Goal:To assess a clinical issue that is the focus of the Quality Improvement Project.Create a SWOT (strengths, weaknesses, opportunities, threats) analysis for the project.Content Requirements:Identify strengths, weakness, opportunities, and threats for improvement related to the clinical issue identified.Analyze the SWOT data to provide the foundation for an action plan for quality improvement.Submission Instructions:The paper is to be clear and concise, and students will lose points for improper grammar, punctuation and misspelling.The paper is to be 2 – 3 pages in length, excluding the title, abstract and references page.Incorporate a minimum of 3 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.Journal articles and books should be referenced according to current APA style (the library has a copy of the APA Manual).Your paper should be formatted per current APA and references should be current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions)1
Quality Improvement Project
Norma Cruz Handy
St. Thomas University
Prof. Roseann Fibbio
Nov. 13, 2022
Quality Improvement Project
1. Identify the clinical issue that will be the focus of your Quality Improvement
Healthcare settings experience clinical issues that affect patient safety and health
outcome. In this assessment, the clinical issue to be considered is medication errors. Typically, a
medication error refers to any preventable event that may result in the use of inappropriate
medication by patients, thus causing harm (Assiri et al., 2018). Medication errors occur through
omission, prescribing, use of unauthorized drugs, taking medications at the wrong time, improper
dose, and wrong dose preparation or prescription. Thus, medication errors should be addressed in
the quality improvement project to reduce negative consequences. Medical errors are also mainly
caused by a lack of support staff, interruptions, complex workloads, similar drug names, illegible
handwriting, and inadequate time to counsel patients (Assiri et al., 2018). The quality
improvement project should therefore focus on how to prevent and reduce risks of medication
errors to ensure patient access to quality and safe care.
2. Provide a rationale for the need to change the status quo.
Changing the existing state of affairs regarding medication errors as a clinical issue is
essential. The first rationale for changing or addressing medication errors is reducing the risk
associated with medication errors. For example, medication errors increase hospital admissions
and readmissions. Therefore, changing the status quo will ensure that medication errors reduce,
thus significantly reducing the number of patients readmitted to hospitals after discharge.
Secondly, medication errors cause a substantial economic burden on patients, making it difficult
to access quality treatment. Thus, it is essential to change the status quo to ensure patients can
afford health services once medication errors are prevented or reduced. Another rationale for
changing the status quo regarding medication errors is to reduce the severe and harmful impacts
of medication errors, such as disability, congenital disabilities, death, life-threatening situations,
and hospitalization (Robertson & Long, 2018). The quality improvement project will focus on
changing the status quo on medication errors as a clinical issue to ensure the above negative
consequences are eliminated in the healthcare system.
3. Identify best practices from the literature related to the issues.
Medication errors have been addressed through various best practices as presented in
various pieces of literature. The first best practice for preventing medication errors is using
proposed proprietary names to reduce confusion about drug names. Another practice is to use
container labels that clearly and accurately indicate the drugs to ensure that patients and
healthcare professionals choose the correct drug product (Billstein-Leber et al., 2018). It should
also involve clear or accurate prescribing and patient information to enhance medication
preparation, prescription, and usage. The next best practice for preventing medication errors is
using barcode scanning technology. Barcodes are crucial in preventing medication errors because
healthcare providers can accurately check the correct medications and dosage form, thus
avoiding dispensing errors (Strudwick et al., 2018). It is also essential to track medication errors
to reduce adverse events and near misses resulting in adverse drug reactions.
Minimizing clutter in the pharmacy environment is also a best practice for preventing
medication errors (Godshall & Riehl, 2018). Once the pharmacy counters are clear and free from
clutters, it is easy to avoid dispensing errors. The last best practice for preventing medication
errors is ensuring the five rights of medication administration are adhered to or met. Therefore,
healthcare providers should ensure that institutional guidelines and policies for medication
transcription are emphasized and followed (Godshall & Riehl, 2018). Once the above best
practices are followed, medication errors will be prevented, thus preventing patient morbidity
and mortality. It will also improve the image and reputation of healthcare organizations because
the institutional and governmental costs incurred through medication errors will reduce
Assiri, G. A., Shebl, N. A., Mahmoud, M. A., Aloudah, N., Grant, E., Aljadhey, H., & Sheikh, A.
(2018). What is the epidemiology of medication errors, error-related adverse events and
risk factors for errors in adults managed in community care contexts? A systematic
review of the international literature. BMJ Open, 8(5), e019101.
Billstein-Leber, M., Carrillo, C. J., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP
guidelines on preventing medication errors in hospitals. American Journal of HealthSystem Pharmacy, 75(19), 1493-1517. https://doi.org/10.2146/ajhp170811
Godshall, M., & Riehl, M. (2018). Preventing medication errors in the Information Age.
Nursing, 48(9), 56-58. https://doi.org/10.1097/01.nurse.0000544230.51598.38
Robertson, J. J., & Long, B. (2018). Suffering in silence: Medical error and its impact on health
care providers. The Journal of Emergency Medicine, 54(4), 402-409.
Strudwick, G., Reisdorfer, E., Warnock, C., Kalia, K., Sulkers, H., Clark, C., & Booth, R.
(2018). Factors associated with barcode medication administration technology that
contribute to patient safety. Journal of Nursing Care Quality, 33(1), 79-85.
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