Running head: QUALITY AND SAFETY GAP ANALYSIS 1
Quality and Safety Gap Analysis
Kathryn Forsyth
Capella University
Healthcare Quality Safety Management
Quality and Safety Gap Analysis
July, 2020
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QUALITY AND SAFETY GAP ANALYSIS 2
Quality and Safety Gap Analysis
Medication errors continues to be one of the most important areas to address in the
healthcare setting. These near miss or adverse events increase patient harm, reduce quality of
care, and increase healthcare costs. More common than adverse events are near misses by about
70%. Among the most common causes of death are preventable near misses and adverse events
in the United States (Nambiar, Das, & Chakravarty, 2016). This paper will review interventions
to decrease near misses and adverse events which will hopefully lead to solutions.
The process of administering medication is complex and involves multiple interactions
and high-risk activities. Errors can happen at any stage of the process, one third of errors that are
harmful to patients occur during the administration phase. Nurses administer most medications
therefore any errors that occur is the nurse’s responsibility. Nurses provide a safety against
medication errors by intercepting prescriber and pharmacists errors however they potentially
place the patient at risk as well (Cloete, 2015).
Adverse events (ADE) is related to overuse of medication, under use of medication, or
using the wrong medication. Adverse events are increasing yearly and is one of the main causes
of death for hospitalized people. Nurse turnover rates and increase nurse to patient ratio have
limited the quality of care provided by nurses. There are many responsibilities placed on nurses,
to include providing quality of care, being cost efficient, monitoring patients, checking all orders,
and verifying medications are correct. With high patient caseloads, the nurse is often tired and
that is when errors are made. One of the highest adverse events on a unit is medication errors,
which is about 50% of all mistakes reported (Nambier, 2016).
On the 50 bed burn unit in the past six months there has been an increase in administering
the wrong drug by 40% as well as an increase in administering the drug with the right time by
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QUALITY AND SAFETY GAP ANALYSIS 3
35%, the wrong route by 16%. These errors can be attributed to distractions, lack of drug
knowledge, and the physician not including enough information when writing the prescription.
This is trending upwards and this plan is to address the need to implement interventions to
address the issues. This unit has also had an influx of new graduate nurses which could be
another reason for the increase in errors. “Out of 168 participants, 55% admitted to making a
medication error. They reported the errors had resulted from lack of experience, lack of time,
unclear on the technology use, lack of adequate staffing, and needs of patients. Twenty-four
percent of the respondents did not report their errors due” (Treiber & Jones, 2018, page 277).
Plan
Due to rising medication errors, many facilities have added systems such as High
Reliability and encouraging self reporting without fear of adverse events. The application of
high-reliability principles in healthcare is being used for strategic planning. “The Joint
Commission established the Center for Transforming Healthcare to work on transforming
healthcare into a high-reliability industry. The Center and healthcare organizations work together
to analyze breakdown in care, determine underlying causes, and use the finding to educate
organizations. This effort shares data on near misses, adverse events to support learning,
prevention, and improvement” (Chochrane et al, 2017, page 63).
High reliability introduces methods to reduce ADE’s by addressing the need for
electronic checks, use of second person to verify information, and encouraging questions. Use of
the interventions in medication administration can reduce and prevent errors. This increases
safety, quality, and cost effectiveness (Hughes, 2008). High Reliability was introduced in 2013
which has led to an increase in quality of care and health initiatives (Chassin & Loeb, 2013).
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QUALITY AND SAFETY GAP ANALYSIS 4
New skills and ideas learned have been turned into sustainable improvements which has made
measurable change in medication administration (Chassin, 2013).
Most healthcare facilities are using technology to improve communication. Written
orders are often hard to read and lead to greater room for error. The electronic health records
provide legible orders, is verified by the doctor, pharmacist, and nurse. The admitting nurse also
review all medications with the patient to verify everything is correct. This ensures any missed
information is addressed, verified allergies, and decrease errors. This practice is based on high
reliability use of triple check system to improve safer health care (Chassen, 2013).
Focus for healthcare facilities should be on quality and safety of patients. Interventions
should focus on areas to reduce patient harm and increase safety (Hughes, 2008). High
Reliability not only focus’ on reducing medication errors but it addresses improving leadership,
culture of safety, and encouragement of continuous learning (Chassen, 2013). The first step of
the process is to start the triple check system, this will allow the nurse to use technology with a
fellow nurse to review the information and verify it is correct which will assist with catching
errors. Improving nurse education of pharmacology is needed for a better understanding of
medication. This will help the nurse know when to question an order and improve patient safety.
Around six percent of nurse do not have proper knowledge and understanding of medications
(Aronson, 2013).
