· Write an executive summary, 4-5 pages in length, of existing out.docx

· Write an executive summary, 4-5 pages in length, of existing
outcome measures related to a performance issue uncovered in
your gap analysis that you intend to address.
Introduction
Note: Each assessment in this course builds on the work you
completed in the previous assessment. Therefore, you must
complete the assessments in this course in the order in which
they are presented.
As a nurse leader, you must be able to access, identify, and
describe outcome measures as they relate to safety and quality
problems in your organization.
This assessment provides an opportunity to examine existing
outcome measures, assess their strategic value, and present your
findings to executive leaders in a manner that will help you gain
their support.
Quality and safety are everyone's responsibility as a team of
interprofessional care delivery partners. Together we develop
policies that support quality and safe care delivery. As part of
the interprofessional team, nurses are leaders in care and thus
are responsible and accountable for leading and providing safe
quality care.
Health care delivery is structured around evidenced-based
information. Quality is defined by exploring proven, evidenced-
based information. After reviewing and defining evidenced-
based information, the interprofessional team applies this
knowledge to assess the organization's or the practice setting's
ability to provide evidenced-based care delivery. When a gap in
care is identified, it is important to propose an evidenced-based
change and to execute a plan for improved care.
Your summary of relevant outcome measures is based on your
findings from the quality and safety gap analysis you completed
in the previous assessment.
Preparation

Your analysis of the gap between current and desired
performance was the first step toward improving outcomes. You
now have the information you need to move forward with
proposed changes. Your next step is to focus on existing
outcome measures and their relationship to the systemic
problem you are addressing. For this assessment, you have been
asked to draft a summary of existing outcome measures for your
organization's executive team to raise awareness of the problem
and the strategic value of existing measures.
Note: As you revise your writing, check out the resources listed
on the Writing Center's
Writing Supportpage.
As you prepare to complete this assessment, you may want to
think about other related issues to deepen your understanding or
broaden your viewpoint. You are encouraged to consider the
questions below and discuss them with a fellow learner, a work
associate, an interested friend, or a member of your professional
community. Note that these questions are for your own
development and exploration and do not need to be completed
or submitted as part of your assessment.
Building stakeholder support is crucial to fostering and
sustaining change. Therefore, as you approach this assessment,
think about the stakeholders whose support you will need for
the change you want to bring about.
· What information is most essential for both the formal and
informal stakeholders to understand about the proposed change?
· How might you communicate the need for change using just a
few sentences (this is often referred to as an "elevator speech").
The following resources are required to complete the
assessment.
·
APA Style Paper Tutorial [DOCX]. Use this for your
executive summary.
Requirements

Note: The requirements outlined below correspond to the
grading criteria in the Executive Summary Scoring Guide. Be
sure that your written analysis addresses each point, at a
minimum. You may also want to read the Executive Summary
Scoring Guide and
Guiding Questions: Executive Summary [DOCX] to
better understand how each criterion will be assessed.
Composing the Executive Summary
· Explain key quality and safety outcomes.
· Determine the strategic value to an organization of specific
outcome measures.
· Analyze the relationships between a systemic problem in your
organization or practice setting and specific quality and safety
outcomes.
· Determine how specific outcome measures support strategic
initiatives related to a quality and safety culture.
· Determine how the leadership team would support the
implementation and adoption of proposed practice changes
affecting specific outcomes.
Writing and Supporting Evidence
· Write clearly and concisely, using correct grammar and
mechanics.
· Integrate relevant and credible sources of evidence to support
assertions, correctly formatting citations and references using
APA style.
Additional Requirements
Format your document using APA style.
· Use the
APA Style Paper Tutorial [DOCX]. Be sure to include:
11. A title page and reference page. An abstract is not required.
11. A running head on all pages.
11. Appropriate section headings.
11. Properly-formatted citations and references.
· Your summary should be 4–5 pages in length, not

