NURS-FPX4035 Assessment 1 Enhancing Quality and Safety: sample paper, in real form

Reducing Insulin Administration Errors on a 28-Bed Medical-Surgical Unit

Student Name

School of Nursing and Health Sciences, Capella University

NURS-FPX4035: Enhancing Patient Safety and Quality of Care

Instructor Name

Month Day, Year

Reducing Insulin Administration Errors on a 28-Bed Medical-Surgical Unit

Insulin is the highest-volume high-alert medication given on the 28-bed adult medical-surgical unit described here, and it is also the drug most often involved when a dose goes wrong. Across the two quarters ending March 31, the unit's safety event system captured 62 medication administration events over 9,120 patient days, a rate of 6.8 events per 1,000 patient days. Seventeen of those 62 events, or 27 percent, involved insulin: a wrong dose, a dose given at the wrong point relative to the meal tray, or a dose given without the point-of-care glucose result the order required. Five of the seventeen reached the patient and required rescue for a glucose below 54 mg/dL.

The distribution matters more than the total. Insulin accounts for roughly one in six doses the unit administers, yet more than one in four of its reported administration events, which means the error rate per insulin dose runs several times the unit's baseline. Severe hypoglycemia below 54 mg/dL occurred 41 times across 1,340 insulin-treated patient days in the same window, or 3.1 episodes per 100 insulin-treated patient days. AHRQ ties preventable inpatient adverse drug events to added length of stay and added direct cost measured in thousands of dollars per event (Agency for Healthcare Research and Quality, 2023). Applying a conservative 1.5 added inpatient days at the unit's average direct cost of $2,300 per patient day, the five harm events alone carry roughly $17,000 in avoidable cost every six months.

Insulin is classified as a high-alert medication because its therapeutic window is narrow and the harm from a wrong dose arrives immediately rather than after a delay, which leaves no interval in which a second person can catch it (Institute for Healthcare Improvement, 2012). The Joint Commission's National Patient Safety Goal on medication safety asks organizations to reduce harm from this class of drug rather than to reduce error counts in the abstract (The Joint Commission, 2024). The practical consequence for this unit is that a general medication safety campaign will not move the number. The analysis below therefore isolates the factors that produce insulin events specifically, then attaches one intervention to each.

Factors Leading to the Safety Risk

Three factors account for most of the seventeen events, and they sit at different distances from the bedside. The nearest is interruption during the medication pass. Across 40 observed passes on this unit, nurses were interrupted a mean of 4.2 times per pass, most often by call bells, phone consults, and family questions asked at the door of another room. Westbrook and colleagues found that each interruption during administration was associated with a measurable rise in both the frequency and the severity of medication administration errors, with severity rising faster than frequency (Westbrook et al., 2010). Insulin is unusually sensitive to this factor because the correct dose depends on a glucose value and a meal that are both moving targets.

The second factor is inconsistent barcode scanning. The unit's electronic medication administration record supports scanning at the bedside, but an audit of the same six-month window found scanning completed for 84 percent of doses against an organizational target of 95 percent. The gap concentrates at shift change and during the 0730 insulin round, when meal trays arrive and nurses carry doses for several patients at once. Truitt and colleagues reported that adding barcode technology to an electronic medication administration record reduced adverse drug events substantially, but the reduction tracked the proportion of doses actually scanned rather than the presence of the technology itself (Truitt et al., 2016). A scanner used 84 percent of the time is a control that is off for one dose in six.

The third factor sits upstream of the nurse entirely. Sliding-scale and basal orders on this unit are entered as free-text modifications to a standard set more often than they are entered from the set itself, which produces orders that read differently from patient to patient and force the nurse to interpret rather than to verify. The unit also has no defined independent double check for insulin doses above a threshold, so a second nurse is involved only when the first one happens to feel unsure. Under the QSEN safety competency, a control that depends on an individual's self-assessment of risk is not a system control at all (Cronenwett et al., 2007). These three factors are ordered here from most immediate to most structural because the interventions have to be sequenced the same way.

Evidence-Based Solutions and the Nurse's Coordinating Role

Each factor gets one intervention rather than a bundle, so the effect of each can be read separately. Against interruption, the unit adopts a protected insulin round: a 30-minute window at 0730 and again at 1730 during which the charge nurse holds non-urgent calls and a visible sash marks the nurse who is administering. Against scanning gaps, the unit posts weekly scan compliance by shift and converts the 0730 doses to a scan-then-carry workflow using a single-patient tray. Against order variability, pharmacy and informatics retire free-text insulin entry and require an independent double check for any single dose above 10 units. IHI's high-alert medication guidance treats standardized ordering and independent verification as the two controls that survive real staffing pressure (Institute for Healthcare Improvement, 2012).

The cost argument is what converts a safety proposal into an approved one. Protected rounds cost no new positions; they cost a charge nurse's attention for one hour a day, which the unit already spends absorbing the fallout from interrupted passes. The independent double check costs about two minutes per qualifying dose, roughly 14 minutes per nurse per shift at current volumes. Set against an avoidable direct cost near $17,000 per six months from harm events alone, plus the unmeasured cost of rescue treatment and extended monitoring, the package pays for itself if it prevents two harm events a year. The unit reads results against three measures: insulin events per 1,000 patient days, severe hypoglycemia per 100 insulin-treated patient days, and scan compliance by shift, each baselined on the two quarters described above.

Coordination is the nurse's contribution here, not an addition to it. The bedside nurse is the only person who sees the glucose result, the meal tray, and the patient's oral intake inside the same ten minutes, which makes the nurse the natural owner of the timing decision and the natural convener of everyone whose timing depends on it. In practice that means a standing item at the daily safety huddle with nutrition services on tray delivery, a direct line to the clinical pharmacist for any order that has to be interpreted rather than read, and a documented handoff of the glucose trend at shift change instead of the last value alone. The stakeholders are staff and charge nurses, pharmacy, informatics, nutrition services, the hospitalist group, and quality, with the patient and family included in teaching before discharge. Naming who owns each control is what keeps the plan from reverting to a poster on the medication room door.

References

Agency for Healthcare Research and Quality. (2023). Medication errors and adverse drug events. AHRQ Patient Safety Network.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D. T., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.

Institute for Healthcare Improvement. (2012). How-to guide: Prevent harm from high-alert medications. Institute for Healthcare Improvement.

The Joint Commission. (2024). National patient safety goals effective January 2024: Hospital accreditation program. The Joint Commission.

Truitt, E., Thompson, R., Blazey-Martin, D., NiSai, D., & Salem, D. (2016). Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events. Hospital Pharmacy, 51(6), 474-483.

Westbrook, J. I., Woods, A., Rob, M. I., Dunsmuir, W. T. M., & Day, R. O. (2010). Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170(8), 683-690.