NURS-FPX 4020 – Assessment 1: Enhancing Quality and Safety

Assessment overview

For Assessment 1, write a focused 3–5 page paper that analyzes a medication-administration safety risk in your chosen practice setting and links it to a realistic quality-improvement (QI) initiative aimed at enhancing patient safety and reducing costs. Work from a specific, concrete situation rather than a generic description.

Assessment context

Medication-administration errors remain among the most common and preventable causes of patient harm in hospitals and other care settings, with issues such as look-alike/sound-alike drugs, high-alert medications, workflow interruptions, and technology workarounds undermining safety. Nurses are often the last checkpoint in the medication-use process, so your ability to recognize risks, apply evidence-based strategies, and collaborate with interprofessional stakeholders is central to improving quality and safety outcomes.

Assessment instructions

1. Select a practice setting and safety issue

• Choose a real or realistically constructed practice setting (for example, an acute care medical-surgical unit, emergency department, long-term care facility, home-care service, or ambulatory clinic).
• Identify one specific medication-administration safety risk in this setting, such as:
  • High-alert medications (for example insulin, anticoagulants, opioids).
  • Look-alike/sound-alike medications and storage or labeling issues.
  • Workflow interruptions during the “five rights” of medication administration.
  • Nonadherence to bar-code medication administration (BCMA) procedures or other technology workarounds.
  • Communication breakdowns in verbal or telephone orders.

2. Analyze the medication-administration safety risk

In the body of your paper, provide a clear, evidence-informed analysis of the safety issue and its contributing factors.

1. Describe the practice context and safety concern.
   • Briefly outline the unit or setting, typical patient population, and relevant organizational characteristics (for example staffing patterns, technology in use, or safety culture indicators).
   • Describe the medication-related safety risk or event in precise terms, including what happened or could happen and who is affected.
2. Explain contributing factors and potential outcomes.
   • Analyze human factors (for example fatigue, interruptions, knowledge gaps), system factors (for example policies, procedures, workflow design), and environmental factors (for example noise, layout, technology usability) that contribute to the risk.
   • Discuss potential consequences for patients, nurses, the organization, and costs if the safety issue is not addressed.

3. Propose an evidence-based quality-improvement initiative

Develop a realistic QI initiative that directly targets the identified medication-administration safety risk, integrating current best evidence and professional standards.

1. Summarize relevant evidence and standards.
   • Identify current evidence-based guidelines, systematic reviews, or practice standards that address the type of medication-safety problem you selected (for example QSEN safety competencies, national medication-safety alerts, professional position statements).
   • Explain how this evidence supports specific changes in practice, workflow, or technology use within your setting.
2. Outline the QI initiative.
   • Describe a focused QI initiative that you could implement to mitigate the safety risk (for example BCMA compliance audit and feedback, standardized double-check process for high-alert medications, medication-safety huddles, redesign of medication-room layout, or targeted staff education with simulation).
   • Specify key activities, resources required, basic timeline, and how success would be measured (for example reduction in near-miss reports, improved adherence rates, decreased adverse drug events, or cost savings).

4. Examine nurse and stakeholder roles in enhancing safety and reducing costs

Link your QI initiative to interprofessional collaboration, coordination of care, and cost implications.

1. Identify relevant stakeholders.
   • Identify at least three stakeholders (for example bedside nurses, nurse managers, pharmacists, prescribers, quality and safety officers, informatics or IT staff, patients and families) who are critical to the success of the initiative.
   • Describe each stakeholder’s role in implementing, sustaining, and evaluating the safety intervention.
2. Discuss quality, safety, and cost outcomes.
   • Explain how the proposed initiative is expected to improve patient safety and quality of care (for example fewer errors, improved patient satisfaction, stronger safety culture).
   • Analyze how preventing medication errors can reduce direct and indirect costs for the organization (for example avoided readmissions, reduced length of stay, lower liability, more efficient use of staff time).

