XQ4001 Assignment Safety and Quality Fundamentals

Nursing Specialty

Medical/ Surgical Nurse in an acute care hospital’s general surgical-medical unit

Chapter

National Patient Safety Goals: Hospital

NPSG 1

Identify Patients Correctly (2025, NPSG.01.01.01)

The Joint Commission (2025) emphasizes the importance of an accurate identification of a patient using NPSG 01.01.01, meaning that at least two identifiers are required, and most frequently being the full name of the patient and date of birth, prior to delivery of any type of treatment, medication, or procedure. This goal will play a crucial role in reducing instances of wrong patient, medication, and inappropriate treatment. The Joint Commission specifically prohibits the use of room number or geographic location as form of identification, in favor of more precise ones such as barcode scanning or wristband verification to ensure every intervention is correctly matched with the right person.

NPSG 2

Use Medicines Safely – Medication Reconciliation (2025, NPSG.03.05.01)

NPSG 03.05.01 encourages medication reconciliation that requires health professionals to obtain a complete and correct list of all medications the patient receives during the process of admission, transfer, and discharge. The list is expected to be reconciled with any new or updated medication orders to identify and eliminate discrepancies. The purpose places the medication safety as a top priority, especially in the case of high-risk medication like anticoagulants or insulin and focuses on educating the patients about their medication regimen. These processes are very strict to avoid medication omissions, duplications, unwanted interactions, and difference in doses.

NPSG 3

Prevent Mistakes in Surgery – Universal Protocol (2025, UP.01.01.01)

In NPSG UP.01.01.01 (as a part of the Universal Protocol), a set of pre-procedure actions is presented to avoid disastrous surgical errors. These include a pre-procedure check, marking the site, and a time-out period where the surgical team would ensure that they have the correct patient, procedure scheduled and have checked the correct site before making the first incision. Vercification, marking, and time-out are the three measures that are known to considerably decrease wrong site, wrong patient, and wrong procedure surgery by introducing checkpoints into surgical practices (Singh et al., 2024).

NPSG Priority

The most important safety issue in my acute care organization is the need to reconcile medication (NPSG 03.05.01). Medication errors remain a major cause of avoidable harm in healthcare facilities and particularly when they are on high-risk medication as insulin or anticoagulant. Structured medication reconciliation has enough evidence to support its usefulness: research has found that when pharmacists are present and patients are actively capable of verifying their regimens, medication discrepancies during the process of care shifting considerably decrease (King et al., 2021). One example of the near-miss events that could be dramatically decreased in our unit is repeated insulin injections carryover due to home prescriptions only to be increased with clinical decision support warnings in our electronic health record.

In NPSG 03.05.01, medication reconciliation involves the healthcare staff being given a full and up to date list of all the drugs a patient uses during the admission, transfer and discharge. It should be crosswise verified with new or changed medication orders to address and solve discrepancies to avoid omissions, duplications, and dosing errors.

Besides this, the safe administration of anticoagulants- drugs like warfarin and heparin- are directly provided by NPSG.03.06.01, which are drugs that are high-risk and that when used improperly can cause an absolute devastation. The following objective facilitates the implementation of protocols of monitoring therapeutic levels, patient education, and standardized dosing patterns to avoid the development of bleeding complications.

Reflection

Nurses are at the forefront of patient safety and an excellent safety culture is one that is characterized by adamant adherence to the National Patient Safety Goals. One way nurses develop an atmosphere of accuracy and responsibility is due to the use of procedures such as conducting surgical time-outs before the start of a surgical procedure, counting drugs with every shift change, and employing two identities before initiating an intervention. The second nature of attention to detail will encourage employees to speak up in case of an unfinished check or something that appears suspicious (Medvedev et al., 2024). In the long run, these routine activities create a sense of trust among the patients and team members which helps to minimize errors and increase the level of confidence among all concerned that safety is a key component of our institutional culture.

Real-World Example

Case: Joe Massa, age 2, died at Northern Beaches Hospital in Australia (Chung, 2025)

What happened: Joe Massa has shown up at the emergency department complaining of persistent vomiting overnight, dehydrated, clinical deterioration, which includes an increase in heart rate – a warning sign of shock. Despite such red flags, he was classified as a Category 3 emergency (30-minute treatment), but he had to wait over two hours to be attended to by a doctor. They were not monitored, not escalated, not listened to by the staff, their parental concerns were not taken seriously, and some important indicators were not taken care of. The care was not observed and escalated by staff members working with the major vital signs, i.e., an increased heart rate (tachycardia) significantly, dehydration symptoms (as a result of repeated vomiting), and poor perfusion. Despite these clinical warning signs, the level of triage did not change and the immediate intervention did not begin.

