NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Quality Improvement Initiative Evaluation

The assessment of the usefulness of quality improvement (QI) initiatives is crucial for fostering safer patient care, especially in handling near-miss incidents such as the insulin administration incident at St. Mary’s Medical Center. A check on the effectiveness of the adopted safety measures can help us determine whether they are actually error-preventive and patient-protective. Such an evaluation process assists the healthcare team in learning that certain measures are effective, like structured handoffs or two-check procedures, and identifies gaps that still exist (Amberson et al., 2020). Finally, the careful evaluation of QI practices contributes to a culture of responsibility and never-ending improvement in which future medication errors could be avoided, and patient safety could be increased.

Analysis of Quality Improvement Initiative

The near-miss event that triggered the quality improvement initiative at St. Mary’s Medical Center involved a diabetic knee replacement patient, Mr. Robert Hall. In his postoperative follow-up, the wrong amount of insulin was nearly given to the patient because of a breakdown in communication between the surgical team and the nursing staff. Though the mistake was not caught in time, the case subjected Mr. Hall to a high risk of hypoglycemia, which would have resulted in serious complications. This incident emphasized some of the most significant deficiencies in medication checks, interdisciplinary communication, and documentation procedures at the hospital (Heydarikhayat et al., 2024).

The response to this is that the initiative aims to enhance medication safety practices by using standardized protocols, staff training, systematic approaches to communication, and continuous monitoring of performance. Some of the strategies implemented are computerized physician order entry (CPOE) to reduce transcription errors, barcode medication administration (BCMA) to achieve correct patient-medication matching, and increased utilization of electronic health records (EHRs) to maintain a clear and complete patient-medication match (Austin et al., 2022). Finally, the project will develop a culture of patient safety in which compliance with the medication protocols will be put at the forefront in all departments.

A significant increase in the number of medication-related errors reported in the hospital’s annual quality review also informed the decision to adopt this improvement plan officially. Based on the report, the same problems were identified: the wrong dosage, the delay in medication delivery, and the lack of communication between medical experts (Heydarikhayat et al., 2024). The case that Hall presented was a clear-cut example of how such lapses can expose vulnerable patients to such dangers, in particular those with long-term illnesses, whose medication management requires exact control.

The close call helped the leadership to critically analyze the existing practices and find the alteration at the system level instead of holding individual staff members accountable. This led St. Mary’s Medical Center to undertake a systematic, organization-wide strategy to improve quality aimed at mitigating the occurrence of preventable medication errors, improving the coordination of care, and adhering to the state and national regulations on patient safety. The project supports the hospital in its mission to protect patient health and ensure trust in the process of care delivery.

Knowledge Gaps and Missing Information

Although the current state of medication safety improvement in St. Mary’s Medical Center has significantly improved, there are still numerous knowledge gaps that should be filled in. Despite the current policy of improving medication safety in St. Mary’s Medical Center, there are still several gaps that need to be closed in the scope of understanding. A continuing issue is that there is not much clarity on the precise issues in the breakdown of communication in the medication process (Branch et al., 2021).

As an example, in the case of Mr. Robert Hall, it was not entirely established how the misunderstanding regarding his insulin dosage occurred due to some documentation error, oral miscommunication, or vague role duties among clinical staff (Austin et al., 2022). It is also not clear how such close-call incidents have a long-term impact on patients, both physically and psychologically, such as stress or lack of trust in medical professionals. Further details are also required to know the impact of this quality improvement initiative on the overall patient safety outcomes and the financial resources of the organization in the long term. A better insight into these domains would assist in increasing the initiative further and contribute to a long-term enhancement of medication safety behaviors.

Evaluating the Success of a Quality Improvement Initiative

The effectiveness of the quality improvement program that was implemented following the near-miss incident involving Mr. Robert Hall can be estimated by evaluating changes in the medication safety outcome. One of the initial metrics is the decrease in the number of insulin-related mistakes and near misses, and it can be measured by comparing these incidents prior to the practice of standardized handoff communication, barcode medication administration, and double-check procedures (Ferreira et al., 2025). Nationally, insulin has been linked to 11-16% of adverse medication errors and is classified as a high-alert drug (McKay et al., 2022).