5. Academic writing and format requirements

• Length: 3–5 pages of scholarly narrative (excluding title page and reference list).
• Format and style: Use current APA style for formatting, in-text citations, and references.
• Sources: Include at least 3–5 current, peer-reviewed scholarly sources published between 2018 and 2026 that directly support your analysis of medication safety and quality-improvement strategies.
• Writing quality: Organize the paper logically with clear headings, precise language, and careful proofreading to demonstrate professional communication consistent with BSN expectations.

Scoring guide (marking criteria)

Criterion 1: Explain a medication-administration safety risk in a specific practice setting

• Exemplary: Provides a clear, nuanced explanation of a well-defined medication-administration safety risk within a specific practice context, integrating organizational details and patient-population characteristics to show why the issue is significant.
• Proficient: Clearly describes a medication-administration safety risk and basic contextual factors.
• Needs improvement: Description is vague, generic, or missing critical contextual details.

Criterion 2: Analyze factors that contribute to the safety risk and potential outcomes

• Exemplary: Critically analyzes human, system, and environmental factors contributing to the safety risk and clearly connects them to plausible patient, staff, organizational, and cost outcomes, supported by current evidence.
• Proficient: Identifies and explains key contributing factors and outcomes with reasonable clarity.
• Needs improvement: Limited or superficial analysis of contributing factors and outcomes, or minimal use of evidence.

Criterion 3: Propose an evidence-based quality-improvement initiative

• Exemplary: Proposes a coherent, realistic QI initiative that clearly targets the identified medication-safety risk, aligns with current best evidence and professional standards, and specifies activities, measures, and expected results.
• Proficient: Describes a plausible QI initiative supported by appropriate evidence.
• Needs improvement: Initiative is vague, poorly aligned with the safety risk, or lacks clear evidence base and outcome measures.

Criterion 4: Explain how nurses and stakeholders collaborate to enhance safety and reduce costs

• Exemplary: Clearly articulates how nurses and interprofessional stakeholders coordinate care, share responsibility, and use QI processes to improve medication safety and generate cost benefits, integrating specific examples and evidence.
• Proficient: Identifies key stakeholders and explains their roles in improving safety and reducing costs.
• Needs improvement: Stakeholders are incompletely identified, or their roles and cost implications are minimally developed.

Criterion 5: Demonstrate scholarly, professional writing in APA style

• Exemplary: Writing is logically organized, concise, and precise, with virtually no grammatical or spelling errors; citations and references consistently follow current APA style.
• Proficient: Writing is generally clear and mostly free of errors; APA style is mostly correct.
• Needs improvement: Frequent errors in mechanics or APA style that interfere with clarity or professional tone.

A focused analysis of medication-administration safety reveals how frequent workflow interruptions during high-alert drug preparation increase risk for dosing errors and near-miss events in busy acute care units. Aligning a bar-code medication administration compliance initiative with evidence-based safety guidelines and interprofessional collaboration allows nurses, pharmacists, and leaders to systematically reduce preventable harm and associated costs. Positioning the bedside nurse as a central change agent within this quality-improvement effort demonstrates how frontline practice decisions intersect with organizational policies and patient outcomes in measurable ways.

Study Materials

• Agency for Healthcare Research and Quality (AHRQ) 2019, Patient safety and medication errors, AHRQ Patient Safety Network, viewed 19 January 2026, <https://psnet.ahrq.gov/>.
• Grissinger, M 2020, ‘The five rights: A destination without a map’, P&T, vol. 45, no. 10, pp. 620–622, viewed 19 January 2026, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605436/>.
• Manias, E, Kusljic, S & Wu, A 2020, ‘Interventions to reduce medication errors in adult intensive care: A systematic review’, British Journal of Clinical Pharmacology, vol. 86, no. 3, pp. 401–415, doi:10.1111/bcp.14143.
• Rodziewicz, TL, Houseman, B & Hipskind, JE 2023, ‘Medical error reduction and prevention’, in StatPearls, StatPearls Publishing, Treasure Island (FL), viewed 19 January 2026, <https://www.ncbi.nlm.nih.gov/books/NBK499956/>.
• Schutijser, B et al. 2019, ‘The effect of bar‑code medication administration (BCMA) on medication administration errors: A systematic review’, BMJ Quality & Safety, vol. 28, no. 7, pp. 593–602, doi:10.1136/bmjqs-2018-008455.

