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Proposal For A Quality Improvement To Be Implemented In A Healthcare Organisation Add in library

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Question - Prepare an evidenced based proposal for a quality improvement to be implemented in your healthcare organisation ? Describe it in two parts -

(a) Quality improvement/change proposal 

(b) Reflaction




Evidence based practices are available for a number of health conditions like cardiac disorders, asthma, diabetes or osteoporosis. But it is not necessary that these practices are implemented in care delivery and therefore, variation in these practices is possible. Earlier, the patient safety resided in the fact that the complete analysis of the patient safety issues would result in improvements and new implementations that would promise better health outcomes (Leape LL. 2005). Implementation of evidence based practices is practically very difficult as it requires strategies and the plans to address the complexity of systems of care, leadership of the seniors, individuals as practitioners and eventually changing the health care culture that prevails into an evidence based safety practice environments (Leape LL. 2005).

Evidence based practice can be defined as a concept of judicious use of clinical practices along with the clinical expertise and consideration of the patient values as well when the patient related health care decisions are to be made. Research has shown that the best examples of evidence based literature comes from the randomized controlled trials, evidence that is collected from scientific experiments which includes descriptive as well as qualitative research based studies (Titler, M. 2008). In several cases, the evidence based practice is not sufficient to implement the strategies and in such scenarios the non research evidence is selected along with experts’ opinion and the scientific principles. Evidence based practice is important to establish the base for the International Patient Safety Goals (IPSG), according to which evidence and expert based consensus is required to promote specific improvements in the patient safety and health care measures. There are six major goals, as mentioned in IPSG- identification of the patient correctly, improvement of the effective communication strategies, improving the safety of the high alert medications, ensuring correct site, dosage, procedure and surgery, reduction in the risk of site infections and lastly reduction in the risk of patient harm that can result from falls (Titler, M. 2008).


The aim of this research proposal is to analyze the quality of strategies that can be implemented in order to improve the safety of the high alert medications. This paper describes the medicines that fall into the category of high alert medicines and also discussed about the policies or the procedures that have been defined or described to address the identification, labeling, location and proper storage of such medicines.


Medication error is a term that is used to describe any preventable event that can lead to inappropriate medication use and harm the patient eventually causing fatal outcomes. There are many factors associated with medication errors, like similarity in the names of the medicines, uncommon medicines that are seldom prescribed, common medicines to which the patient is allergic and medicines that require testing for their toxicity and maintenance of their therapeutic levels (Hughes, R. & Blegen, M. 2008). High alert medications are those medicines that have the potential of causing maximum harm if used with error. The top five high alert medicines are insulin, opiates/ narcotics, potassium chloride or phosphate concentrate that is injectable, intravenous anticoagulants like heparin and solutions of sodium chloride (> 0.9%) (Hughes, R. & Blegen, M. 2008). In order to ensure medication safety, it is important to make and implement strategic plans for prevention of errors. There are several objectives that need the focus of the health care department. It is important to improve the methods of detection of errors, their reporting and the use of relevant information when dealing with or involved in the administration of medications. The primary focus will be on the errors that are associated with the medication and the corresponding adverse drug reactions. The very first objective should be to keep the process of focusing and learning about the medication errors ongoing so that the errors can be prevented in future (Kirke C. 2009). Secondly it will be important to enhance the awareness of the staff regarding the conditions that risk the safety of the patient, like easy and accurate identification of serious or hazardous conditions, by the staff members (Kirke C. 2009). The next objective should be to utilize the information on medication errors and their prevention, proactively. Another objective for the health care facilities should be to seek improved patient related outcomes. Lastly, the health care providers should reduce the legal liabilities for the patients who are poor, their health outcomes due to adverse drug reactions (Manias et al. 2014).

Every objective will be faced with some form of potential barriers and threats like the nurses or the other health care staff might face the fear of reporting errors due to compulsory requirements of that hospital relating to the harm to the professional license of the practitioner. In certain cases even the culture gets the blame and even worse can be the legal restrictions that are imposed on the medication error information (Kirke C. 2009). To avoid these barriers and threats it is important for the hospital authorities to implement the programs of quarterly focused discussion in which the front line staff can discuss about the problems that they face with the use of the medication. Secondly, the hospital authorities and the administration staff should ensure that they conduct training programmes and education training programmes for teaching the members of the medication safety team regarding the principles of error reduction by learning to standardize, restrict access, simplify, limit the use, automate, creation of false safes and improvement of access to information (Cronenwett et al. 2007). The utilization of electronic techniques is increasing gradually in the medical line. Therefore, the strategy of using electronic devices to record the administration of medications, their dosage, time duration, time of administration, patient reaction to the dose, changes in the dose and other relevant observation. In other words, a method should be created to capture or record the pharmacy interventions electronically either by using a palm held system or using the pharmacy computer system for the same. The data that is stored this way can be further used to identify the additional opportunities that can be utilized for improvement of the medication process.