including the title page and reference page.
Portfolio Prompt: You may choose to save your executive
summary to your
ePortfolio.
Competencies Measured
By successfully completing this assessment, you will
demonstrate your proficiency in the following course
competencies and assessment criteria:
· Competency 1: Analyze quality and safety outcomes from an
administrative and systems perspective.
13. Explain key quality and safety outcomes.
13. Analyze the relationships between a systemic problem in an
organization and specific quality and safety outcomes.
· Competency 2: Determine how outcome measures promote
quality and safety processes within an organization.
14. Determine how specific outcome measures support strategic
initiatives related to a quality and safety culture.
· Competency 3: Determine how specific organizational
functions, policies, processes, procedures, norms, and behaviors
can be used to build reliability and high-performing
organizations.
15. Determine the strategic value to an organization of specific
outcome measures.
· Competency 4: Synthesize the various aspects of the nurse
leader's role in developing, promoting, and sustaining a culture
of quality and safety.
16. Determine how a leadership team would support the
implementation and adoption of proposed practice changes
affecting specific outcomes.
· Competency 5: Communicate effectively with diverse
audiences, in an appropriate form and style, consistent with
applicable organizational, professional, and scholarly
standards.
17. Write clearly and concisely, using correct grammar and
mechanics.

17. Integrate relevant and credible sources of evidence to
support assertions, correctly formatting citations and references
using APA style.
POSITIVE SOCIAL CHANGE
Nursing, at its very core, is a profession rooted in social change
and growth. As a nurse returning to school to further your
education, you can learn to enhance your practice to become a
“Walden Scholar of Change.” The nursing professional holds a
responsibility to serve the interests of people and society. As
part of this responsibility, nurses are bound by Nursing’s Social
Policy Statement. Consider how your own professional practice
can expand in shaping the future of nursing, improving the
profession, and enhancing the quality of the health care that
nursing delivers.
Assignment: 2-to-3-page Paper
· In this Assignment, you will discuss how furthering your
nursing education, with a focus on social change, will enhance
your current practice and supports your future career planning.
Nursing’s Social Contract entails expectations between the
nursing profession and society to elevate the health of society.
· Choose 2 of Nursing’s Social Contract elements and discuss
how they are foundational to your nursing practice. Elements
include caring service; privacy of the patient; knowledge, skill,
and competence; hazardous service; responsibility and
accountability; progress and development; ethical practice;
collaboration; promotion of the health of the public; etcetera.
· Address your future career planning. How do you intend to
make a difference by confronting a current challenge in health
care where you live, in your profession, or on a global scale?
· Support your responses with at least two scholarly sources
from the Learning Resources and/or outside sources. Reference
in proper APA format.

Running Head: MEDICATION ERRORS 1
Executive Summary- Medication Errors
Kathryn Forsyth
Capella University
HealthCare Quality Safety Management
July, 2020
Proprietary
This study source was downloaded by 100000855641916 from
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MEDICATION ERRORS 2
Executive Summary- Medication Errors
Medication administration continues to be an issue, from start
to finish, errors can occur.

The bedside nurse if responsible for about a quarter of medicine
errors as they happen during the
administration phase (Armstrong et al, 2017). Medication
administration is a multistep process
that requires clinical judgements, professional care, and
analytical thinking. Medication
administration often happen is a busy environment, nurses must
be able to manage multitasking
while upholding patient safety and clinical skill (Armstrong et
al, 2017). Currently medication
errors are under reported, researched, and recognized and this
needs to be addressed.
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). Factors to
address when developing a plan to reduce medication errors
include increasing reporting without
punishment, when and where did the error occur, and how many
changes did the staff have to
prevent the error. Creating quality initiatives, improvement
strategies, new policies and

procedures are ways to decrease medication errors.
Administration and leadership should use
each near miss and adverse event as a teaching opportunity with
the staff and determine how the
error can be prevented in the future.
Many healthcare organizations have banded together to research
ways to decrease
medication errors. Nurse education is an ongoing process as
there are new medications with look
alike, sound alike names. Understanding the cause of
medication errors will improve the nurse’s
knowledge and provide nurses the ability to learn from
mistakes. About 5% of medication
adverse events are related to a lack of nurse knowledge related
to the medication (Patient Safety
Network, 2019). Nurses should always look up information on
any drug they are unfamiliar with
and be encouraged to ask questions to try to reduce these
events. Use of technology has also