Safer medication initiatives provider better outcomes for patients. Quality improvement
projects are dependent on ability to measure goals and self-reporting. By analyzing the data,
using statistics we can identify gaps in areas to be able to address the issues. The use of
technology has been able to better track interventions, goals, and outcomes. By using technology,
we are enabling the nurse to better care for the patient, verify information, research information
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QUALITY AND SAFETY GAP ANALYSIS 5
at bedside, and improve patient satisfaction. The focus is on interventions that improve nurse
knowledge, use of time, increase safety, and reduce near miss and adverse events.
Some barriers to the plan would include communication and a resistance to change by the
staff. Communicating with an interdisciplinary team, between staff, and with patients can be
difficult at times as there is a way a person speaks which may not be what the person
understands. We must remember to consider the ability of each person to understand what is
being said, nonmedical people will not understand medical language. To address this issue and
improve communication, the facility can use the SBAR tool. SBAR stands for situation,
background, assessment, recommendations (O'Shea & Roney, 2020). Use of the SBAR can
provide the staff with a method to provide a clear, concise report which leads to better patient
care.
Providing standard reporting tool, the nurse can provide effective communication, allows
the other party to ask questions, and have a better understanding of what is needed to be done
during their shift. This will also improve communication between nurse and patient/family. The
need to remain up to date on current evidence-based practices to improve quality, safety, patient
outcomes, and improve medication safety (Hughes, 2008). Administration needs to encourage
open, honest communication without fear of retribution to improve relationship and trust
between staff. This will improve self-reporting of near misses and adverse events that can
become teaching opportunities later.
Evidence based leadership (EBL) was created in response into organizational change to
research that identified alignment and accountability. EBL aligns all functions to prioritize goals
aligned with the mission, vision, and values of the organization. EBL is adaptable,
comprehensive, flexible, and scalable. EBL incorporates aligned goals, behaviors, and processes,
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QUALITY AND SAFETY GAP ANALYSIS 6
each with a set of tools and techniques. EBL is an integral process for culture transformation and
performance improvement, various goals and initiatives can be layered into the framework to
support the goals (Chochrane, 2017).
The organization administration and leadership are supportive of the need for new
policies and procedures related to medication administration. The need to decrease adverse
events and near misses on the burn unit is needed immediately. The first steps to implement a
double check system as well as increasing education on medications have been widely accepted
by all stakeholders. The leaders have agreed there is a need for improved communication and
will have a multidisciplinary team come up with a standard reporting tool that incorporates
SBAR.
Conclusion
Change is always challenging, however providing proper education, tools, resources, and
realistic interventions and goals can improve the willingness of staff to accept change.
Medication errors will likely always be an issue as there is a human component to medication
administration and humans make mistakes. We can implement ways to reduce errors, recognize
gaps, and improve communication to decrease errors, improve patient safety, and patient
outcomes. The healthcare system can implement safer interventions with the use of technology,
SBAR for handoffs, education, communication, and evidence-based leadership to help reduce
errors, improve communication, and potentially save lives.
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QUALITY AND SAFETY GAP ANALYSIS 7
References
Aronson, J. K. (2013). Medication errors: Definitions and classification. British Journal of
Clinical Pharmacology, 67(6), 599-604. doi:10.1111/j. 1365-2125.2009.03415.x
Chassin, M. R., & Loeb, J. M. (2013). High‐reliability health care: getting there from here. The
Milbank Quarterly, 91(3), 459-490.
Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice
(2014+), 14(1), 29. DOI:10.7748/cnp.14.1.29.e1148
Cochrane, B. S., Hagins, M., Picciano, G., King, J. A., Marshall, D. A., Nelson, B., & Deao, C.
(2017). High reliability in healthcare: Creating the culture and mindset for patient safety.
Los Angeles, CA: SAGE Publications. doi:10.1177/0840470416689314
Hughes, R. G (2008). Tools and Strategies for Quality Improvement and Patient Safety. Chapter
44. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2682/
Nambiar, B. C., Das, A. K., & Chakravarty, A. (2016). Medication error: An unfortunate reality.
Medical Journal Armed Forces India, 72(3), 297-298. doi: 10.1016/j.mjafi.2015.04.011
O'Shea, E. R. & Roney, L. N. (2020). SBAR. Nurse Educator, Publish Ahead of Print,doi:
10.1097/NNE.0000000000000887.
Treiber L., Jones J.(2018). After the Medication Error: Recent Nursing Graduates' Reflections on
Adequacy of Education. J Nurs Educ. 57(5) 275-280. doi: 10.3928/01484834-20180420-
04
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