Draft a 6-page report on outcome measures, issues, and opportunities for the executive leadership team or applicable stakeholder group. Introduction Note: Each assessment in this co

Running head: OUTCOMES, ISSUES, AND OPPORTUNITIES 1

Outcomes Measures, Issues, and Opportunities

Kathryn Forsyth

Capella University

HealthCare Quality Safety Management

Outcome Measures, Issues, and Opportunities

July, 2020

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2 Outcome Measures, Issues, and Opportunities

Medication administration is a large part of care provided to patients during each shift.

Nurses must deal with multitasking, interruptions, chaotic environments, and maintain

professional quality care. The United States has between 7,000 and 9,000 medication error

related deaths each year (Tarig, Vashisht, & Scherback, 2020). Near misses and adverse events

can occur during any point during the medication process from orders, documenting,

transcribing, dispensing, administering, and/or monitoring (Tarig, 2020). Nurses have high

patient loads, increased responsibilities, need to be aware of health costs and ways to decrease

those costs. This report will address measurable patient outcomes, gaps that need to be addressed

and interventions that are available to improve patient safety.

The Agency for Healthcare Research and Quality (AHRQ) has defined patient safety as

“freedom from accidental or preventable injuries produced by medical error” (Agency for

Healthcare Research and Quality (AHRQ), N.D.). A Quality Interagency Coordination Task

Force was created by the Department of Health and Human Services and other federal agencies

has advised using teamwork is an important way to improve patient safety (Buljac-Samardzic,

Dekker-van Doorn, & Maynard, 2018). This interagency team provided an increased awareness

to the media which put a spotlight on an issue that many would have rather ignored. The group

has pushed to increase reporting of all adverse medical events (ADEs). By exposing the issues,

the agency has forced facilities to create new policies and procedures to reduce adverse events.

High-Performing Organizations

Doctors Hospital is a high performing facility with many awards for providing the best

care. This organization has a culture to encourage the staff communicate when they have an

opinion on a way to improve patient care. The administration and leaders use the Triple Aim

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3 Framework to evaluate the root cause of medication errors within the facility. The goal of Triple

Aim is to provide interventions to improve quality of healthcare. The interventions and goals are

used to improve patient outcomes, patient satisfaction, decrease errors, and reduce cost of

healthcare (American Hospital Association, 2015).

Initiatives focusing on patient-centered quality provides an analysis of the issues and how

to become a High Reliability organization and implement the Triple Aim framework. Both high

reliability and Triple Aim focuses on quality improvement initiatives to reduce and/or prevent

patient injury and improve safety. When using High Reliability and Triple Aim framework, the

facility is seeing quality interventions with improved patient outcomes, patient satisfaction, a

decline mortality rates, adverse events, and near misses (Bodenheimer & Sinsky, 2014). The use

of technology, specifically bar code scanning has decreased medication errors however the use of

technology should never replace nurses knowledge, competency, continued use of double

checking information for high risk medications and using the computer as the third check to

completed the triple check system. By encouraging a questioning attitude, the facility is

encouraging nurse to seek additional information on unfamiliar drugs and asking questions for

when the medication orders does not make sense for the patient’s diagnosis (Rodziewicz &

Hipskind, 2020). The implementation of the above initiatives has reduced the medication errors,

improved communication, and increased patient education on medications.

Doctors Hospital is working to address medication errors after each event is report.

Trying to address adverse events and near misses as a systemic approach is very difficult as there

are many different units in the facility and each unit high risk medications are not the same.

Nursing leaders encouraging self-reporting of adverse events or near misses has improved

communication between administration, leaders, and other staff. The use of non-punitive or

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4 retribution when reporting medication errors or concerns has built trust between all parties.

Leadership using medication errors as a learning opportunity instead of placing blame, will

increase the overall quality of care. Determining the root cause of the medication error to create

interventions to prevent the same error in the future is critical. Doctors Hospital received a grade

of “c” in 2017, in 2018 the grade was a “d”, and in 2019 the grade was a “b”. Per the Leapfrog

Group 2020 website, the issues with medication and patient safety are related to communication

about medications, discharge planning, and staff communication. Leapfrog automatically gives

the facility a 100 is they are using the barcode system, which is not indicative of adverse events

and near misses since this is int addressed. In 2018, the hospital developed initiatives, objectives,

and goals to improve their rating. The new score is now a “b” in 2020 which is attributed to

improved training, improved technology, encouraging expressing concerns and adverse events,

and creating multidisciplinary group to improve communication.

Outcomes Measured

Doctors hospital mission and vision include a commitment to the care and improvement

of human life. To strive to deliver high quality, cost effective healthcare by incorporating the

following value statements, to recognize the unique and intrinsic worth of each individual, to

treat everyone with compassion and kindness, act with absolute honesty, integrity and fairness in

our business and personal lives. Also, our colleagues are valuable members of our healthcare

team and vow to treat each other with loyalty, respect, and dignity (Doctors Hospital, 2020).

