontline staff members, are primarily accountable for efficient collaboration with interdisciplinary professionals.

Nurses boost patient care and medicine administration standards to ensure patients’ safety (Oldland et al., 2020). Furthermore, nurse managers are accountable for supporting effective procedures and preventing malpractices by regulating their departments and efficiently resolving issues adhering to the medical center’s QI strategy. They are also responsible for addressing the challenges nursing staff face within the workplace (Haskins & Roets, 2022). Nurse educators are primarily responsible for training medical staff in standard principles and procedures and developing a continuous professional education program.

Furthermore, comprehensive knowledge assessment is part of their responsibilities (Gcawu & Rooyen, 2022).  The quality control group monitors the QI initiative’s development and success.  Finally, lawmakers and administrators are mainly accountable for developing regulations and protocols that all medical personnel must follow. They are also crucial for efficiently allocating resources to implement QI initiatives (Maher et al., 2019).

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Throughout the evaluation, discussions with various medical professionals provided deep insight into their responsibilities and viewpoints. These discussions emphasized the initiative’s effectiveness in increasing medication safety and creating a setting of safety and responsibility in the Henry Ford Hospital. Feedback from stakeholders, including nurses, other medical professionals, and nurse supervisors, highlighted the initiative’s beneficial effect on patient care effectiveness and staff abilities (Ghosh et al., 2020).

Incorporating interprofessional feedback within the QI initiative offered comprehension of performance and outcomes. The program successfully tackled complicated challenges and enhanced patient care by involving medical staff from various backgrounds. The initiative’s successes demonstrated the need for interprofessional cooperation in driving QI in patient safety and care quality (Wei et al., 2020).

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Collaboration and coordination within interdisciplinary teams increase the efficacy of the QI plan. Deliberately recognizing challenges and actively discussing with patients while resolving their concerns allows the team to create effective improvement plans for the medical system. The ability to devote attention to problems and communicate efficiently are critical interpersonal skills required for the QI plan’s efficacy and success (Hossny et al., 2022).

Another significant factor is that patient-oriented care promotes patients and caregivers to become more involved and responsive, and nurses become more cautious about following MAE prevention guidelines. An open mind and a precise discussion of the patient’s health issues and concerns are among the interpersonal skills considered valuable in resolving difficult situations like Jennifer’s ADE. Nurses must communicate efficiently with patients to comprehend their requirements (Kwame & Petrucka, 2021)

Knowledge Gaps and Additional Information

There is an unclear knowledge gap in this assessment issue regarding whether any measures have been implemented to track ADEs continuously. Furthermore, no information is provided about the primary risk factor for MAEs. It is also vital to incorporate perspectives from patients and comprehend their encounter with implementing MAE prevention guidelines and its impact on their participation in care (Holmstad et al., 2023).

Additional Indications and Protocols

QI actions should be regularly evaluated and monitored to address the increasing difficulties of ADEs in the Henry Ford Hospital. Necessary changes should be made to improve its success. Additional protocols can be adopted to improve the outcomes. These approaches include:

  • Integrating the latest technologies into the medical system can enhance quality outcomes. Incorporating a Computerized Provider Order Entry (CPOE) system along with EHR and BCMA in the care setting of Henry Ford Hospital can efficiently reduce the chances of MAEs during drug administration. It will enable clinicians to enter electronic drug order entries, which can mitigate confusion and misunderstanding among nurses due to bad handwriting and inaccurate transcription. The CPOE system frequently integrates functionalities, including medicine dosage guidance, alerts concerning dangerous interactions, and assistance with clinical decisions, which can further reduce ADEs (Kinlay et al., 2021). However, the cons of the CPOE strategy involve technical glitches and poor technical knowledge, resulting in system inefficiency. Moreover, there is susceptibility to wrong-patient errors with medical records (Jungreithmayr et al., 2021).
  • Incorporating regulations for checking and balancing guidelines and examination standards will help stakeholders monitor medication errors. It can also offer training to medical staff and resolve patient issues linked with MAEs.  Moreover, establishing action policy procedures also assists healthcare personnel by providing knowledge about the consequences of adverse events (Ghosh et al., 2020). This approach is beneficial because it offers in-depth knowledge and analysis of the efficacy of interventions. However, the cons of this recommended technique include overloading the healthcare staff and disturbing their routine and workflow.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

  • Implementing pharmacist-led intervention helps to improve the nurses’ knowledge of drug prescriptions. Assigning pharmacists in the hospital wards will significantly reduce ADEs. Ward-based pharmacists help nurses avoid prescription errors by providing real-time guidance and education. It enhances the standard of care by preventing ADEs. They also train nurses about medicine dosage and prescriptions (Jaam et al., 2021). However, the cons of this strategy include the resources for organizing training and educational discussions and professionally structured educational materials. Furthermore, it economically strains medical centers (Jaam et al., 2021).
  • Acquiring patient and nurse feedback on drug safety guidelines and their impact can help formulate an efficient care plan (Ghosh et al., 2020). It is beneficial in providing knowledge of aspects for further improvements, but it also requires additional resources, and uncertainties can occur during analysis. By incorporating interdisciplinary perspectives and technological innovations, these recommendations intend to improve the current QI initiative and increase patient safety, cost-effectiveness, and nurses’ practice efficiency in Henry Ford Hospital.


QI strategies are vital for healthcare facilities due to the rising occurrence of adverse events. The Henry Ford Hospital should prepare ADE implementation plans to increase patient safety. Implementing the QI project is insufficient; measuring its success and constantly improving the plans is vital.


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NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

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NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

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NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

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