Enhancing Quality and Safety

Enhancing Quality and Safety


For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Medication Errors

One of the most common quality issues pertaining to medication administration in the healthcare setting is medication error. Despite the increasing prevalence of medication errors, it’s preventable through quality improvement interventions. Medication error is any preventable event resulting from inappropriate use of medication, which may or may not results in patient harm while under the care of a health care professional. Medication error results from a failure in one or more of the five rights of medication. The five rights include medication, time, route, right patient, and dosage (Hammoudi et al., 2018). Modern healthcare delivery systems have continued to evolve, and emphasis has been placed on system design complementing the medication administration process. Unfortunately, system design has contributed to medical administration errors through inadequate training of healthcare providers, convoluted processes, distractors, and system misconfiguration.

Despite the invention of various technologies aimed at promoting better healthcare delivery, medication errors remain prevalent in the US (Tsegaye et al., 2020). A significant portion of the medication errors occurs to hospitalized children due to the difficulty of weight-based pediatric dosing, where dosage depends on calculations of weight and height. The variability in weight calculations increases the risk of wrong dosage administration. The most common medication errors are missing doses, wrong dosage, and wrong medication. The most significant causes of these errors include poor health provider and patient communication, lack of health literacy among patients, shortage of healthcare providers, and poorly developed medication safety protocol. To resolve this quality issue, evidence-based interventions should focus on mitigating the cayuses.


The potential evidence-based solution to Medication Errors

Increased studies on medication errors have led to various recommendations with the potential to address medication errors. Medication error is a complex quality issue that requires the collaboration of various healthcare stakeholders for better results. Healthcare leaders, nurses, and patients have a critical role in addressing this quality issue. One of the identified leading causes of medication error is poor health literacy among patients. This can be addressed through a collaboration of patients and nurses. The patient’s role includes being informed and vigilant about the prescribed medication’s purpose, dosage, and side effects. The knowledge will help patients take an active role in their care administration. The role of a nurse, in this case, is educating the patient on correct medication administration. Their role also includes giving clear instructions on medication administration and notifying the patient when the medication rules change (Kim et al., 2018).

Another significant cause of medication errors is the regular distraction of healthcare providers, contributing to errors and omissions in drug administration. Healthcare leaders and nurses can play a critical role in addressing this healthcare deficiency. Healthcare leaders can implement and enforce organizational policies aimed at optimizing workflow. The policies aim at preventing distractions during medication administration by ensuring that nurses are not interrupted to focus on other roles before they finish attending to a particular patient. In institutions where interruptions are unavoidable, strategies should be implemented to ensure that the nurses comply with the safety procedures by introducing monitoring ad surveillance programs.

Healthcare organizations can also use the rapidly advancing technology to mitigate medication errors. Examples of High-tech solutions to mitigate medical administration errors include barcode scanning of medication, patient armbands, and smart infusion bands. Barcode medication administration uses barcodes to link the patient with the right medication. This significantly reduces medical errors as the correct prediction and medication are given to the right patient. The use of barcodes in a study showed that medical errors were reduced by 41% and adverse drug events reduced by 51% (Rudzewicz, 2021). This affirms the effectiveness of barcodes as a solution to medication administration errors. In addition, many hospitals have adopted smart infusion pumps in the United States. About 88% of hospitals currently use smart infusion pumps with dose error reduction software. However, smart infusion pumps interfaces and programming requirements are prone to errors. Inaccurate programming negates the advantages of smart infusion pumps. Therefore, it is essential to use a drug library to ensure accurate programming.

Although technology can help mitigate medication errors, it has been found to play a part in facilitating medication errors. This is through poor knowledge of operating the most advanced technology medical tools and systems (Dyb & Warth, 2019). Besides, the lack of clear guidelines and policies governing medical technology in organizations contributes to medication errors. Healthcare leaders and healthcare providers have a role in mitigating this issue. Healthcare providers have a role to keep updated on the rapidly developing therapeutic products regarding safe administration and side effects. On the other hand, healthcare leaders have a role in implementing policies to govern the integration of new therapeutic products in healthcare settings to promote patient safety.

Therefore, despite medication error being a prevalent issue in many healthcare settings, it’s preventable through evidence-based strategies, such as patent education, provider education, and implementation of drug safety protocols in organizations. However, since this is a complex problem, a collaboration of various healthcare providers is required to implement the proposed evidence-based solutions.




Dyb, K., & Warth, L. L. (2019, July). Implementing eHealth Technologies: The Need for Changed Work Practices to Reduce Medication Errors. In ICIMTH (pp. 83-86). https://books.google.co.ke/books?hl=en&lr=&id=1mawDwAAQBAJ&oi=fnd&pg=PA83&dq=addressing+medication+errors&ots=dJ30RwEcPr&sig=F9JV0kl1yaUI9DTxu2W48QTS0JA&redir_esc=y#v=onepage&q=addressing%20medication%20errors&f=false

Hammoudi, B. M., Ismaile, S., & Abu Yahya, O. (2018). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian journal of caring sciences, 32(3), 1038-1046. https://onlinelibrary.wiley.com/doi/abs/10.1111/scs.12546

Kim, P. C., Shen, J. J., Angosta, A. D., Frakes, K., & Li, C. (2018). Errors associated with the rights of medication administration at hospital settings. Journal of Hospital and Healthcare Administration. https://pdfs.semanticscholar.org/4fa4/ae1574b8c12944f96be772c3b55b59f18b4d.pdf

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, 13, 1621. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7764714/



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