MEDICATION ERRORS 3
decrease medication errors by using the barcode to scan the
patient arm band and the medication
to prevent errors by verifying the right patient is getting the
right medication at the correct time
(Alotaibi & Federico, 2017). Adding healthcare technology has
reduced the near miss and
adverse events however all healthcare staff must not rely in the
technology and continue to use
their knowledge, double check system, and allow the computer
to be the verification of the
information we have already verified.
Analyzing the Issue
Medication adverse events and near misses are costly to the
facility and insurance
companies. Approximately 400,000 hospitalized patients per
year experience some type of
preventable harm, with a result in approximately 100,000 people
dying as a result each year.
These errors cost about $20 billion dollars per year which
creates a financial burden, some errors

that cause death or cause long term effects can lead to legal risk
that will only increase the
financial burden (Rodziewicz & Hipskind, 2020). Many
agencies are blaming the system for
medication errors as the staff are required to work long hours,
often interrupted with
administering medication, and having to multitask. By not
blaming the person, more events can
be reported without fear of retaliation and policies and
procedures can be updated as we always
learn from the mistakes we make.
The systemic issues is with drug packaging, “The American
Food and Drug
Administration (FDA) estimated that 20% of medication errors
may be attributed to confusing
packaging and poor labeling; others suggested even higher
rates” (Larmené-Beld, Alting, &
Taxis, 2018, page 1). Many drugs have look alike labels, names,
and packaging. The primary
labels on the medication containers is very important as
administering the incorrect drug can
have serious consequences for the patient. There have been
many measures suggested to enhance
the improvement of being able to read the of labels and reduce

errors related to look-alike labels.
MEDICATION ERRORS 4
Use of technology is one option that most hospitals have
already implemented which is the a
closed-loop system with barcode technology. Another
suggestion is the use of 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). Administration and
leadership at our local hospitals are
encouraging nurses to report look alike, sound alike drugs to aid
in the fight to get labels and
names changed to make it easier to differentiate between drugs.

The current unit we are evaluating is a 50 bed burn unit,
statistics show in the past six
months there has been an increase in administering the wrong
drug by 40%, right timeframe by
35%, and the wrong route by 16%. Nurses have attributed these
errors to a few issues that
include distractions, lack of drug knowledge, and not enough
information provided by the
prescriber. Medication errors is trending upwards on this unit
and the plan is to address the need
for new interventions, education, and improving use of
technology to reduce errors. This unit has
also had an influx of new graduate nurses which could be
another reason for the increase in
errors.
Effects of ongoing medication errors include increase cost of
healthcare, increased length
of stay related to adverse medication events, legal issues from
events that lead to long term
complications or death. This causes a huge financial burden and
reportedly costs up to $20
billion dollars per year (Rodziewicz & Hipskind, 2020).Most
medication errors are preventable

and that is what this plan is addressing, ways to decrease harm
to patients, improve patient
outcomes, decrease healthcare costs and try to prevent legal
issues which increase overall cost to
the facility.
Safety Culture
MEDICATION ERRORS 5
By creating a safe environment for reporting of medication
errors, adverse events, and
near misses we are improving communication between
everyone. As previously stated in this
paper, we can all learn from mistakes that we make or others
make. A safe cultural is comprised
of several elements to include a just culture, engaged
leadership, and complexity and improving
the of environment of care. Just culture understands that even
the best, smartest individuals make

mistakes however there is no tolerance for behaviors that are
repeated or violates policies and
procedures. People are not punished for making errors or
voicing concerns but there is a clear
accountability principle. Engaged leadership as the force behind
a safe culture. Leaders should
make safety part of the daily dialog and be addressed at each
meeting. Leaders should encourage
staff to share concerns to allow a flow of information from staff
to leaders and back. Leaders
should have clear expectations, support reporting of adverse
events to patient and family and by
having a non-disciplinary response for those who self report or
share concerns related to patient
safety. Understanding that healthcare is complex with many
interdependent parts that can
continue to run even when someone goes to lunch, calls out, or
the unit is short staffed. The unit
adapts to changes however sometimes a gap is left, which then
causes nurses to alternate their
normal delivery of care, this increasing the risk for errors. An
organization willing to discuss and
face problems is one way to identify emerging issues that could
cause harm (Hemphill, 2015).