Research in the field of medication safety is being conducted on a large scale. The medical practices involve great risk and include such practices that are vulnerable to error and these threats pose fatal risks for the health outcomes of the patients. The errors that occur during the process of administration of medication, arise due to many reasons but these reasons are still unknown (Pretorius et al. 2013). Therefore, it is important for the medical facilities to understand the cause of error and try to implement the strategies that aim in reducing or preventing medication errors.


Collection of data, when the question is of patient safety, is very important. The factors that contribute to medication errors are poorly understood by the medicine practitioners. The review discussed here is based on the survey of the staff and the physicians in the United States (Kaldjian et al. 2008). This survey explores the reporting of actual, hypothetical errors, the attitude of the staff towards these errors and the demographic factors that are responsible for the same. The study involved responses from 338 participants. Most of the participants agreed that the act of reporting errors significantly improved the quality of care for the future patients. After selection of the potential participants, the survey was conducted. It was self administered, paper based survey that did not require and personal identification information and the authorities assured the participants that their identities would be kept anonymous. The survey questionnaire dealt with the actual experiences of the participants (Kaldjian et al. 2008). The disclosures were queried for two basic mistakes that either resulted in prolonged treatment regime or caused discomfort or resulted in any form of disability or death. In each of the case, the participants were asked whether they reported or did not report the incident. The question included in the questionnaire were based on the knowledge and the attitude that was present among the participants regarding the reporting of the errors and these varying attitudes were based on the taxonomy of the factors that facilitated and impeded disclosure. The survey was designed in such a way that it encompassed the details relating to the responsibilities towards the community, the barriers in the attitudes, uncertainities, helplessness, anxieties and fears. Several demographic variables were also considered like the training level of the hospital staff, sex, speciality, differenciation between medical error and the mistake. The survey was conducted by ensuring anonymity of the details of the participants by not asking for their age, graduation year or their race or ethnicity. The survey was tested for validity of face, its clarity and the stability over time and the variation that would arise by surveying 16 participants. Time interval of two weeks was set and two rounds of identical survey was distributed to these participants. Statistical measures like the Spearman correlation of each of the response, was done depending upon the stability of each of the items. Items, for which the Spearman coefficient was less than 0.50, were neglected and not included in the final questionnaire. The reliability of all the questions that were included in the questionnaire, varied from being good to excellent, with Spearman p>= 0.6 (Kaldjian et al. 2008).