Leadership skills, communication, and trust is an integral part of change, the leader must

be able to lead, deal with conflict, inspire, and communicate effectively. The interventions,

objectives and goals must be clearly stated and defined for the staff so there is no

misunderstanding. Outcomes and culture are positively connected to leadership atmosphere and

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5 staff satisfaction with their jobs. Experienced staff that have been with the same facility for many

years has experienced changes in policies and procedures, shifts in vision and mission

statements, working through nursing shortages and improvement of quality measures. The lack

of leadership will lead to increase in stress in the work environment, increases the rate of failures

for new interventions, policies, procedures, and outcomes. Highly motivated leadership can

improve the work environment, increase adherence to new policies, procedures and intervention

therefore encouraging the staff to meet objectives and goals of the project.

Adding technology to include bar scanning, smart pumps, ability to research medication

at bedside to provide education and addressing look alike, sound alike drugs have decreased

adverse events and near misses. By adding technology, the facility has enabled the nurses to

provide a third check to use of medication which increases patient safety and quality of care. By

using High Reliability, we can focus on key elements to include providing better education to

staff, increase training for leadership, encourage a culture focused on safety and reduction of

medical errors (Chassin & Loeb, 2013).

Performance Issues and Opportunities

Medication errors are extremely costly for the organization and insurance carriers.

Almost 400,000 a year hospitalized patient has experienced preventable harm of some type. This

has resulted in approximately 100,000 deaths each year. This creates an extreme financial burden

that can cost up to $20 billion dollars. Errors may contribute to the death of a patient or cause

long term harm which can lead legal issues that will increase costs to the facility (Rodziewicz &

Hipskind, 2020).

Many errors are related to look alike, sound alike drugs, which is being dealt with by

each facility as well as drug companies. Facilities are encouraging staff to report these types of

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6 medications so the facility can come up with a plan to address the drugs and ways to differentiate

between them. One suggestion for drug manufactures is to use Tall Man lettering and color-

coding which aims to highlight the difference between two similar drugs by capitalizing part of

the drug names. Many organizations have endorsed Tall Man lettering including the Joint

Commission and the Institute for Safe Medication Practices (ISMP) (Larmené-Beld, Alting, &

Taxis, 2018). By encouraging voluntary reporting in a blameless, guiltless environment will lead

the facility to be able to investigate and determine the core issue and develop ways to prevent the

error in the future (Patient Safety Network, 2019).

After researching 2019 medication errors, the evidence shows there is an overwhelming

incorrect usage of the bar code scanning, only 30% of staff was using the system correctly.

Personally, I have scanned the bar code from the chart which led to making a medication error by

scanning the wrong bar code and giving the medication to the wrong patient. There are many

ways to override the system when alerts pop up, many nurses do not even read the alerts. One

way to address this is update the bar code system for the nurse to have to manually type a reason

why the alert is being overridden. This will impact time but will overall make the nurse more

accountable. Total numbers of errors on the 50 bed burn unit for 2019 was 6000. Total resulting

in injury was 600 and total deaths 15. In 2019, the average number of medical errors on the 50-

bed unit was sixteen per day, this seems high, however medication errors include the route,

dosage, time, patient, and medication. So many of these errors could be related to time and most

errors did not cause injury or death. The attached spreadsheet breaks down the errors in 2019 and

2020 by total errors per year, total errors resulting in injury, total errors resulting in death, and

correct use of bar code scanning.

Strategy Outline

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7 Nursing leadership plays a key role in implementation of change, encouraging quality

communication, and improving patient outcomes. Lack of strong leaders will ultimately lead to

failure of the initiative, objectives, and goals of the project. Barriers may inadvertently be placed

by administration, leadership, and other staff which may limit the nurse being able to provide

quality, cost efficient, safe care. Forces that can drive change in healthcare include cost, need of

specific treatments, high patient to staff ratios, ethics, values, code of conduct, and the drive to

improve patient outcomes and satisfaction (Salmond & Echevarria 2017). Use of change theory

for this report is useful as without a structured approach the initiatives and goals will fail.

Change theory includes Mr. Lewin’s use of unfreezing, moving, and refreezing. Unfreezing is to

identify the issues and assess need for change. Moving is the interventions needed for a plan to

be created and put into effect. Refreezing the plan is in place, the changes have been made and a

new normal is established (Cummings, Bridgman, & Brown, 2016).

Leading change is a challenge for leaders with the intricacies and challenges of ever-

changing health care environments to ensure quality patient care. Rogers’ Innovation Diffusion

Theory includes five stages include knowledge, persuasion, decision, implementation, and

confirmation (Udod & Wagner, 2018). Leaders using the change theory and the five steps of

Rogers’ theory will be able to ignite change, address strengths and weaknesses of the team,

encourage the team to incorporate interventions to achieve the goals. Leaders need to be able to

adapt and use multiple types of leadership theories, have excellent listening skills, and create a

welcoming environment to encourage open, honest communication, and defuse conflict.

