NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal


NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal


Capella university

NURS-FPX 6016 Quality Improvement of Interprofessional Care

Prof. Name


Data Analysis and Quality Improvement Initiative Proposal

In this presentation, we delve into the critical endeavor of enhancing patient safety and medication management at Riverview General Hospital through the proposed implementation of the Enhanced Medication Management and Safety System (EMMSS). This initiative emerges from a comprehensive analysis revealing a notable increase in medication errors, underscoring the urgent need for systemic improvements. Our approach integrates advanced clinical decision support functionalities, real-time alerts, a barcode medication administration system, a robust training program, and a shift towards a non-punitive reporting culture. We aim to foster a culture of continuous improvement and safety through collaborative strategies involving a multidisciplinary task force and promoting interprofessional dialogue. This presentation outlines our findings, proposed solutions, and the collaborative framework essential for the successful implementation and sustainability of the EMMSS, with the ultimate goal of significantly improving patient safety and care quality.

Analysis of Health Care Issues

Health Care Issue: Increase in Medication Errors

An analysis of the dashboard metrics at Riverview General Hospital over the past year has revealed a concerning upward trend in medication errors, with a reported increase of 20% in incidents. These incidents primarily involve incorrect medication administration and the provision of improper dosages to patients (Isaacs et al., 2020). When benchmarked against state and national safety standards provided by the Agency for Healthcare Research and Quality and The Joint Commission, the data indicates that the medication error rates at Riverview General Hospital exceed the average rates observed at similar healthcare institutions. This disparity underscores a significant healthcare issue that warrants immediate and thorough intervention to align the hospital’s performance with the expected benchmarks for patient safety and quality of care (Ibrahim et al., 2022).

Quality of Data

The data underpinning this analysis is critically assessed across several dimensions: completeness, accuracy, timeliness, and consistency. The source of the medication error reports is the hospital’s Electronic Health Record (EHR) system, designed to ensure the accurate and timely collection of data related to medication administration processes. The reliance on the EHR system supports the data’s accuracy and timeliness. However, concerns regarding the completeness of the data have been identified, particularly related to the potential underreporting of medication error incidents. Staff fear of retribution may contribute to this underreporting, creating a significant gap in the data’s completeness and, consequently, understanding the issue’s full scope (Askarian et al., 2022). This situation highlights the necessity for fostering a hospital culture that promotes transparency and reporting errors, which is essential for leveraging error incidents as opportunities for learning and improvement in patient safety initiatives (Marbouh et al., 2021).

Quality Improvement Initiative Proposal

A comprehensive Quality Improvement (QI) initiative, the EMMSS, has been developed to address the escalating issue of medication errors at Riverview General Hospital. This initiative is underpinned by a thorough analysis that underscores the frequency of medication errors, especially during transitions of care and in the management of high-risk medications. Such errors compromise patient safety and highlight the need for systemic improvements within the hospital’s medication management practices. The Plan-Do-Study-Act (PDSA) cycle has been chosen as the guiding QI model for this initiative. The PDSA cycle is a systematic series of steps for gaining valuable learning and knowledge to improve a process or product continually. This model will facilitate the structured implementation and evaluation of the EMMSS through its four phases:

  • Plan: Identify medication management as a critical area needing improvement, set measurable goals, and develop strategies for achieving these goals.
  • Do: Implement the advanced clinical decision support (CDS) functionalities within the existing EHR system and the barcode medication administration (BCMA) system to ensure accurate patient medication administration.
  • Study: Monitor and analyze the implementation outcomes to assess the impact on medication error rates and identify any areas needing adjustment.
  • Act: Based on the analysis, make necessary adjustments to the EMMSS strategies to optimize performance and effectiveness.

The primary target area for this initiative is the hospital’s medication management process, specifically focusing on enhancing nursing practices, prescribing by physicians, and dispensing by pharmacists. The outcome measures will include reduced medication error rates, improved patient safety metrics, and increased patient satisfaction scores.

Evidence-Based Strategies

To support this initiative, several evidence-based strategies will be employed:

  1. Integration of CDS functionalities within the EHR system to provide real-time alerts for potential medication errors, as supported by research indicating their effectiveness in reducing errors (Nanji et al., 2021).
  2.  Implementation of a BCMA system to decrease the likelihood of administration errors by ensuring accurate medication delivery (Beaudart et al., 2023).
  3. Development of a comprehensive staff training program to educate staff on the new systems and promote a culture of transparency and continuous improvement (Dounia Marbouh et al., 2021).