The results obtained through the survey were such that 17.8% of the participants acknowledged the reporting of minor errors that occurred during prolonged treatment or during the case of discomfort (Kaldjian et al. 2008). 3.8% of the participants reported major errors that occurred during the cases of death or in serious cases of disability. Among the other data, 16.9% participants did not acknowledge reporting minor error while 3.8% participants did not acknowledge reporting of major error. However, the likelihood of reporting a hypothetical error was based on the outcome of the error (Kaldjian et al. 2008). 92% of the respondents hinted that they would report a hypothetical harm if it resulted in major harm, while 73% indicated that they would report hypothetical error if it resulted in minor harm. The physicians believed that reporting of the errors would enhance the quality of care being provided to the patients and also improve the treatment methodologies (Kaldjian et al. 2008). But 54.8% of the participants did not know how to report error to their institutions while 40% of the respondents were not able to distinguish between the types of errors that should be reported. The consequences of this study make vital commitments to a constrained experimental writing on doctor reporting of therapeutic slips to enhance tolerant wellbeing. Our information give new data from showing healing facilities about demeanor to reporting, real practices, and the potential impact of demographic components, for example, level of preparing and convictions about absolution (Kaldjian et al. 2008). Especially eminent was the finding that albeit a large portion of our respondents showed they would likely appear for their establishments a speculative lapse bringing about minor or real mischief to a patient, just 17.8% recognized perpetually reporting a genuine minor mistake, and just 3.8% recognized regularly reporting a real significant blunder. Moreover, 16.9% of respondents recognized not reporting a real minor lapse and 3.8% recognized not reporting a genuine significant blunder. Taken together, these results propose there may be a crevice in the middle of demeanor and practice among doctors with respect to the reporting of therapeutic lapses. The consequences of this study make vital commitments to a constrained experimental writing on doctor reporting of therapeutic slips to enhance tolerant wellbeing. Our information give new data from showing healing facilities about demeanor to reporting, real practices, and the potential impact of demographic components, for example, level of preparing and convictions about absolution. Especially eminent was the finding that albeit a large portion of our respondents showed they would likely appear for their establishments a speculative lapse bringing about minor or real mischief to a patient, just 17.8% recognized perpetually reporting a genuine minor mistake, and just 3.8% recognized regularly reporting a real significant blunder. Moreover, 16.9% of respondents recognized not reporting a real minor lapse and 3.8% recognized not reporting a genuine significant blunder. Taken together, these results propose there may be a crevice in the middle of demeanor and practice among doctors with respect to the reporting of therapeutic lapses. One of the major concerns of the participants was about the legal liabilities of the error reporting as this was supposed to have a greater impact on the future consequences associated with the reporting of the error. But the major drawback of the study was that it did not consider the case of legal implications post error reporting (Kaldjian et al. 2008). There were many other limitations as well. The primary drawback was the anonymity of the survey. This was because even though the survey was anonymous, the social desirability factor may have led to biased answers that the participants would have thought to be more acceptable socially. Secondly, the hypothetical error vignette was considered in the study such that the outcomes of the severity of the variables served as the dependent variables for the multivariate analysis but the answers that were given to the hypothetical scenarios did not actually predict the real behavior during the actual situation. Thirdly, the participants that were included in the study belonged to the teaching hospitals and mainly represented internal medicine, pediatrics and family medicine. This restricted the scope of the study that was conducted. Although the use of multivariate setting might not have affected the multivariate analysis but the lack of generalization of results can be contemplated (Kaldjian et al. 2008).

The consequences of this study recommend that doctors' state of mind about the estimation of mistake reporting may not be matched by real practices. On the off chance that rectify, the potential reasons for this error should be tended to. Human services organizations ought to proceed with endeavors to make learning situations in which slip examinations are esteemed and the individuals who examine their own mistakes are regarded. Foundations ought to likewise guarantee that blunder reporting frameworks are secret, straightforward, and worthwhile. To persuade doctors that reporting mistakes is not a vain activity, organizations ought to promote cases that show the association between slip investigation and framework change. Foundations ought to additionally show doctors how to report mistakes and what slips to report (Kirke C; Irish Medication Safety Network 2009). Without such endeavors to encourage a movement to a society of reporting among doctors, the impact of governmentally secured patient security reporting frameworks is liable to be decreased and the reporting predisposition natural in these frameworks will be unrealistic to diminish. Finally, establishments ought to consider approaches to advance patient-focused moral values that may spur doctors to report mistakes amidst countervailing pressures, particularly in showing healing facilities where good examples have key influence in the arrangement of trainees' disposition and practices. Such values are rightly seen as a feature of medicinal professionalism and reflect a pledge not only to great frameworks yet to the benefit of our future patients (Kaldjian et al. 2008).




The medication error that occurs at the time of administration occurs mainly due to omission or commission when administering parenteral drug that might harm the patient (Valentin, et al. 2009). In most of the studies the errors that were addressed belonged to majorly five type or categories: wrong drug, wrong dose, wrong time, wrong route and missed dose of medication. The errors can be further classified into different categories based on their type of administration like intravenous bolus, subcutaneous, intravenous continuous (Valentin, et al. 2009). Secondly, the errors can be classified based on the class of drug like sedation or analgesia, catecholamines or vasopressors, coagulation related, antimicrobial, insulin and others (Valentin, et al. 2009).