For this project I believe I would use Rogers’ Innovation Diffusion Theory, the first stage

is knowledge, implementing new education on technology, the need for the change, and the

initiatives, objectives and goals would be reviewed. This would encourage everyone to be ready

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8 for the change. The leaders would want to address the strengths and weakness of the staff, by

determining the staff that area already using the bar code system correctly so they can pair up

others who are not for mentoring. The idea would be to use the strength of some to overcome the

weakness of others with mentoring, peer reviews, and encouragement, this would be part of the

persuasion step. The third step is the decision, which is when the interventions are decided upon,

when the project will start. Fourth step is to implement the interventions and lastly would be to

confirm the interventions are moving the staff towards the goals set.

By implementing additional teaching on use of bar scanning system, updating the

technology to force the nurse to address the reason when the system alerts, adding triple checks

to high risk medications, encouraging nurses use Wi-Fi to address any medication they need

education on and provide that education to the patient and reporting of look alike, sound alike

drugs so the pharmacist can tag those drugs with an additional alert. By implementing these

initiatives, the 2020 data shows a 50% reduction in medication errors, errors resulting in injury

are down 66%, injury resulting in death is down 66% and correct use of bar code scanning has

improved by 60%. Please see attached spreadsheet to review the past six months and see how the

initiatives implemented has reduced errors per month.

Proposed plans will be shared with all stakeholders either in a staff meeting or

electronically. During the group presentation, the need for change will be addressed,

interventions, objectives, and goals will be shared. Everyone present will be given an opportunity

to review the written material, ask questions and express concerns or ideas.

Conclusion

Medication errors have always been an area we can all improve on, use of technology

with bar code scanning, smart pumps, and the ability to research drug information at the bedside

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9 has reduced errors. Healthcare is an ever-changing environment; we must learn to change and

initiate policies and procedure to improve patient safety. Striving to reduce near misses and

adverse events will be a goal for every facility. We must work together to improve safety and

patient outcomes by being more diligent when administering medications.

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10 References

Agency for Healthcare Research and Quality. (n.d.a). Patient safety.

https://psnet.ahrq.gov/glossary?glossary%5B0%5D=term%3AP

American Hospital Association. (2015). Care and payment models to achieve the Triple Aim.

Retrieved from https://www.aha.org/ahahret-guides/2016-01-26-care-and-payment-

models-achieve-triple-aim-0#:~:text=Hospitals%20and%20health%20care

%20systems,designing%20new%20care%20delivery%20systems.

Bodenheimer, T and Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient

Requires Care of the Provider. The Annals of Family Medicine, 12 (6) 573-576; DOI:

https://doi.org/10.1370/afm.1713

Buljac-Samardzic, M., Dekker-van Doorn, C., & Maynard, M. T. (2018). Teamwork and

teamwork training in health care: An integration and a path forward. Group &

Organization Management, 43(3), 351-356. doi:10.1177/1059601118774669

Chassin, M., & Loeb, J. (2013). High-reliability health care: getting there from here. The

Milbank quarterly, 91(3), 459–490. https://doi.org/10.1111/1468-0009.12023

Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps:

Rethinking Kurt Lewin’s legacy for change management. Human relations, 69(1), 33-60.

Doctors Hospital. (2020). Mission and Vision. Retrieved from https://doctors-

hospital.net/about/mission-and-vision.dot

The Leapfrog Group. (2020). Hospital Safety Grade. Retrieved from

https://www.hospitalsafetygrade.org/h/doctors-hospital-of-augusta?

findBy=hospital&hospital=Doctors+Hospital+of+Augusta&rPos=237&rSort=grade

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11 Larmené-Beld, K.H.M., Alting, E.K. & Taxis, K. (2018). A systematic literature review on

strategies to avoid look-alike errors of labels. Eur J Clin Pharmacol 74, 985–993.

https://doi.org/10.1007/s00228-018-2471-z

Patient Safety Network (PSA). (2019). Medication Errors and Adverse Drug Events. Retrieved

from https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

Rodziewicz L., Hipskind J. (2020). Medical Error Prevention. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK499956/

Salmond, S. W., & Echevarria, M. (2017). Healthcare Transformation and Changing Roles for

Nursing. Orthopedic nursing, 36(1), 12–25.

https://doi.org/10.1097/NOR.0000000000000308

Tariq, A., Vashisht, R., Scherbak, Y. (2020). Medication Errors. StatPearls Publishing. Retrieved

from: https://www.ncbi.nlm.nih.gov/books/NBK519065/

Udod, S., & Wagner, J. (2018). Common Change Theories and Application to Different Nursing

Situations. Leadership and Influencing Change in Nursing.

Upadhyay, S. (2020). Keeping patients safe: How has the patient safety movement evolved in the

U.S.? Patient Safety & Quality Healthcare. Retrieved from

https://www.psqh.com/analysis/keeping-patients-safe-how-has-the-patient-safety-

movement-evolved-in-the-u-s/

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