A quasi-experimental investigation of non-timing medication errors with the help of full barcoding and electronic medication administration technology has indicated that 41% of errors were reduced, and a 51% decrease in possible ADEs was observed (Küng et al., 2021). In 2000, the insulin-related therapeutic error rate was 0.21; this rate rose by 619% as of 2014 (1.51) and decreased by 16.6% as of 2021 (Giarman et al., 2024). A related aspect is the compliance of the staff with national patient safety measures aimed at reducing medication errors, offered by The Joint Commission and the Institute for Safe Medication Practices (ISMP), which highlight proper medication identification and documentation of the findings (Brady et al., 2021).

Some of the strategies that could be implemented to minimize the prevalent errors in therapy are the use of pill organizers and teaching patients and those providing their care on proper medication monitoring by use of either written or computer records (Giarman et al., 2024). Professionals in these areas should be improved, which would signify that the initiative is contributing to reinforcing medication practices and lowering the risks of such events happening in the future.

Identifying Core Performance Measurements

The core performance measures of medication safety at St. Mary’s Medical Center, which were used in analyzing the incident involving Mr. Robert Hall, have a number of specific indicators. The rate of insulin-related medication errors and near misses is one of the primary measures since it is directly related to the quality of safety measures implemented in the postoperative period (Coles et al., 2020). It is also necessary to track the incidence of adverse drug events ADEs, in particular, the events concerning the wrong dosing of insulin or delayed blood glucose monitoring.

The other performance requirement is that there should be clarity and accuracy in the communication between the staff during shift changes and between the nursing staff and the pharmacy staff, as the interactions between these parties significantly contribute to avoiding the occurrence of dosing errors (Branch et al., 2021). Patient safety reports and events documentation are expected to be reviewed in order to detect trends and recurrent challenges. Moreover, the evaluation of patient outcomes, including stable blood glucose levels and recovery progress, as well as patient satisfaction with medication management, can be used to understand the extent to which the initiative is enhancing holistic care and safety.

Evaluating the Impact of Quality Indicators

The implementation of specific quality indicators to reinforce the quality of medication has created a significant difference at St. Mary’s Medical Center, particularly in the avoidance of a similar case to Mr. Robert Hall’s near-miss. Among the most meaningful outcomes, a change in overall patient safety has been achieved by reducing insulin-related medication errors and enhancing consistency when it comes to checking blood glucose levels (Ferreira et al., 2025).

They improve the recovery process of patients after the operation and reduce the emergency response associated with wrong dosing. Financially, it is also beneficial to the organization to cut the expenses of treating complications that could be prevented and diminish the risks of lawsuits related to medication errors. Moreover, the implementation of the safety standards by the country has enhanced the reputation of the facility and built a sense of trust among patients. Continuous employee training, improved communication patterns, and sticking to new requirements have contributed to the development of an effective safety culture, minimizing the chances of the recurrence of a similar near-miss incident in the future.

Identifying Assumptions

The assessment of the quality improvement project was done in St. Mary’s Medical Center and is based on a number of assumptions. It presupposes that the near-miss of Mr. Robert Hall could be caused by the communication problems on the system level, as opposed to a personal mistake, which implies the necessity of more robust and standardized procedures (Dejos, 2021). It also presupposes that technologies such as barcode medication administration and better EHR alerts will effectively help to eliminate dosing errors and enhance care coordination (Austin et al., 2022). And finally, it presupposes that the chosen performance measures that involve monitoring the insulin-related near misses and the accuracy of communication are suitable to measure progress and identify areas for improvement.

Inter-professional Perspectives and Actions

The quality improvement initiative to prevent the occurrence of insulin administration errors in St. Mary’s Medical Center should also include the input of various healthcare professionals. In the case of a near miss involving Mr. Robert Hall, to enhance medication safety, nurses, physicians, pharmacists, and the patient safety leaders should be involved because each of these groups has an interaction with the medication process at a different level. Nurses have an opportunity to provide feedback on the feasibility of shift handoffs and checking insulin doses during rush hours.