Enhancing Quality and Safety: Reducing Workflow Interruptions During Insulin Administration in an Acute Care Setting

Introduction

Medication administration errors represent a leading cause of preventable patient harm in healthcare settings. In acute care environments, high-alert medications such as insulin pose significant risks due to potential for severe hypoglycemia or hyperglycemia if dosing errors occur. This paper examines workflow interruptions during insulin preparation and administration in a busy medical-surgical unit as a key safety risk. It analyzes contributing factors and outcomes, proposes an evidence-based quality improvement (QI) initiative integrating bar-code medication administration (BCMA) compliance and interruption reduction strategies, and discusses interprofessional collaboration to enhance safety and reduce costs.

Practice Context and Safety Concern

The practice setting is a 32-bed medical-surgical unit in a mid-sized urban hospital, serving primarily adult patients with chronic conditions such as diabetes, cardiovascular disease, and postoperative recovery needs. The unit operates with a nurse-to-patient ratio of 1:5–6 during day shifts, uses electronic health records (EHR) with BCMA technology, and has a moderate safety culture with voluntary error reporting. Patients often require multiple medications, including high-alert drugs like insulin for glycemic control.

A common safety concern involves workflow interruptions during insulin administration. For example, a bedside nurse preparing subcutaneous insulin for a patient with type 2 diabetes may be interrupted by call lights, physician inquiries, or colleague requests, leading to omitted double-checks or incorrect dosing. Interruptions disrupt adherence to the “five rights” of medication administration (right patient, drug, dose, route, time), increasing near-miss events or actual errors such as administering the wrong dose. This affects patients (risk of adverse events), nurses (increased stress), and the organization (potential for harm).

Contributing Factors and Potential Outcomes Interruptions stem from human, system, and environmental factors. Human factors include fatigue from high patient loads and cognitive overload during multitasking. System factors encompass inadequate policies for protected administration time and workflow designs that fail to prioritize critical tasks. Environmental factors involve noisy unit layouts, frequent alarms, and lack of dedicated “do not interrupt” zones during medication passes (Rodziewicz et al., 2023). Evidence shows each interruption raises procedural failures by 12.1% and clinical errors by 12.7%, particularly with high-alert medications (from PSNet summaries on interruptions).

If unaddressed, consequences include patient harm (e.g., severe hypoglycemia requiring rescue treatment or prolonged hospitalization), nurse burnout, organizational liability, and costs. Preventable adverse drug events from medication errors contribute to extended stays and add billions in annual U.S. healthcare expenses, with estimates of $20–40 billion yearly from errors, including prolonged care and readmissions (Rodziewicz et al., 2023; AHRQ resources).

Evidence-Based Quality-Improvement Initiative

Relevant evidence supports targeted interventions for medication safety. The QSEN safety competencies emphasize recognizing human limits and designing systems to prevent errors. Systematic reviews highlight BCMA’s role in reducing administration errors by verifying identity and dose, though compliance varies due to workarounds (Schutijser et al., 2019, though access limited; supported by AHRQ PSNet). Guidelines from the Institute for Safe Medication Practices (ISMP) classify insulin as high-alert, recommending safeguards like independent double-checks and minimized distractions. Interventions reducing interruptions show promise in lowering error rates (Manias et al., 2020).