Addressing knowledge gaps and uncertainties is crucial for the EMMSS’s success. A significant concern is the need to understand the root causes behind the underreporting of medication errors, as a culture of fear can hinder error reporting, which is vital for system improvement (Douglas et al., 2022). Additionally, the effectiveness of existing training programs on medication safety is questioned, highlighting the need for a comprehensive staff training component within the EMMSS. Furthermore, the integration capabilities of the proposed EMMSS with the existing EHR technology require thorough evaluation to ensure seamless compatibility and minimize workflow disruption (Nanji et al., 2021).

Integration of Interprofessional Perspectives

A comprehensive approach involving a diverse team of healthcare professionals is essential to successfully implement the Enhanced Medication Management and Safety System (EMMSS) at Riverview General Hospital. This approach includes forming a multidisciplinary task force, acknowledging each professional’s unique perspectives on the project, and recognizing the underlying assumptions critical for the initiative’s success.

Multidisciplinary Task Force Formation

A task force of nurses, pharmacists, IT specialists, and physicians oversees the seamless integration of EMMSS into the hospital’s infrastructure. This team’s responsibilities include analyzing current workflows for potential enhancements, pinpointing optimal points for system integration, and curating specialized training programs to equip the hospital staff with the necessary skills and knowledge for effectively leveraging the new system (Olson et al., 2023).

Leveraging Interprofessional Insights

Integrating diverse professional insights is pivotal for addressing the multifaceted challenges of medication management. Nurses on the frontline of patient care offer invaluable feedback on the system’s usability and impact on patient interactions. Pharmacists contribute their expertise on drug safety, interactions, and the logistical aspects of medication distribution, ensuring the system’s recommendations are clinically sound. IT specialists focus on technical integration, ensuring the system’s compatibility with existing digital infrastructure and adaptability to future technological advancements. With their comprehensive understanding of patient care protocols, physicians oversee how the system supports clinical decision-making processes (Beaudart et al., 2023; Olson et al., 2023).

Assumptions Underpinning the Initiative

The initiative is predicated on several assumptions:

  1. Comprehensive Training: By providing thorough training for all users of the EMMSS, the task force anticipates a reduction in medication errors through improved system literacy among staff (Askarian et al., 2022).
  2. Supportive Reporting Environment: Establishing a non-punitive culture for error reporting is expected to encourage staff to share incidents more openly, contributing to a continuous learning environment (Ibrahim et al., 2022).
  3. Technological Integration: The seamless integration of EMMSS with existing hospital EHR systems is assumed to streamline medication management processes, enhancing overall efficiency and patient safety (Olson et al., 2023).

By establishing a multidisciplinary task force, Riverview General Hospital aims to harness interprofessional perspectives to tackle the challenges of implementing a complex system like EMMSS. The collective expertise and collaborative effort are expected to substantially improve patient safety, cost-effectiveness, and work-life quality for healthcare professionals. These efforts are grounded in the belief that the initiative will achieve its objectives through comprehensive training and a supportive environment, fundamentally transforming the hospital’s approach to medication management.

Effective Collaboration Strategies

Strategic collaboration efforts are essential to enhance the integration and effectiveness of the EMMSS at Riverview General Hospital. These efforts aim to foster a culture of continuous improvement and safety within the interprofessional healthcare team. The establishment of regular interprofessional meetings is a cornerstone strategy. These meetings serve as a platform for physicians, nurses, pharmacists, IT specialists, and other healthcare professionals to discuss the ongoing progress, address challenges, and share feedback regarding the EMMSS implementation.

The team can identify and resolve issues collaboratively by engaging in open dialogue, ensuring the system’s integration enhances patient care and safety. Furthermore, developing a shared dashboard plays a pivotal role in this strategy. This tool enables real-time monitoring of medication safety metrics, providing all team members with immediate access to critical data. Such transparency is crucial for making informed decisions and adjusting care practices as needed (Vaismoradi et al., 2020).