Doctors can explain the expectations regarding the transmission of severe laboratory values and the revision of treatment programs. Pharmacists can leverage their understanding of dose and dose safety checks of high-alert drugs such as insulin, and quality improvement personnel can help in the development of standardized practice and evaluate performance results (Cheng et al., 2021). Conducting frequent interdisciplinary meetings promotes free communication and ensures that all are on the same page regarding the importance of safety and workflow expectations. This team-based strategy will enhance teamwork, minimize future errors, and foster a culture of patient safety being a priority.

Areas of Uncertainty and Knowledge Gaps

Although the quality improvement plan is structured at St. Mary’s Medical Center, there are certain uncertainties. The communication breakdown that took place during the handoff and caused the incorrect report of the blood glucose value of Mr. Hall remains unknown to the reader, but it has been the result of verbal miscommunication, the incompleteness of charting, or a problem with the electronic health record (Dejos, 2021). Additional knowledge is also required about the way other health systems have managed to avoid similar insulin-related near misses and what strategies were the most effective (Cheng et al., 2021). Also, there are questions of whether the new safety protocols will also be maintained over the long run, and how they will influence patient outcomes, staff practices later, and also the overall safety culture.

Recommending Additional Indicators and Protocols

To enhance the quality improvement program to be implemented to avoid the occurrence of insulin administration errors at St. Mary’s Medical Center, it would be prudent to implement a number of additional indicators and protocols. Monitored adherence of the staff to the necessary double-check procedure with high-alert drugs like insulin, which would ensure that possible dosing errors are detected prior to the patient receiving treatment, would be one of the key performance indicators (Ferreira et al., 2025).

The other value initiative is the assessment of clarity and accuracy of communication in transferring between shifts. This can be evaluated by conducting periodic audits and employee feedback in order to determine the long-standing communication issues. The adoption of a unified handoff process, for instance, SBAR, would have the benefits of providing key patient data, for instance, the current blood glucose levels and the amount of insulin administered to the patient, in a consistent and reliable manner. This process should be standardized to directly respond to the handoff miscommunication that led to the near miss with Mr. Robert Hall and enhance safety, and minimize the risks of the occurrence of comparable situations in the future.

Additional Protocols

To reinforce the safety initiative at St. Mary’s Medical Center, staff training on insulin administration through simulation can be conducted regularly. These practice sessions help team members enhance accuracy and confidence in a controlled environment (Amberson et al., 2020). Also, when barcode wristbands are linked to the electronic health record, it would ensure that every dose of insulin is properly aligned with the correct patient, which would prevent another near-miss episode such as the one with Mr. Hall.

Pros and Cons of Additional Indicators and Protocols

The adoption of double-check measures with high-alert medications such as insulin is evidently advantageous at St. Mary Medical Center because it introduces a significant step towards preventing mistakes prior to them reaching the patient. This control measure would have averted the wrong dosage of insulin that Mr. Hall was almost administered. Nevertheless, the time-consuming aspect of the procedure can slow down the workflow during the busiest shift changes, making staff less motivated to adhere to them regularly (Branch et al., 2021).

Equally, communication can be enhanced through the application of standard handoff tools, including SBAR, which enhances the accuracy and clarity of communication, eliminating the chances of misreporting glucose values, like in the case of Mr. Hall. However, regular usage of SBAR involves continuous training and supervision to make sure that the staff utilizes it properly. Training through simulation offers the staff a chance to perform these procedures within a safe setting, which gives them confidence and eliminates the possibility of making mistakes at the workplace. Barcoded patient wristbands enhance the safety of the procedure by ensuring that there is a proper match of the patient with the medication, eliminating the possibility of insulin misdosing errors (Rao et al., 2005b). Although these systems are effective, they need to be initial in terms of financial investment and staff training.

