NURS 8302 Quality Improvement Initiative

NURS 8302 Quality Improvement Initiative

NURS 8302 Quality Improvement Initiative

Week 6 Main Question Post- Quality Improvement Initiative

Quality improvement aims to understand the complex healthcare environment, apply a systematic approach, and design, test, and implement modifications using real-time measurement to improve safety, effectiveness, and care experience (Jones et al., 2019). It is an opportunity to address concerns about how care processes and systems are delivered. Quality improvement (QI) is a team activity that collaborates with other disciplines, including patients, to improve care processes (Jones et al., 2019).  Done well, QI is a valuable process, enabling clinicians to deliver actual change to benefit themselves, their organizations, and their patients (Jones et al., 2019). This week’s discussion will focus on a quality improvement initiative, how adverse events are handled at my organization and impact public and internal perspectives on healthcare quality, and review a scholarly article where a serious error occurred and how this may relate to my organization.

QI Initiative Selected 

            I have been the co-chair of the Fall Prevention Quality Improvement Team for the network for several years. My co-chair and  I have led many fall prevention initiatives, including Dr. Patricia Quigley and Dr. Amy Hester’s (Hester Davis Scale for fall risk assessment) on-site visits to educate the network on fall prevention. I am fortunate to have met both fall prevention experts.

The QI initiative selected is a Fall Prevention Agreement to reduce fall events. I chose this QI initiative because I am passionate about fall prevention. This QI initiative was initially a Nurse Residency evidence-based project in 2018 and then expanded network-wide. Most patients are unaware of their fall risk. The Fall Prevention Agreement provides a standard format for communication between nursing staff and the patient, increasing patients’ knowledge of their fall risk factors. It is a two-sided agreement with specific fall prevention interventions and things the patient can do to prevent a fall. The nurse reviews the Fall Prevention Agreement on admission, and then after review, the patient and nurse sign/date the agreement. It is scanned into the electronic health record, being a permanent part of the electronic health record.

Adverse Events in My Healthcare Organizations 

My organization supports a just culture where colleagues are encouraged to do the right thing. It is a culture that promotes reporting and open discussion when adverse events occur. The aim is to avoid similar adverse events. Frontline staff is included in root cause analysis meetings to learn and discuss adverse events, identify opportunities for improvement, and implement action items to improve safety and quality of care. Research has shown that in units where feedback about adverse events is routinely given, staff have positive views on patient safety and are more apt to report adverse events (Liukka et al., 2017).

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Leadership and the organizational structure play a vital role in developing and implementing QI plans (U.S.

NURS 8302 Quality Improvement Initiative
NURS 8302 Quality Improvement Initiative

Department of Health and Human Services Health Resources and Services Administration, 2011). In my organization, senior leadership acknowledges the importance of discussing adverse events and encouraging frontline staff involvement in decision-making and policy development, positively impacting public and internal healthcare quality perspectives. I believe it is crucial to include frontline staff to gain a firsthand perspective on potential solutions. When firsthand perspectives are not discussed in the aspects of QI planning, the QI initiative may fail.

Published Scholarly Article that Recounts a Serious Error

            Medication reconciliation is an essential component of patient safety. The scholarly article I selected refers to a 71-year old female who accidentally received Navane, an antipsychotic medication, instead of her anti-hypertensive drug Norvasc for three months (da Silva & Krishnamurthy, 2016). She sustained physical and psychological harm, including ambulatory dysfunction, tremors, mood swings, and personality changes (da Silva & Krishnamurthy, 2016). Unfortunately, multiple healthcare providers overlooked her symptoms (da Silva & Krishnamurthy, 2016). Errors occurred at numerous levels, including prescribing, pharmacy dispensation, hospitalization, and outpatient follow-up. (da Silva & Krishnamurthy, 2016). The outpatient pharmacy accidentally dispensed Navan instead of Norvasc (da Silva & Krishnamurthy, 2016). Navane/Norvasc is one of many sound-alikes, look-alike drug names (da Silva & Krishnamurthy, 2016). “It is believed that preventable medication errors impact more than seven million patients and cost almost $21 billion annually across all care settings” (da Silva & Krishnamurthy, 2016, p. 1).

