NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Student Name

Capella University

NURS-FPX 6218 Leading the Future of Health Care

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Change Proposal Summary Report

The primary objective of this executive summary report is to suggest a modification for Tampa General Hospital’s pharmaceutical error reduction program. To achieve this, extensive research on medication errors is carried out. Then, a comparative analysis of how they are managed in healthcare systems outside of the United States is done. This will identify practical solutions and strategies for change proposals that will enhance the health of individuals by lowering medication errors.

Executive Summary

Proposed Change

At Tampa General Hospital, one critical aspect requiring focused attention is the reduction of drug administration errors, which includes routine medications and nutritional supportive therapies. The current services offered by TGH include the implementation of Electronic Medication Records (EMR) and Barcoding Medication Administration System (BCMA). However, the ability to administer, track, and maintain the continuity of medication administration remains a gap, posing significant risks to patient safety and well-being. Thus, TGH requires an interoperable BCMA system that improves interoperability from admission to discharge (Citty et al., 2020).

By prioritizing efforts to address this issue, the hospital can enhance the quality of care provided to its patients while mitigating adverse outcomes associated with medication errors. Clear expectations for improvement include implementing comprehensive medication reconciliation processes at all points of care and ensuring accurate documentation of medication orders and administration. Moreover, healthcare provider education and training on safe medication practices should be enhanced. Additionally, technology solutions such as implementing interoperable barcode scanning should be further leveraged to reduce errors (Citty et al., 2020)

Desired Outcomes

The desirable outcomes to be examined through the proposed change are reduced medication errors and financial and health implications. Firstly, accurate medication reconciliation processes ensure that patients’ medication regimens are thoroughly reviewed and documented upon admission, transfer, and discharge, reducing the risk of errors due to discrepancies in medication records. Reduction in medication errors will be measured through dashboard metrics. Secondly, the implementation of advanced technology solutions, such as interoperable barcode scanning systems, facilitates the safe and efficient administration of medications, minimizing the potential for duplication errors and reducing patient complications, thus producing positive impacts on patient health outcomes and cost-effectiveness (Luokkamäki et al., 2020).

This outcome will be measured through post-implementation patient satisfaction scores, financial viability within the organization, and cost-saving outcomes. Moreover, comprehensive healthcare provider education and training programs enhance awareness and competency in safe medication practices, fostering a culture of vigilance and accountability among staff members. This outcome is measured through improved healthcare practices and reducing errors through nursing practices by evaluating medication error incident reports. 

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

In terms of payment for care, the hospital may need to allocate resources for the initial investment in technology upgrades, staff training initiatives, and ongoing monitoring and evaluation efforts to sustain the improvements. Hospital administration will pay for these innovative procedures with the help of governmental funding or aid such as Medicaid services. However, the long-term benefits of reduced medication errors, including decreased patient harm, readmissions, and associated healthcare costs, justify these investments (Manias et al., 2020).

Factors limiting the achievement of these outcomes may include resistance to change among healthcare staff, resource constraints, and interoperability issues with existing healthcare information systems. However, proactive leadership, stakeholder engagement, and continuous quality improvement efforts can help overcome these barriers. Ultimately, they will drive meaningful progress toward the goal of enhancing patient safety and quality of care.

Health Care System Comparative Analysis

In an effort to learn more and identify an improved strategy, we have carried out a comparative analysis of the prevention and reduction of medication errors in two healthcare systems outside of the United States. In the Netherlands, a voluntary medication error reporting system has been implemented to produce measurable outcomes, such as reducing medication errors, improving health outcomes, and cost-effectiveness. This system allowed healthcare professionals to report errors without fear of punitive action. This approach also encouraged transparency and a culture of learning from mistakes, ultimately leading to improved patient safety and outcomes.

Through the Netherlands healthcare system, we have learned that healthcare providers should report any adverse drug events, near misses, or medication errors to a centralized reporting system, such as the Dutch Institute for Safe Medication Practices (DIMS), preventing the incidence of similar errors in the future. Thus, TGH must build a similar error reporting system and analyze reports to find common trends and contributing factors within the healthcare setting (Bosma et al., 2020).

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

The second non-U.S. healthcare system I will consider is in Sweden. This healthcare system implements a patient-centered approach and emphasizes collaborative care. In Sweden, medication reconciliation is a critical component of the healthcare process, with healthcare providers systematically reviewing and reconciling patients’ medication lists at each point of care transition. This includes reconciling medications when patients are admitted to hospitals, transferred between care settings, and discharged to home or other facilities. Through this system, Swedish healthcare providers can reduce the possibility of medication errors and enhance patient safety by making sure that medication information is correct and current (Säfholm et al., 2019).

Comparing these outcomes with present outcomes at Tampa General Hospital, we can identify areas for potential improvement. While Tampa General Hospital may already have some medication safety protocols in place, such as EMR and BCMA, there are opportunities for improving the BCMA system by making it interoperable, improving medication reconciliation processes, and staff training initiatives. Learning from the two non-US-based healthcare systems helps improve the services provided within TGH, reduce medication errors, and improve financial viability.

However, initial investments may be required for practical solutions like voluntary reporting among healthcare staff and enhancing collaboration among healthcare professionals to optimize medication reconciliation (Mohanna et al., 2021). By learning from successful strategies employed in other healthcare systems, Tampa General Hospital can further enhance patient safety and quality of care, ultimately reducing medication errors and improving health outcomes for patients.