Conclusion

 The case involving Mr. Hall underlines the significance of continuous quality improvement in health care. The hospital can enhance patient safety activities by examining the causes of the near-miss medication error that happened following his knee surgery. By collaborating with staff, questioning the events, and modifying their practices, they can provide safer workplaces for all patients. Events such as this can help improve the accuracy, consistency, and patient-centered care in the future.

References

Amberson, T., Wells, C.,; Gossman, S. (2020). Increasing disaster preparedness in emergency nurses: A quality improvement initiative. Journal of Emergency Nursing, 46(5), 654-665. https://doi.org/10.1016/j.jen.2020.05.001

Austin, J. M., Bane, A., Gooder, V., Saltsman, C., Wilson, M., Stewart, K. B., Derk, J., Danforth, M., & Michalek, C. (2022). Development of the leapfrog group’s bar code medication administration standard to address hospital inpatient medication safety. Journal of Patient Safety, 18(6), 526–530. https://doi.org/10.1097/pts.0000000000001052

Brady, P. J., Gandhi, T. K., McGaffigan, P. A., Novak, A., & Watson, S. R. (2021). Safer together: A National action plan to advance patient safety. Management in Healthcare, 6(2), 155–168. https://www.ingentaconnect.com/content/hsp/mih/2021/00000006/00000002/art00006

Branch, J., Hiner, D., & Jackson, V. (2021). The impact of communication on medication errors. Patient Safety Network. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors

Cheng, M. K. W., Collins, S., Baron, R. B., & Boscardin, C. K. (2021). Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams. Journal of Graduate Medical Education, 13(6), 822–832. https://doi.org/10.4300/jgme-d-20-01555.1

Coles, E., Anderson, J., Maxwell, M., Harris, F. M., Gray, N. M., Milner, G.,MacGillivray, S. (2020). The influence of contextual factors on healthcare quality improvement initiatives: A realist review. Systematic Reviews, 9(1). https://doi.org/10.1186/s13643-020-01344-3

Dejos, M. C. (2021, January 1). Chapter 40 – Medication safety and medication error prevention (A. Adejare, Ed.). ScienceDirect; Academic Press. https://www.sciencedirect.com/science/article/abs/pii/B9780128200070000398

Ferreira, C. L., Forbes, A., Hashim, R., & Winkley, K. (2025). Insulin errors and contributing factors affecting people with diabetes in hospital: A scoping review. International Journal of Nursing Studies, 167, 105074. https://doi.org/10.1016/j.ijnurstu.2025.105074

Giarman, A. T., Hays, H. L., Badeti, J., Rine, N. I., Spiller, H. A., Zhu, M., & Smith, G. A. (2024). Therapeutic errors involving diabetes medications reported to United States poison centers. Injury Epidemiology, 11(1). https://doi.org/10.1186/s40621-024-00536-y

Heydarikhayat, N., Ghanbarzehi, N., & Sabagh, K. (2024). Strategies to prevent medical errors by nursing interns: A qualitative content analysis. BioMed Central (BMC) Nursing, 23(1). https://doi.org/10.1186/s12912-024-01726-1

Küng, K., Aeschbacher, K., Rütsche, A., Goette, J., Zürcher, S., Schmidli, J., & Schwendimann, R. (2021). Effect of barcode technology on medication preparation safety: A quasi-experimental study. International Journal for Quality in Health Care, 33(1), 1–8. https://doi.org/10.1093/intqhc/mzab043

McKay, C., Schenkat, D., Murphy, K., & Hess, E. (2022). Review of medication error sources associated with inpatient subcutaneous insulin: Recommendations for safe and cost-effective dispensing practices. Hospital Pharmacy, 57(6). https://pmc.ncbi.nlm.nih.gov/articles/PMC9631006/

Rao, A. C., Burke, D. A., & Dighe, A. S. (2005a). Implementation of bar coded wristbands in a large academic medical center: impact on point of care error rates. Point of Care the Journal of Near-Patient Testing & Technology, 4(3), 119–122. https://www.researchgate.net/publication/232152923_Implementation_of_Bar_Coded_Wristbands_in_a_Large_Academic_Medical_Center_Impact_on_Point_of_Care_Error_Rates