Best practice uses patient-centered quality initiatives focus on
the analysis of the issues
and how best to become a High Reliability organization and
obtain a Triple Aim framework.
Both address quality improvement initiatives to reduce possible
patient injury and improve
patient safety. By using High Reliability and Triple Aim
framework, we are seeing quality
interventions that improve patient outcomes, satisfaction,
decrease mortality rates and
medication errors (Bodenheimer & Sinsky, 2014).
MEDICATION ERRORS 6
Currently, the facility is using the bar code system which helps
reduce medication errors
when used correctly, additional education is needed on correct
use the scanner. The unit has

implemented the double check system with allowing the
computer to be the triple check. We can
never replace nurse knowledge with computer as there are many
things to take into consideration
when administering medications. Also, by increasing nursing
education on pharmacology,
encouraging asking questions, self reporting without fear of
punishment we learn the core reason
for the error to better create an initiative to prevent the error in
the future. Currently the
multidisciplinary group is working on a standard way of
reporting using the SBAR system
specifically for the burn unit however this could be modified to
fit another unit needs as well.
Leadership has stepped up to provide support, an environment
that encourages nurses to ask
questions, self-report errors, and voice any concerns. By
working as a team, we will improve our
knowledge, procedures and decrease errors.
Leadership in a pivotal role in implementing quality
improvement and keeping the team
engaged on the goal. Transformational leadership is a leader
with a vision for the team who can
stimulate others in a clear and concise but also appreciative of

the individual team members.
Transactional leaders influence their followers based on
providing rewards for a job well done
and in response to their achieved defined goals (Saravo, Netzel,
& Kiesewetter, J. 2017). Lack of
leadership can result in failure of implementing the initiatives,
reaching objective, and not
meeting goals. Barriers may limit the nurse ability to provide
quality patient care, these barriers
could be placed by leadership, management, administration, and
other healthcare personnel
(Bodenheimer & Sinsky, 2014).
Outcomes measures will support the ongoing use of technology,
triple check, increased
communication skills, standardized reporting by having a
decrease in medication errors by ten
percent within the first month. This will be an ongoing process,
so leaders will have to keep the

MEDICATION ERRORS 7
staff motivated to incorporate the changes into their daily
routines. Once habits are formed, we
expected medication errors to drop significantly withing 90
days.
Conclusion
Medication administration remains an area that constant quality
improvements are needed
to decrease harm and improve patient outcomes. By using
technology to create a system to verify
the right patient, right time and right dose medication errors
have decreased. Creating a culture
of safety for staff to self report and express themselves, we are
improving communication and
allowing others to learn from mistakes. This allows gives an
opportunity to research why the
error occurred and create a plan to prevent the error in the
future. Having strong leadership will
increase staff participation in interventions and will improve
patient care and satisfaction.
Quality and safety of healthcare is a result of interventions,
objectives, and goals to work

towards decreasing medication errors by all staff members. This
will have a direct positive
impact on all stakeholders.
MEDICATION ERRORS 8
References:
Alotaibi, Y. K., & Federico, F. (2017). The impact of health
information technology on patient
safety. Saudi medical journal, 38(12), 1173–1180.
https://doi.org/10.15537/smj.2017.12.20631
Armstrong, G., Dietrich, M., Norman, L., Barnsteiner, J. &
Mion, L. (2017). Nurses' Perceived
Skills and Attitudes About Updated Safety Concepts. Journal of
Nursing Care Quality,
32(3), 226–233. doi: 10.1097/NCQ.0000000000000226.
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
Hemphill R. R. (2015). Medications and the Culture of Safety :
Conference Title: At the
Precipice of Quality Health Care: The Role of the Toxicologist
in Enhancing Patient and
Medication Safety Venue ACMT Pre-Meeting Symposium, 2014
North American
Congress of Clinical Toxicology, New Orleans, LA. Journal of
medical toxicology :
official journal of the American College of Medical Toxicology,
11(2), 253–256.
https://doi.org/10.1007/s13181-015-0474-z
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
MEDICATION ERRORS 9
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/
Saravo, B., Netzel, J., & Kiesewetter, J. (2017). The need for
strong clinical leaders –
transformational and transactional leadership as a framework
for resident leadership
training. PLoS One, 12(8)
doi:http://dx.doi.org.library.capella.edu/10.1371/journal.pone.0

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