Results: The mother of the patient (Joe) was becoming increasingly worried about his condition, requesting intravenous fluids and saying that he was getting worse each minute. Employees ignored her warning, neglected to increase his triage level, and did not act in a timely manner. In a later Serious Adverse Event Review, it was discovered that at a critical moment, professionals did not pay attention to parental input, as well as physiological warning signs.

Lessons:

· The early warning signs should initiate the escalation procedures.

· Family concerns are valuable pieces of information.

· Emergency triage procedures should be clear, audit-able and adhered.

Safety Grade

Name of facility: Sibley Memorial Hospital

Overall facility safety grade?

Grade C for Fall, 2024

What areas have been identified as needing improvement? Please list the top three areas.

1. Compliance with Hand Hygiene: Sibley scored below average on hand hygiene, which means that she did not practice basic infection control measures. Since it is a known mode of transmission of disease causing organisms through unclean hands, this becomes of particular concern in post-operational and high-risk patient units.

2. Communication with Patients about Medications: In the area of staff communication with the patient in reference to medicine during the stay of the patient in the hospital as well as after the patient left the hospital, the institution scored poorly. Poor communication may lead to confusion, inappropriate use of drugs, and readmissions (Cam et al., 2023).

3. Prevention of Health Care Associated Infections (HAIs): The hospital had a less than average performance in terms of catheter-associated urinary tract infection (CAUTIs) and central line-associated bloodstream infections (CLABSIs) prevention. They are preventable diseases that may be dangerous especially to the elderly and immunocompromised.

Evidence-Based Interventions

1. Multimodal Hand Hygiene Program (WHO 5 Moments Model): Adopting the One of the best methods to enhance the hand hygiene compliance of healthcare professionals is to adopt the concept of Multimodal Hand Hygiene by the World Health Organization (2021) the Five Moments of Hand Hygiene. This model has the following points of focus before contact with patient, before aseptic or clean procedures, after contact with body fluids, after contact with patient, and after contact with the surroundings of the patient. Application of the paradigm in the healthcare setting helps in promoting the habitual hand hygiene. Multimodal interventions such as education, visual signals, performance feedback and leader intervention have been demonstrated to be very effective in enhancing compliance. As an example, Seferi et al. (2023) demonstrated that the compliance with hand hygiene increased when real-time feedback and a visual reminder were used together. A culture of safety is also reinforced through the presence of leadership and role-modeling, thus making hand hygiene a normal clinical practice. Infection prevention dialogue with staff, frequent auditing and reporting, and dialoguing with staff are also part of the implementation success.

2. Pharmacist-Led Medication Reconciliation at Transitions of Care: An evidence-based approach to reduce medication errors is a medication reconciliation process, which is directed by pharmacists, particularly at the beginning of care as hospital admission, interhospital transfer, and discharge. To eliminate any questions about the medication regimen adhered by the patient, clinical pharmacists or nurse educators have to systematically examine the actual medication list of the patient, identify discrepancies, and discuss them. An important step in this process is to use patient education materials, e.g. teach-back method, to make sure that a patient or a caregiver comprehends any changes in a prescription (Marks et al., 2022). The studies conducted by The Joint Commission and the Institute of Healthcare Improvement (IHI) indicate that such initiatives have very positive effects on patient satisfaction and the decreased number of adverse medication events (Albaadani et al., 2024). Stuijt et al. (2022) in a study found a 15% decrease in medication errors in patients of 6 hospitals when pharmacists were directly engaged in the reconciliation process. This method does not only enhance patient safety but also removes potential avoidable readmissions and contributes to continuity of care by providing the correct and understandable medication orders.

3. CLABSI and CAUTI Reduction Bundles: Standard care bundles are applied to curb the catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSIs). These bundles may include evidence-based practices like strict aseptic technique during insertion procedure, chlorhexidine skin antisepsis, and day-to-day evaluation of the need to have the line or catheter. The employees are also encouraged to disinfect devices once they are not required and document the care of the catheters in a more consistent and regular manner. The use of care bundles has been linked to the reduction of the rates of infection within various healthcare facilities (Centers for Disease Control and Prevention, 2024). This method is based not only on the culture of accountability but on the interprofessional care and clinical protocols. When properly applied, CLABSI and CAUTI bundles can lead to the reduction of complications, exposure to antibiotics, length of stay, and patient outcomes in general.