ITS VERY IMPORTANT TO MEET THE COMPETENCES ! Write 8-10 pages in which you identify a major patient-safety issue within your own organization and use evidence-based best practices and technology to develop a plan to improve the safety issue. Quality improvement and patient safety are central to the nursing leadership role. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: As you prepare for this assessment, complete the following:


Patient safety is a crucial aspect of healthcare delivery. It involves protecting patients from harm, minimizing medical errors, and improving the overall quality of care. In every healthcare organization, identifying and addressing patient safety issues is essential for providing safe and efficient care. This paper aims to identify a major patient safety issue within the selected organization and develop a plan to improve the safety issue using evidence-based best practices and technology.

Identification of Patient Safety Issue:

In my organization, one major patient safety issue that has been identified is medication errors. Medication errors are defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of healthcare professionals, patients, or consumers. These errors can occur along the entire medication use process, including prescribing, transcribing, dispensing, administering, and monitoring. Medication errors can have severe consequences for patients, including adverse drug reactions, treatment failure, and even death.

Evidence-Based Best Practices for Medication Safety:

To address the issue of medication errors, it is crucial to implement evidence-based best practices. The following are some best practices that have been proven to improve medication safety:

1. Computerized Physician Order Entry (CPOE): Implementing CPOE systems allows healthcare providers to electronically prescribe medications, reducing the risk of errors related to illegible handwriting or transcription mistakes. CPOE systems also provide alerts and reminders for potential drug interactions or contraindications.

2. Barcode Medication Administration (BCMA): BCMA utilizes barcode scanning technology to verify the “five rights” of medication administration: right patient, right medication, right dose, right route, and right time. This technology helps prevent medication administration errors and ensures that the correct medication is given to the correct patient.

3. Medication Reconciliation: Medication reconciliation involves reviewing a patient’s current medications and comparing them to the medications ordered during transitions of care, such as admission, transfer, or discharge. This process helps identify and resolve discrepancies, reducing the risk of medication errors.

4. Clinical Decision Support Systems (CDSS): CDSS provides healthcare professionals with evidence-based recommendations and alerts at the point of care. These systems can provide information on appropriate dosage, potential drug interactions, and other relevant clinical guidelines, helping to prevent medication errors.

5. Automated Dispensing Cabinets (ADCs): ADCs are secure devices that store and dispense medications, usually located on nursing units. These cabinets require the healthcare provider to input their identification code and select the desired medication, ensuring accountability and reducing the risk of medication errors.

Developing a Plan to Improve Medication Safety:

To address the issue of medication errors, a comprehensive plan should be developed, incorporating the above-mentioned best practices and leveraging technology. The following steps can be undertaken to improve medication safety in the organization:

1. Conduct a thorough assessment of the current medication management processes, including prescribing, ordering, dispensing, administration, and monitoring. This assessment should identify potential areas of vulnerability and existing gaps in the medication safety system.

2. Establish a multidisciplinary team consisting of nurses, physicians, pharmacists, and information technology specialists. This team will be responsible for designing and implementing the plan to improve medication safety.

3. Implement a CPOE system to replace traditional paper-based medication ordering. The system should feature electronic prescribing, alerts for drug interactions, and dose range checking capabilities.

4. Introduce BCMA technology at the bedside to ensure accurate medication administration. Nurses will scan the patient’s wristband and medication barcode to verify the “five rights” before administering any medication.

5. Enhance medication reconciliation processes during care transitions. This can include assigning a dedicated staff member responsible for reconciling medications, utilizing electronic health records for medication history, and conducting medication reconciliation meetings with patients and their families.

6. Integrate CDSS into the electronic health record system to provide clinicians with decision support at the point of care. The system should provide alerts for potential medication errors, dosing recommendations, and evidence-based guidelines.

7. Install ADCs on nursing units to facilitate secure medication storage and dispensing. The cabinets should be regularly audited to ensure correct medication inventory, and staff should receive appropriate training on their use.

8. Develop an education and training program for healthcare professionals to enhance their knowledge and skills related to medication safety. This program should cover topics such as medication error prevention, proper medication administration techniques, and the effective use of technology.

9. Establish a system for continuous monitoring and feedback. Regular audits, incident reporting, and root cause analysis should be conducted to identify and address any medication errors or near misses.


Improving medication safety is crucial for providing high-quality and safe care to patients. By adopting evidence-based best practices and leveraging technology, healthcare organizations can significantly reduce the occurrence of medication errors. The comprehensive plan outlined above incorporates a range of strategies to address the identified patient safety issue of medication errors within the organization. Implementation of this plan will require collaboration and commitment from all stakeholders, including healthcare professionals, information technology specialists, and organizational leaders. Ultimately, by improving medication safety, the organization can enhance patient outcomes and ensure the delivery of safe and effective care.