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

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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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).


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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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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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


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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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



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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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:

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:


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-



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