NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation


NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation


Capella university

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name


Quality Improvement Initiative Evaluation

In the evolving healthcare settings, the pursuit of excellence in patient safety and care quality remains a paramount objective. Quality Improvement (QI) initiatives, such as the Enhanced Medication Management System (EMMS), epitomize the healthcare industry’s commitment to leveraging technology and interdisciplinary collaboration to mitigate risks and enhance patient outcomes. This assessment delves into the intricacies of evaluating such a QI initiative, focusing on its alignment with established benchmarks, integrating interprofessional perspectives, and exploring strategies to bolster its effectiveness. Through a critical examination of the EMMS initiative, this analysis aims to illuminate the multifaceted challenges and opportunities inherent in implementing and refining QI measures within healthcare settings, underscoring the imperative for continuous improvement and adaptive strategies in the quest for superior patient care.

Analysis of the Current Quality Improvement Initiative

The EMMS initiative was prompted by a critical near-miss incident involving a potential overdose of Digoxin to a patient, Mr. Caldwell, due to a manual entry error in the Electronic Health Record (EHR) system. This incident highlighted significant vulnerabilities in the medication administration process, particularly the risks associated with manual data entry and the absence of a robust system for double-checking medication dosages and orders. The primary motivation for implementing EMMS was to enhance patient safety by preventing such errors, leveraging advanced Clinical Decision Support (CDS) functionalities within the EHR system to provide real-time alerts for potential medication errors, including dosage discrepancies and drug interactions (Mayo Clinic, 2021).

 Despite the initiative’s focus on improving medication safety, several problems still needed to be addressed by the initial implementation of EMMS. One significant gap was the issue of alert fatigue, where healthcare professionals become desensitized to the frequent alerts generated by the system, potentially leading to critical alerts being overlooked or ignored (Shermock et al., 2023). Another area that needed to be fully addressed was the system’s reliance on accurate manual data entry. At the same time, EMMS aimed to mitigate the impact of entry errors. However, the underlying problem of data accuracy and integrity remained a concern, as errors at the point of entry could still lead to inappropriate alerts or missed alerts altogether (Lahti et al., 2022).

Furthermore, the introduction of EMMS brought about new challenges. For example, while the system was designed to enhance medication safety, it required significant adjustments to existing workflows, necessitating additional training and adaptation by the healthcare staff. This adaptation process posed a problem in integrating the system smoothly into daily practices without disrupting patient care. Additionally, the implementation highlighted a need for improved interprofessional communication and collaboration, as the effectiveness of EMMS depended heavily on the seamless interaction between nurses, pharmacists, and physicians. The need for a structured process for addressing and resolving alerts that required interprofessional consultation was a notable concern, indicating a gap in the system’s design to facilitate such collaboration (Ives et al., 2020).

Evaluation of Initiative Success

In evaluating the effectiveness of a QI initiative within a healthcare setting, it is crucial to align the analysis with specific benchmarks and outcome measures recognized by national, state, or accreditation bodies. For example, the EMMS initiative could be assessed based on its ability to reduce medication error rates, a core performance measurement for patient safety initiatives. According to the Agency for Healthcare Research and Quality (AHRQ), reducing medication errors is a key indicator of an effective patient safety strategy (AHRQ, n.d.). Additionally, as reported by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), patient satisfaction scores provide a direct measure of the patient’s experience and perception of care quality, reflecting the initiative’s impact from the patient’s viewpoint (CMS, n.d.).

The impact of the quality indicators on the healthcare facility can be profound. Reducing medication error rates enhances patient safety and contributes to the facility’s reputation for providing high-quality care, potentially influencing patient choice and loyalty. Furthermore, compliance with national safety standards, such as those set by the Joint Commission, can affect the facility’s accreditation status and eligibility for certain reimbursement forms (The Joint Commission, 2022). Improvement in patient satisfaction scores, particularly in medication management and safety areas, can lead to higher overall satisfaction ratings, which are increasingly tied to Medicare reimbursement rates under value-based purchasing programs (CMS, n.d.).

Among the benchmarks and outcome measures, the most significant success of a QI initiative like the EMMS could be its demonstrable reduction in medication errors. This outcome directly addresses a critical risk area in patient care, potentially significantly impacting patient outcomes and healthcare costs. For instance, a study by Xiao et al. (2022) found that implementing advanced medication management systems can substantially decrease preventable adverse drug events, underscoring the potential of such initiatives to significantly improve patient safety and care quality. This reduction meets and exceeds the benchmarks set by healthcare quality and safety organizations, marking a pivotal achievement for the healthcare facility in its ongoing effort to enhance patient care and safety.

Interprofessional Perspectives and Additional Information Needs

Incorporating interprofessional perspectives is vital in evaluating the functionality and outcomes of a QI initiative, as it ensures a holistic view of the initiative’s impact and identifies potential areas for improvement. For example, input from a range of healthcare professionals, including nurses, pharmacists, physicians, and information technology (IT) specialists, is crucial in a medication safety initiative like the EMMS. Nurses at the forefront of medication administration can provide insights into the practicality of the system’s alerts and the efficiency of the medication verification process.

Pharmacists offer a critical perspective on drug interactions, dosing accuracy, and the system’s ability to flag potential errors effectively. Physicians can discuss the system’s impact on prescribing practices and clinical decision-making. Meanwhile, IT specialists can address the system’s integration with existing health records, user interface issues, and technical challenges (Kim et al., 2022).The perspectives of these interprofessional team members highlight the multifaceted contributions to the success of the QI initiative. Nurses may emphasize the system’s role in enhancing patient safety and reducing the cognitive load during busy shifts.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Pharmacists might focus on the improved accuracy of medication orders and the system’s ability to prevent adverse drug events. Physicians could underline the benefits of clinical decision support tools in making informed prescribing decisions. IT specialists might discuss the technical advancements and challenges in implementing such a comprehensive system. The collective input from these professionals not only enriches the understanding of the initiative’s functionality but also uncovers areas of uncertainty and knowledge gaps, such as the need for further training on system use or the management of alert fatigue (Shermock et al., 2023).