The proposed QI initiative is a “Protected Medication Pass with BCMA Enhancement” program. Key activities include: (a) staff education on interruption management and BCMA adherence via simulation training; (b) implementing “do not interrupt” protocols (e.g., visual cues like sashes during passes); (c) monthly BCMA compliance audits with feedback; and (d) interprofessional huddles to address workflow barriers. Resources needed: educator time, simulation equipment, audit tools (approx. $5,000 initial). Timeline: 3-month planning/education, 6-month implementation, ongoing evaluation. Success measures: BCMA compliance >95% (from audits), 30% reduction in interruption-related near-miss reports, decreased hypoglycemic events, and cost savings from avoided ADEs.

Nurse and Stakeholder Roles in Enhancing Safety and Reducing Costs Successful implementation requires collaboration among stakeholders. Bedside nurses lead by modeling protected passes and reporting interruptions. Nurse managers oversee policy enforcement, scheduling adjustments, and audit reviews. Pharmacists provide expertise on high-alert protocols and double-check processes. Quality/safety officers guide data tracking and align with standards like ISMP guidelines.

The initiative improves safety by reducing errors, enhancing patient satisfaction, and fostering a stronger safety culture (Grissinger, 2020). Preventing errors avoids direct costs (e.g., treatment for hypoglycemia) and indirect costs (e.g., reduced length of stay, lower liability, efficient staff time). Evidence indicates preventing ADEs can save thousands per event through avoided readmissions and complications (Rodziewicz et al., 2023).

Conclusion

Workflow interruptions during insulin administration in acute care units heighten risks for dosing errors with high-alert medications. A targeted QI initiative combining interruption reduction and BCMA compliance, grounded in evidence, empowers nurses as change agents while engaging interprofessional stakeholders to improve safety and generate cost savings. Implementing such strategies aligns frontline practice with organizational goals for measurable patient outcomes.

References

Agency for Healthcare Research and Quality. (2019). Patient safety and medication errors. AHRQ Patient Safety Network. https://psnet.ahrq.gov/

Grissinger, M. (2020). The five rights: A destination without a map. P&T, 45(10), 620–622. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605436/

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult intensive care: A systematic review. British Journal of Clinical Pharmacology, 86(3), 401–415. https://doi.org/10.1111/bcp.14143

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Schutijser, B., et al. (2019). The effect of bar-code medication administration (BCMA) on medication administration errors: A systematic review. BMJ Quality & Safety, 28(7), 593–602. https://doi.org/10.1136/bmjqs-2018-008455

# Sample Answer

Barcode Medication Administration Compliance:

Reducing High-Alert Drug Errors in Acute Care

Student Name

Capella University

NURS-FPX 4020: Improvement of Quality and Safety

Instructor Name

January 28, 2026

 

Barcode Medication Administration Compliance: Reducing High-Alert Drug Errors in Acute Care

Medication errors account for roughly one in five adverse events in hospital settings, with high-alert drugs such as insulin, anticoagulants, and opioids involved in a disproportionate share of serious harm cases (Manias, Kusljic & Wu 2020). Barcode medication administration (BCMA) technology was designed to serve as a final safety check at the point of care, yet compliance rates frequently fall below 90 per cent on busy medical-surgical units (Schutijser et al. 2019). Workflow interruptions, time pressures, and workarounds undermine the protective effect these systems were built to provide. A 36-bed general medical-surgical unit at a regional teaching hospital faced exactly these challenges during the first quarter of 2025, recording 14 near-miss events involving high-alert medications and a BCMA override rate averaging 18 per cent. Staff reported that competing demands during peak hours made it tempting to bypass scanning steps, especially when patients lacked readable wristbands or when medication labels were damaged or missing.

Practice Context and Safety Concern

The unit serves an adult population with mixed diagnoses, averaging 28 occupied beds on day shifts and operating with a nurse-to-patient ratio of 1:5. BCMA technology has been standard practice since 2019, integrated with the electronic health record and supported by automated dispensing cabinets on each wing. Despite initial training and periodic reminders, audits conducted in January 2025 revealed that nurses bypassed barcode scanning in nearly one of every five high-alert drug administrations. Common reasons included damaged patient wristbands, last-minute dose changes that had not yet updated in the system, and interruptions by physicians or family members during the medication pass. Nurses described feeling torn between completing the scan and responding to urgent patient needs, often choosing speed over protocol adherence.

High-alert medications involved in near-miss reports included subcutaneous insulin, intravenous heparin boluses, and oral anticoagulants. In two documented cases, doses were prepared for the correct patient but nearly administered to the patient in the adjacent bed when scanning was skipped. Both errors were caught by a second nurse or by the patient questioning the medication, but they highlighted how quickly wrong-patient administration can occur without the BCMA safety net. Staff openly acknowledged the problem during unit meetings, noting that busy mornings and understaffing made it harder to follow every step of the five rights when multiple patients required attention at once.

Contributing Factors and Potential Outcomes

Human factors played a central role in BCMA non-compliance. Cognitive load increases when nurses manage multiple patients with complex medication regimens, and interruptions fragment attention, raising the likelihood of procedural shortcuts (Grissinger 2020). Staff reported that workarounds became normalized over time, with newer nurses observing senior colleagues bypass scanning and interpreting that behaviour as acceptable. Environmental factors also contributed. The medication room layout placed barcode scanners at the far end of the prep counter, forcing nurses to carry prepared doses several steps before scanning. Background noise from overhead pages, call lights, and phone conversations created additional distraction during medication preparation. System-level issues included inconsistent processes for replacing damaged wristbands and delays in updating the electronic medication administration record when orders were modified at the last minute. Nurses expressed frustration that the technology sometimes lagged behind real-time clinical changes, making it feel like an obstacle rather than a support.

Potential consequences of unaddressed BCMA non-compliance are both clinical and financial. Wrong-patient or wrong-dose errors involving high-alert drugs can result in hypoglycaemia, haemorrhage, or respiratory depression, leading to extended hospital stays, ICU transfers, or permanent harm (Rodziewicz, Houseman & Hipskind 2023). Even near-miss events consume staff time for incident reporting, root cause analysis, and remedial training. Organisational costs include increased liability exposure, lower patient satisfaction scores, and damage to the unit&#x2019;s safety culture when staff perceive that protocols are optional. Research has linked improved BCMA compliance with measurable reductions in medication error rates, but only when the system is used consistently and supported by reliable workflows (Schutijser et al. 2019).

Evidence-Based Quality Improvement Initiative

Current evidence supports structured interventions that address both technical and behavioural barriers to BCMA use. Manias, Kusljic and Wu (2020) conducted a systematic review of medication-safety interventions in intensive care settings and found that compliance improved when organisations combined staff education with process redesigns that reduced workaround incentives. Schutijser and colleagues (2019) reported that BCMA error reduction depends on resolving workflow mismatches such as outdated patient information, equipment placement, and interruption patterns. These findings align with QSEN safety competencies, which emphasise minimising reliance on memory and standardising processes to decrease variation in practice (Agency for Healthcare Research and Quality 2019).

Based on this evidence, the proposed QI initiative includes three components implemented over a 12-week period. First, the unit will redesign the medication room layout to position barcode scanners directly at the preparation counter, eliminating the need to carry doses before scanning. Second, nursing staff will participate in a two-hour simulation-based training session focused on managing interruptions during medication administration, with scenarios involving high-alert drugs and competing demands. Third, the unit will implement a daily BCMA compliance huddle at shift change, during which charge nurses review override data from the previous 24 hours and address system issues such as missing wristbands or outdated orders before they lead to workarounds.

Success will be measured through weekly audits of BCMA override rates for high-alert medications, targeting a reduction from 18 per cent to below 5 per cent by week 12. Additional metrics include the number of near-miss reports involving high-alert drugs and staff feedback collected via anonymous surveys at weeks 4, 8, and 12. Cost implications will be tracked by comparing the time spent on incident investigations before and after the intervention. The initiative requires a one-time investment in medication room reorganisation, approximately eight hours of nursing time per participant for simulation training, and ongoing commitment from charge nurses to lead daily huddles.

Stakeholder Roles in Enhancing Safety and Reducing Costs

Successful implementation depends on collaboration among multiple stakeholders. Bedside nurses are the primary users of BCMA technology and the most frequent observers of workflow barriers. Their input during simulation sessions and daily huddles ensures that process changes reflect actual practice conditions. Nurse managers provide administrative support by allocating time for training, approving medication room modifications, and reinforcing the expectation that BCMA compliance is non-negotiable. Pharmacists contribute by conducting medication storage audits, ensuring that barcode labels are legible and correctly applied, and participating in huddles when system issues involve order entry or drug availability.

Quality and safety officers bring expertise in data analysis and regulatory standards, helping the unit track compliance metrics and benchmark results against similar institutions. Informatics staff play a technical role by adjusting electronic health record workflows to reduce delays between order entry and medication administration record updates. Patients and families also have a role in supporting safety by understanding why nurses scan wristbands and medications and by reporting any concerns when they observe workarounds. To be fair, engaging patients as active participants in medication safety requires clear communication about what they should expect during each medication pass.

The proposed initiative addresses both quality and cost outcomes. Improved BCMA compliance directly reduces the risk of wrong-patient and wrong-dose errors, which are among the most preventable forms of medication-related harm. Fewer errors mean fewer adverse events, lower rates of preventable readmissions, and reduced length of stay for patients who experience complications. Financial benefits include avoiding costs associated with extended hospitalisations, additional treatments required to reverse medication errors, and potential malpractice claims. Research by Rodziewicz, Houseman and Hipskind (2023) estimates that each prevented serious medication error saves hospitals between 5,000 and 50,000 dollars, depending on the severity of patient harm and required interventions. Enhanced staff confidence in safety systems also contributes to a stronger safety culture, which correlates with lower turnover and improved nurse satisfaction.

Conclusion

Barcode medication administration technology provides measurable protection against high-alert drug errors, but only when nurses use it consistently under real-world conditions. Workflow interruptions, equipment placement, and normalised workarounds create predictable compliance failures that expose patients to preventable harm. A structured QI initiative combining environmental redesign, simulation training, and daily process huddles can address these barriers systematically. Interprofessional collaboration among bedside nurses, pharmacists, managers, and informatics staff strengthens the intervention by ensuring that solutions reflect both clinical realities and system constraints. Positioning BCMA compliance as a shared responsibility rather than an individual task supports sustainable improvement in patient safety and cost reduction.

References

Agency for Healthcare Research and Quality 2019, Patient safety and medication errors, AHRQ Patient Safety Network, viewed 19 January 2026, <https://psnet.ahrq.gov/>.

Grissinger, M 2020, &#x2018;The five rights: A destination without a map&#x2019;, P&T, vol. 45, no. 10, pp. 620&#x2013;622, viewed 19 January 2026, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605436/>.

Manias, E, Kusljic, S & Wu, A 2020, &#x2018;Interventions to reduce medication errors in adult intensive care: A systematic review&#x2019;, British Journal of Clinical Pharmacology, vol. 86, no. 3, pp. 401&#x2013;415, doi:10.1111/bcp.14143.

Rodziewicz, TL, Houseman, B & Hipskind, JE 2023, &#x2018;Medical error reduction and prevention&#x2019;, in StatPearls, StatPearls Publishing, Treasure Island (FL), viewed 19 January 2026, <https://www.ncbi.nlm.nih.gov/books/NBK499956/>.

Schutijser, B et al. 2019, &#x2018;The effect of bar-code medication administration (BCMA) on medication administration errors: A systematic review&#x2019;, BMJ Quality & Safety, vol. 28, no. 7, pp. 593&#x2013;602, doi:10.1136/bmjqs-2018-008455.