Promotion of Quality Improvement

An integral part of fostering a safety and continuous improvement culture involves sharing success stories and lessons learned from the EMMSS implementation. Highlighting positive outcomes and identifying effective strategies motivates the team and illuminates pathways for replicating success in other patient care areas. Departments are encouraged to share their experiences, both the challenges overcome and the milestones achieved, to inspire ongoing efforts towards quality improvement across the hospital (Isaacs et al., 2020).

Assumptions Underlying Collaboration Strategies

The strategies outlined are based on several key assumptions. First, there is a foundational belief that effective collaboration and open communication channels are essential for enhancing patient safety and optimizing medication management practices. The hospital can create a more cohesive and responsive healthcare team by fostering an environment where interprofessional dialogue and feedback are encouraged. This team-oriented approach is expected to significantly improve patient outcomes and operational efficiency (Dabliz et al., 2021)


In conclusion, the initiative to implement the EMMSS at Riverview General Hospital represents a significant step forward in our ongoing commitment to patient safety and quality care. Through the diligent analysis of medication error trends and the integration of interprofessional insights, we have laid a strong foundation for a system that promises to reduce errors and enhance the overall medication management process. The collaborative strategies outlined, including regular interprofessional meetings and the development of a shared dashboard, are critical to ensuring the effective implementation and continuous improvement of the EMMSS.

By fostering a culture of transparency, learning, and shared responsibility, we are poised to make substantial strides in improving patient outcomes, operational efficiency, and the work-life quality of our healthcare professionals. This initiative underscores Riverview General Hospital’s dedication to leveraging technology and teamwork to address complex healthcare challenges, setting a new standard for excellence in patient care.


Askarian, M., Mousavi-Roknabadi, R., Momennasab, M., Groot, G., & Marjadi, B. (2022). Medical error and under-reporting causes from the viewpoints of nursing managers: A qualitative study. International Journal of Preventive Medicine13(1), 103. 

Beaudart, C., Witjes, M., Rood, P., & Hiligsmann, M. (2023). Medication administration errors in the domain of infusion therapy in intensive care units: a survey study among nurses. Archives of Public Health81(1). 

Dabliz, R., Poon, S. K., Fairbrother, G., Ritchie, A., Soo, G., Burke, R., Kol, M., Ho, R., Thai, L., Laurens, J., Ledesma, S., Abu Sardaneh, A., Leung, T., Hincapie, A. L., & Penm, J. (2021). Medication safety improvements during care transitions in an Australian intensive care unit following implementation of an electronic medication management system. International Journal of Medical Informatics145, 104325. 

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

Douglas, P. S., Mack, M. J., Acosta, D. A., Benjamin, E. J., Biga, C., Hayes, S. N., Ijioma, N. N., Jay-Fuchs, L., Khandelwal, A. K., McPherson, J. A., Mieres, J. H., Roswell, R. O., Sengupta, P. P., Stokes, N., Wade, E. A., & Yancy, C. W. (2022). 2022 ACC health policy statement on building respect, civility, and inclusion in the cardiovascular workplace. Journal of the American College of Cardiology79(21), 2153–2184. 

Dounia Marbouh, Can, M., Salah, K., Jayaraman, R., & Samer Ellahham. (2021). Blockchain-based incident reporting system for patient safety and quality in healthcare. EAI/Springer Innovations in Communication and Computing 

Ibrahim, S. A., Reynolds, K. A., Poon, E., & Alam, M. (2022). The evidence base for US joint commission hospital accreditation standards: Cross sectional study. BMJ377, e063064. 

Isaacs, A. N., Ch’ng, K., Delhiwale, N., Taylor, K., Kent, B., & Raymond, A. (2020). Hospital medication errors: A cross sectional study. International Journal for Quality in Health Care33(1). 

Nanji, K. C., Garabedian, P. M., Shaikh, S. D., Langlieb, M. E., Boxwala, A., Gordon, W. J., & Bates, D. W. (2021). Development of a perioperative medication-related clinical decision support tool to prevent medication errors: An analysis of user feedback. Applied Clinical Informatics12(05), 984–995. 

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

Olson, M. F., Thompson, Z., Xie, L., & Nair, A. (2023). Broadening heart failure care beyond cardiology: Challenges and successes within multidisciplinary heart failure care landscape. Current Cardiology Reports 

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health17(6), 1–15. 

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