Engaging with these diverse professional perspectives is essential to gain a more complete understanding of the QI initiative’s impact. For instance, discussions with nurses and pharmacists can reveal insights into daily operational challenges and the practicality of the system’s alerts. Conversations with physicians can shed light on the clinical relevance of the alerts and the system’s integration with clinical workflows. Feedback from IT specialists is invaluable in understanding the technical underpinnings of the system and identifying future enhancements to improve usability and functionality. This interprofessional feedback is critical for identifying knowledge gaps, such as specific training needs or system features that require modification. It also helps formulate recommendations for future improvements, ensuring that the QI initiative continues to evolve in response to the needs of all users and ultimately leads to better patient care outcomes (Shermock et al., 2023; Xiao et al., 2022).

Recommendations for Improvement

Several additional indicators, protocols, and technologies can be recommended to enhance the outcomes of a quality improvement initiative such as the EMMS. One process change involves incorporating a more granular alert system that differentiates between levels of severity for potential medication errors. This system could utilize advanced analytics to assess patient-specific variables, such as current medications and historical health data, to prioritize immediate alerts (Awad et al., 2023). Additionally, integrating a machine learning component could refine the alert mechanism over time, learning from past interactions to reduce false positives and alert fatigue among clinicians.

Introducing technologies such as BCMA could significantly improve quality outcomes by ensuring that the right patient receives the proper medication in the correct dose at the right time. BCMA systems have been shown to reduce administration errors substantially by providing an additional safety check before medication is given to the patient (Owens et al., 2020). However, implementing such technologies requires substantial investment in hardware and software, staff training, and workflow adjustments, which could be seen as a con. Furthermore, reliance on technology should not diminish the importance of clinical judgment, highlighting the need for balanced integration of technological solutions with human oversight.

To better assess the initiative’s effectiveness and areas for improvement, adding outcome measures related to clinician satisfaction and engagement with the system could provide valuable insights. Clinician feedback can identify usability issues and operational challenges not apparent through quantitative error rates or patient satisfaction scores alone. For example, measuring clinicians’ time interacting with the system versus direct patient care could identify inefficiencies or areas for interface improvement (Kim et al., 2022). While these additional outcome measures could offer a more comprehensive view of the initiative’s impact, they also require the establishment of new data collection and analysis processes, which could be resource-intensive. Balancing the benefits of these expanded indicators and protocols against the potential drawbacks requires careful consideration of the healthcare facility’s objectives, resources, and constraints (Owens et al., 2020). 


In conclusion, the comprehensive evaluation of the EMMS initiative underscores the critical importance of continuous refinement and adaptation in quality improvement efforts within healthcare. By embracing additional indicators and protocols, integrating advanced technologies, and fostering an environment of interprofessional collaboration, healthcare facilities can significantly enhance patient safety and care quality. This analysis highlights the necessity of balancing innovation with practicality, ensuring that QI initiatives meet current healthcare standards and adapt to evolving clinical needs and technological advancements. As healthcare advances, the lessons learned from initiatives like the EMMS provide valuable insights into the dynamic interplay between technology, healthcare professionals, and patient outcomes, guiding future efforts to optimize care delivery and patient safety.


Agency for Healthcare Research and Quality (AHRQ). (n.d.). Making Health Care Safer II. 

Awad, S., Amon, K., Baillie, A., Loveday, T., & Baysari, M. T. (2023). Human factors and safety analysis methods used in the design and redesign of electronic medication management systems: A systematic review. International Journal of Medical Informatics172, 105017. 

CMS. (n.d.). Hospital CAHPS (HCAHPS) | CMS. 

Ives, A. L., Tucker, S. R., & Trovato, J. A. (2020). Using electronic health record technology to teach inpatient medication order verification to pharmacy students. American Journal of Pharmaceutical Education84(8), ajpe7534. 

Kim, E. D., Kuan, K. K. Y., Vaghasiya, M. R., Penm, J., Gunja, N., El Amrani, R., & Poon, S. K. (2022). Passive resistance to health information technology implementation: The case of electronic medication management system. Behaviour & Information Technology, 1–22. Lahti, L. C., Kivivuori, S.-M., Lehtonen, L., & Schepel, L. (2022). Implementing a new electronic health record system in a university hospital: The effect on reported medication errors. Healthcare10(6), 1020. 

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Mayo Clinic. (2021, February 7). Medication errors: Cut your risk with these tips. Mayo Clinic News Network. 

Owens, K., Palmore, M., Penoyer, D., & Viers, P. (2020). The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. Journal of Emergency Nursing46(6), 884–891. 

Shermock, S. B., Shermock, K. M., & Schepel, L. L. (2023). Closed-loop medication management with an electronic health record system in U.S. and finnish hospitals. International Journal of Environmental Research and Public Health20(17), 6680. 

The Joint Commission. (2022). Benefits of Joint Commission Accreditation | the Joint Commission. 

Xiao, Y., Smith, A., Abebe, E., Hannum, S. M., Wessell, A. M., & Gurses, A. P. (2022). Understanding hazards for adverse drug events among older adults after hospital discharge: Insights from frontline care professionals. Journal of Patient SafetyPublish Ahead of Print 

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