Quality of health care is assumed to be the sole foundation of patient safety and therefore, it is important to effectively manage and improve the existing gaps and errors that exist in the care providing facilities. Institute of Medicine (IOM) is one such work group that attempts to define the health quality in terms of standard. These standards are not compulsorily in terms of the possibilities or the clusters of concepts for the indicators. Quality improvement in terms of error prevention mean prevention of major or minor errors by the nurses or the physicians so that the health of the patient is not at stake. All the medication errors that have been classified on different basis need to be avoided in order to ensure proper and un obstructed process of treatment without and negative health outcomes (Mitchell, P. 2008). This improvement can be done by implementing different strategies that will help in identifying the main causes of errors as well as the preventive measures that can train the staff and also make the staff aware of the precautions that need to be taken when handling the drug administration process. Over time more robust measure like the accreditation standards and the increase in the requirements of error reporting have led to a stronger business case for the hospitals and have thereby led to increased safety of the patient. Before, we have regularly seen nursing's obligation in patient wellbeing in slender parts of patient consideration, for instance, dodging medicine lapses and anticipating patient falls. While these measurements of security stay vital inside the nursing domain, the broadness and profundity of patient wellbeing and quality change are far more noteworthy. The most basic commitment of nursing to patient wellbeing, in any setting, is the capacity to facilitate and coordinate the different parts of value inside the consideration straightforwardly gave by nursing, and over the consideration conveyed by others in the setting. This integrative capacity is likely a part of the oft-rehashed finding that wealthier staffing (more prominent rate of enrolled attendants to other nursing staff) is connected with less inconveniences and lower mortality (Mitchell, P. 2008). The evaluation, measurement and research on this component of effective health care and patient safety is essential step towards promoting positive health outcomes for the patients because the medication errors play a major role in controlling the recovery and cure of the illness. Due to this, majority of the hospitals have already implemented various strategies to overcome and prevent the medication related errors.





The practice of reflection has become very common in the recent years such that it governs the process of nursing and influences the practice and education all around the world. The profession of nursing requires the nurses to be educated and have practice based skill implementation. Reflection has been referred as the transferable skill which is implemented or incorporated into the clinical practice enabling the practitioner and the patients to understand themselves as well as others in a better way. In order to utilize reflection for the benefit, it is essential to ensure that the reflection is purposeful and goal directed. Since reflection is a dynamic process, there have been many frameworks that aim in compiling all the components of a perfect reflection based approach. One such framework is Gibbs’ (1998) Reflective cycle. The framework of this cycle is based on the experimental learning phenomenon and uses a series of questions as a base or guide to provide a genuine structure for the practitioner to reflect upon his experience in the clinical set up. The Gibbs reflective cycle focuses upin six major highlights: Description about what happened, feelings about the entire case or scenario, evaluation of the situation of whether it was good or bad, analysis of the complete situation, conclusion about what else could have been done and plan of action and the preparedness for the situation if it arises again.


The case revolves around an elderly woman who is admitted in intensive care unit. She was admitted with the problem of respiratory failure requiring incubation and demonstrating symptoms that are consistent with sepsis. The lady was being care for at a continuous stretch of 12 hour shift but she faced problems in renal function with increase in the inotrope dependence. Knowing that the CT scan had been done one week prior to the present scenario, and also knowing about no significant findings, the lady’s son was told about the poor prognosis of her ailment. Since the patient had to be transferred to the radiology department for other scans and tests, she was sedated, as a result of which there was increase in inotropes as hypertension occurred due to heavy sedation. Throughtout the transfer the patient was unstable with episodes of bradycardia and hypotension. Adrenaline boluses were given and large fluid boluses (gelofusine) were also given. CT scan was abandoned mid way and the resustication process was carried out. But there was lack of appropriate resustication process and thus, it led to cardiac arrest of the patient and she died. The son was present when the patient died.


When these events occurred I had the feeling of guilt and inadequacy. I felt that since the patient was already suffering from multiple health problems, transferring the patient would result in further discomfort and cause potential danger. During the transfer, when the patient started showing signs of bradycardia and hypotension, I was worried and had concerns for preventing cardiac arrest. When I returned to the ICU, I realized that the dignity as well as the concerns of the family of the patient were ignored and not respected in any form.


There were both positive as well as negative implications of the experience. On a positive note, the team work of the heath care unit was worth appraisal as they took good care of the patient but on the negative side I feel the ethical issues surrounding the patient, the clinical condition of the patient and the problems being encountered during the patient’s care should have been discussed more appropriately and the error in the dosage of sedative should have been prevented.


In situations of severe sepsis, there is impairment of tissues and its perfusion along with micro vascular coagulation and all this cumulatively can lead to multiple organ failure, finally leading to death (Robson & Newell 2005). In order to prevent multiple organ failure, the patient should receive targeted organ support in form of mechanical ventilation, rfluids, inotropic or vasopressor administration or administration of blood products in order to increase oxygenation and enable maximum perfusion. The use of steroids in the ICU has been under debate and it has been also shown that if steroid are given in low doses, it can reduce the risk of death in some patients who are suffering from the condition of septic shock (Annane 2000). However, the major question that arises here is about the decision of CT scan post the deteriorating condition of the patient.