Related to My Healthcare Organization

Unfortunately, this alarming medication error can occur in any healthcare organization. At my organization, medications added to the formulary are evaluated for a look-alike, sound-alike potential with other products, and then appropriate safeguard education to staff. Look-alike and sound-alike medications are stored in red bins and different locations in the pharmacy. The regularly updated list appears in the policy manual and the pharmacy website. When possible, the electronic medical record system will place a warning comment and tall man letterings such as DOPAmine and DOBUTamine. My organization has developed a series of procedures to identify look-alike and sound-alike medications to prevent medication errors from these mix-ups. Medication errors are low but still occur. By creating a culture of teamwork and communication, we learn from our mistakes and aim to decrease preventable medication errors.



da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: A patient case and review of Pennsylvania and national data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 31758.

Jones, B., Vaux, E., & Olsson-Brown, A. (2019). How to get started in quality improvement. BMJ, k5408.

Liukka, M., Hupli, M., & Turunen, H. (2017). How transformational leadership appears in action with adverse events? A study for finnish nurse manager. Journal of Nursing Management, 26(6), 639–646.

U.S. Department of Health and Human Services Health Resources and Services Administration. (2011). Developing and implementing a QI plan. Retrieved October 3, 2021, from

Choose a QI initiative which has been the subject of focus in any healthcare setting. Explain the rationale that your senior leaders used in selecting this initiative for attention and focus.

            Hospital acquired infections (HAI) is a serious concern in healthcare and has been the focus of quality improvement in recent years. Infections that occur after hospitalization significantly increase hospital costs. HAI and the extra costs that are incurred are absorbed by the hospital or healthcare system. Patients who acquire these infections require more days of care in the hospital and in turn develop feelings of anger for providers and increases the chance of patients pursuing legal action. The increased costs that hospitals incur secondary to HAI is a good reason for senior leaders to place HAI on the top of the QI initiative list. These costs can be incurred in several ways described above.


Explain how adverse events are handled in your organization from the public’s perspective and well as internally.

            The organization that I currently work for places great priority in a culture of safety. In Air Medical Transports, errors can mean life or death of the patient as well as the crew. Many years ago, one of our helicopters crashed after picking up a patient and departing to the hospital with the patient and crew on board. The helicopter got caught in power lines that were not visualized and no one on board survived. Every year we “stand down”, shut down our transport services on the anniversary of the crash to honor the victims but to also refocus our attention on safety. After thorough investigation, the public was made aware of the cause of the accident and internal staff utilized this information to improve safety processes within our transport team. Punitive actions are not taken when adverse events occur but instead education occurs for all staff to learn from the event. Discussion in staff meetings and process improvement efforts occur. The goal is to eliminate the possibility of the same event happening again. “Acknowledging that errors and adverse events are systems problems and not people problems is a crucial first step, but follow-through on that acknowledgement- with appropriate response when something happens – is critical” (Joshi, Ransom, E., Nash, Ransom, S., 2014, p. 277).


Find a scholarly article or one from the public press, published within the last 5 years which recounts a serious error. Relate this error to any organization with which you have some familiarity.

In the news article “Nurse charged in fatal drug-swap error pleads not guilty” a nurse was charged with reckless homicide after a medication error resulted in death of the patient (Loller, 2019). The nurse administered the paralytic agent of Vecuronium instead of the ordered agent of Versed which is a sedative. The report from the Centers for Medicare and Medicaid Services communicated that the nurse overrode the medication automatic dispensing cabinet and typed “VE” and chose the first medication that appeared. A medication error can occur in any organization where medications are given. The risk of an error is inevitable but efforts to improve the process of administering medications with safety stops in place have improved medication errors. One of the 6 key dimensions identified by the second IOM report Crossing the Quality Chasm is to avoid injury to patients from the care that is intended to help them (IOM, 2001). Medication errors can happen in any health care facility or setting in which medications are administered. Medication errors can result in differing outcomes for patients and for providers which can range from mild to severe. A medication time out, like a surgical time out which has been shown to prevent surgical errors, has proven to be an effective strategy to decrease mediation errors with utilizing few resources (Santos et al., 2021).



Institute of Medicine (U.S.) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.

Joshi, M. S., Ransom, E. R., Nash, D. B., & Ransom, S. B., (Eds.).  (2014). The Healthcare Quality Book (3rd ed.).  Chicago, IL:  Health Administration Press

Santos1, L. L., Camerini, F. G., Fassarella, C., de Almeida, L. F., Setta, D. X. d. B., & Radighieri, A. R. (2021). Medication time out as a strategy for patient safety: Reducing medication errors. Revista Brasileira De Enfermagem, 74(1), 1-7. doi: