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

Assessment 1: Enhancing Quality and Safety

Weighting: 25%

Length: 3–5 pages (excluding title and reference pages)

Format: APA 7th Edition Paper

Course Level: BSN (FlexPath)

Due Date: Flexible (Suggested: Week 2-3)

1. Assessment Context

Patient safety is a foundational element of professional nursing practice. This assessment requires you to apply the principles of safety science to a real-world clinical scenario. You will analyze a specific medication administration error or a near-miss incident, identifying the systemic and human factors that contributed to the event. By utilizing evidence-based frameworks such as the Quality and Safety Education for Nurses (QSEN) competencies, you will propose actionable interventions to enhance care quality and mitigate future risks.

2. Task Description

You are required to draft a formal paper that evaluates a patient safety risk, specifically focusing on medication administration. Your analysis must go beyond individual performance to examine the organizational culture and systems that allow errors to occur.

Section 1: Analysis of the Safety Risk

• Identify a specific medication administration safety risk or incident (you may use a personal professional experience or the provided “Vila Health” or “St. Luke’s” case studies).
• Describe the factors that contributed to the risk, including environmental distractions, communication breakdowns, and technological failures.
• Explain the impact of the error on the patient, the staff involved, and the healthcare organization’s financial and reputational standing.

Section 2: Evidence-Based Safety Interventions

• Propose two or three specific evidence-based interventions to address the identified risk. These may include Barcode Medication Administration (BCMA), Computerized Provider Order Entry (CPOE), or standardizing “quiet zones” during med passes.
• Analyze how these interventions align with QSEN competencies (specifically Patient-Centered Care and Informatics).
• Justify your choices with current peer-reviewed literature published within the last five years.

Section 3: Stakeholder Coordination and Implementation

• Identify the key stakeholders necessary for successful implementation (e.g., nurse managers, pharmacists, IT specialists, and patient advocates).
• Describe the role of interprofessional collaboration in sustaining a culture of safety.
• Discuss how you would communicate these changes to the frontline staff to ensure buy-in and compliance.

3. Submission Requirements

• Academic Tone: Maintain a professional, objective, and authoritative voice throughout the paper.
• Structure: Include a clear introduction with a thesis statement, body paragraphs with level 1 and 2 headings, and a concluding summary.
• Evidence: Cite a minimum of 3 to 5 peer-reviewed sources.
• Formatting: Standard APA 7th edition formatting (Double-spaced, 12pt Times New Roman, 1-inch margins).

4. Scoring Rubric / Marking Criteria

Criteria	Distinguished	Proficient	Basic	Non-Performance
Safety Risk Analysis (30%)	Provides a comprehensive and insightful analysis of a safety risk, identifying all relevant systemic and human factors.	Analyzes a safety risk and identifies most contributing factors.	Identifies a safety risk but the analysis is superficial or incomplete.	Does not identify or analyze a safety risk.
Evidence-Based Interventions (30%)	Proposes highly relevant, evidence-based interventions clearly linked to the identified risk and QSEN competencies.	Proposes evidence-based interventions that address the risk.	Proposes interventions that are generic or not well-supported by evidence.	Does not propose evidence-based interventions.
Stakeholder Coordination (20%)	Develops a sophisticated plan for stakeholder coordination and interprofessional collaboration to implement change.	Describes the roles of stakeholders and the importance of collaboration.	Mentions stakeholders but lacks a clear plan for coordination.	Does not address stakeholders or collaboration.
APA and Writing (20%)	Writing is flawless, professional, and adheres strictly to APA 7th edition guidelines.	Writing is clear with minor APA errors that do not distract the reader.	Frequent writing or APA errors that impede clarity.	Poor writing and lack of APA formatting.

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Healthcare leaders must prioritize the integration of safety science principles to mitigate the occurrence of adverse medication events in clinical settings. Interprofessional teams that leverage Quality and Safety Education for Nurses (QSEN) competencies significantly reduce systemic vulnerabilities and improve patient outcomes. Proactive identification of latent errors through root cause analysis allows organizations to move from a culture of blame to a high-reliability model of care. Effective application of barcoded medication administration (BCMA) technology has been shown to decrease transcription and administration errors by up to 50% in acute care environments (Watanabe et al., 2021). Nurses who champion these evidence-based interventions act as the final line of defense against patient harm while fostering a sustainable safety climate.

Learning Materials and Resources

• Armstrong, G. E. (2020) ‘Quality and Safety Education for Nurses (QSEN): The Key to Patient Safety’, Nursing Clinics of North America, 55(4), pp. 601–611. doi: 10.1016/j.cnur.2020.06.014.
• Ghasemi, M., Fazlollah, A. and Aghamohammadi, D. (2022) ‘Communication gaps among healthcare professionals and its impact on medication errors: A qualitative study’, Journal of Patient Safety and Risk Management, 27(2), pp. 88–95. doi: 10.1177/25160435221081234.
• Hassen, S. S., Belay, A. S. and Kassie, A. M. (2022) ‘Inadequate nurse training and its contribution to medication administration errors in hospital settings’, BMC Nursing, 21(1), pp. 14–22. doi: 10.1186/s12912-022-00810-w.
• Melnyk, B. M. and Fineout-Overholt, E. (2022) Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. 5th edn. Philadelphia, PA: Wolters Kluwer.
• Watanabe, M., et al. (2021) ‘Impact of Barcode Medication Administration on Nursing Workflow and Patient Safety’, The Journal of Nursing Administration, 51(12), pp. 620–626. doi: 10.1097/NNA.0000000000001089.