Rationale for the Proposed Change

Practicing particular changes such as interoperable BCMA integration, medication reconciliation processes, and staff training on safe medication practices are anticipated to produce better results in patient safety and healthcare quality. Interoperable BCMA systems can result in a reduction of medication errors and associated adverse events, ultimately improving patient outcomes and reducing healthcare costs (Citty et al., 2020). Similarly, throughout care transitions, medication reconciliation procedures guarantee accurate and current drug information. This results in minimizing the risk of errors due to discrepancies in medication records (Säfholm et al., 2019).

By providing adequate training to healthcare staff, such as nurses on safe medication administration, medication administration errors will be reduced, and patient safety will be enhanced (Luokkamäki et al., 2020). Expected improvements include a decrease in medication-related adverse events, fewer hospital readmissions, and improved medication adherence among patients. While implementing these changes may require initial investments in technology, staff training, and quality improvement initiatives, they are reasonable expectations within the existing healthcare system, as they align with the broader goals of enhancing patient safety and quality of care.

Financial and Health Implications

The proposed changes, such as implementing an interoperable BCMA system, medication reconciliation processes, and staff training initiatives, have significant financial and health implications. If implemented, these changes will have several upfront costs associated with implementing new technology systems for medication administration and reconciliation, as well as ongoing expenses for staff training and quality improvement efforts. However, in the long term, these investments are expected to yield cost savings by reducing the occurrence of medication errors, which can lead to costly adverse events, hospital readmissions, and malpractice claims.

Moreover, improving patient safety through these changes can enhance the hospital’s reputation and potentially attract more patients, thereby boosting revenue in the long run (Manias et al., 2020). On the other hand, if these changes are not implemented, there may be increased incidences of medication errors, thus, increasing costs associated with additional treatment, duplication of treatment, and increased length of patient stays. 

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

In terms of health implications, making these changes can have profound positive effects on patient outcomes. By implementing the proposed changes, we can address medication errors more effectively, preventing patients from complicated health outcomes and adverse drug events, and improving overall patient safety. Similarly, medication reconciliation processes help ensure that patients receive accurate and appropriate medications throughout their healthcare journey, reducing the risk of harmful drug interactions, medication discrepancies, and related health complications.

Ultimately, these changes contribute to better health outcomes for patients, including lower rates of morbidity and fatalities, higher patient satisfaction, and better quality of life (Luokkamäki et al., 2020). However, if not implemented, patients may experience several complications from medication errors, thereby increasing the risk of morbidity and mortality. Furthermore, if these changes are not implemented, they may lead to increased medication errors, causing physical harm, psychological distress, and long-term health complications. These consequences will eventually erode patients’ trust, burdening healthcare systems. 


In conclusion, the comparative analysis of non-U.S. healthcare systems highlighted innovative approaches to reducing medication errors, emphasizing interoperable BCMA integration, medication reconciliation processes, and training healthcare providers. The evidence supports the expectation that implementing these changes can lead to improved patient safety, reduced healthcare costs, and enhanced healthcare quality. Given the financial and health implications associated with the proposed changes, prioritizing patient safety through proposed changes is crucial for achieving better outcomes and maintaining the hospital’s reputation. Therefore, investing in these initiatives aligns with the hospital’s goals of delivering high-quality care, enhancing patient satisfaction, and ensuring long-term financial sustainability.


Bosma, B. E., Hunfeld, N. G. M., Roobol-Meuwese, E., Dijkstra, T., Coenradie, S. M., Blenke, A., Bult, W., Melief, P. H. G. J., Dixhoorn, M. P.-V., & van den Bemt, P. M. L. A. (2020). Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in the Netherlands. International Journal of Clinical Pharmacy43(1), 66–76. https://doi.org/10.1007/s11096-020-01101-5

Citty, S. W., Bjarnadottir, R. I., Marlowe, B. L., Jones, S., Lucero, R. J., Garvan, C. W., Kamel, A. Y., Westhoff, L., & Keenan, G. (2020). Nutrition support therapies on the medication administration record: Impacts on staff perception of nutrition care. Nutrition in Clinical Practice36(3), 629–638. https://doi.org/10.1002/ncp.10590  

Luokkamäki, S., Härkänen, M., Saano, S., & Vehviläinen‐Julkunen, K. (2020). Registered nurses’ medication administration skills: A systematic review. Scandinavian Journal of Caring Sciences35(1). https://doi.org/10.1111/scs.12835 

NURS FPX 6218 Assessment 1 Proposing Evidence-Based Change

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety11(1), 1–29. https://doi.org/10.1177/2042098620968309 

Mohanna, Z., Kusljic, S., & Jarden, R. (2021). Investigation of interventions to reduce nurses’ medication errors in adult intensive care units: A systematic review. Australian Critical Care35(4). https://doi.org/10.1016/j.aucc.2021.05.012 

Säfholm, S., Bondesson, Å., & Modig, S. (2019). Medication errors in primary health care records; a cross-sectional study in Southern Sweden. BMC Family Practice20(1). https://doi.org/10.1186/s12875-019-1001-0


Table 1: Health Care System Comparative Analysis

Netherlands Healthcare System 
Swedish Health Care System 
Tampa General Hospital 

Reduction in Medication Errors

A voluntary medication error incident reporting system helps in fostering a transparent reporting culture to identify the medication errors, eventually decreasing the adverse events. 

The medication reconciliation process helps in accurate medication delivery, diminishing medication errors. 

Ongoing challenges with medication errors

Financial Implications

Investment in technology and staff training

Upfront costs for quality improvement initiatives

Initial costs vs. long-term saving for patient safety

Health Implications

Enhanced patient safety and reduced adverse events

Better health outcomes, decreased morbidity

Potential patient harm and increased healthcare costs

(Bosma et al., 2020; Mohanna et al., 2021; Säfholm et al., 2019)


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