It can be concluded that the condition of sepsis in the critical care environment is a very complex process to handle and the treatment for this condition is possible only under specialized conditions. There may be many ethical considerations and dilemmas for the staff that caters to a septic patient, but in such cases it is important to consider the condition of the patient in the first place and then prescribe the medications/ drugs or treatment measures. In this case, I felt, that the need for CT scan made the case slip out of our hands. Since the patient was not at all stable during the transfer, it would have been sensible to skip transfer and CT scan and progress with the treatment and prevention plan for cardiac arrest. Although the final decision regarding the choice of treatment resided with the anaesthetist, however, I could have challenged the decision of the anesthetist, thereby advocating the interests of the patient.


By reflecting on this case study, I have gained understanding of sepsis and the potential threats and the ethical problems which were or can be encountered when caring for the patient. I am now more confident to face challenge the decisions made relating to treatment which do not fit best in the interest of the patient. I have now a greater understanding of the professional responsibility to advocate on patient’s behalf with the aim of safeguarding against the potential dangers. It is thus, possible for me now to hope for better patient related outcomes and health benefits for future patients.




American Hospital Association, 2002, Pathways for medication safety: Leading a strategic planning effort.

Annane, D., 2001, Effects of the Combination of Hydrocortisone-Fludro-Cortisone on Mortality in Septic Shock Critical Care Medicine Vol. 28, pp. 46.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., et al., 2007, Quality and safety education for nurses, Nursing Outlook, Vol. 55, no. 3, pp: 122-131.

Hughes, R. & Blegen, M, 2008, Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 37-Medication Administration Safety, Rockville, MD: Agency for Healthcare Research and Quality.

Kaldjian, L., Jones, E., Wu, B., Hoffman, V., Levi, B. & Rosenthal, G., 2008, Reporting medical errors to improve patient safety, JAMA, Vol. 168, no. 1, pp: 40-46.

Kirke C; Irish Medication Safety Network, 2009, Medication safety in hospitals, Ir Med. J., Vol. 102, no. 10, pp: 339-41.

Landrigan, C. et al., 2010, Temporal trends in rates of patient harm resulting from medical care, The New England Journal of Medicine, Vol. 363, pp: 2124- 2134.

Leape LL., 2005, Advances in patient safety: from research to implementation , Implementation issues. Vol. 3. Rockville, MD: Agency for Healthcare Research and Quality.

Manias E, Williams A, Liew D, Rixon S, Braaf S, Finch S., 2014, Effects of patient-, environment- and medication-related factors on high-alert medication incidents, Int J Qual Health Care, Vol. 26, no. 3, pp: 308-20.

Mitchell, P., 2008, Chapter 1: Defining patient safety and quality care, Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Agency for healthcare Research and quality (US).

Pretorius RW, Gataric G, Swedlund SK, Miller JR., 2013, Reducing the risk of adverse drug events in older adults, Am Fam Physician, Vol. 87, no. 5, pp: 331-6.

Robson, W., Newell, J.,2005, Assessing, Treating and Managing Patients With Sepsis Nursing Standard Vol.19, no. 50, pp. 56-64.

Soerensen, A., Lisby, M., Nielson, L., Poulsen, B., Mainz, J., 2013, The medication process in a psychiatric hospital: are errors a potential threat to patient safety? Risk Manag Healthc Policy, Vol. 6, pp: 23-31.

Titler, M., 2008, Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 7-The Evidence for Evidence-Based Practice Implementation, Rockville, MD: Agency for Healthcare Research and Quality.

Toker, D., Pronovost, P., 2009, Diagnostic errors- the next frontier for patient safety, JAMA, Vol. 301, no. 10, pp: 1060-1062.

Valentin, A., Capuzzo, M., Moreno, R. et al., 2009, Errors in administration of parenteral drugs in intensive care units: multinational prospective study, BMJ, Vol. 338, pp: b814.

Wachter, R., 2009, Patient Safety At Ten: Unmistakable Progress, Troubling Gaps, Health Aff., Vol. 29, no. 1, pp: 165-173.

Varkey, P., Reller, K. & Resar, R., 2007, Basics of quality improvement in health care, Mayo Clinic Proceedings, Vol. 82, no. 6, pp: 735-739.

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