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Description of Quality Initiative



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Description of Quality Initiative

The quality improvement initiative I selected is healthcare staff education on the essence of patient monitoring before the administration of medicine. This initiative is relevant as it is directly related to the QI improvement gap in my organization, which is medication management lacking consideration for physical monitoring such as vital signs, weight, and blood levels for illicit drugs. Education on patient monitoring will reiterate the basics of healthcare provision that may have become complacent during their practice. The education initiative will differ from a training program in that it will be an in-service education for the participants, lasting only a few hours.

Handling of Adverse Events in an Organization

My organization appreciates that adverse events may lead to fatal outcomes in healthcare provision. This appreciation leads to heightened sensitivity for potential adverse events and their prevention. When unwanted events occur, the healthcare organization encourages immediate reporting of incidents. Implementing reflective practice may help investigations discover the cause and prevent their occurrence in the future. In this case, the mental health care facility encourages a just culture and ensures care providers are not persecuted when they make mistakes. According to Barkell and Snyder (2021), Just Culture balances systems and individual accountability. When people perceive they will be treated fairly they are more likely to report mistakes during care provision. When an organization responds to adverse events justly, systematically the internal and external stakeholders perceive that the care organization provides quality care.

Error Rate from Article

The article I selected is one from Mulac, Taxis, Hagesaether, and Granas (2020), states medication errors still occur and cause patient harm despite the global efforts towards their prevention. According to the article, most medication errors occur during administration, accounting for 68% of the errors and the leading types of errors were dosing, omission, and wrong drug errors at 38%, 23%, and 15% respectively (Mulac, Taxis, Hagesaether and Granas, 2020). Furthermore, according to the article, 62% of the errors were harmful, resulting in severe harm or fatal outcomes (Mulac, Taxis, Hagesaether, and Granas, 2020). The error rates from the article relate to my healthcare organization as they reflect the adverse outcomes it may experience if the QI initiative is not undertaken. The mental health patients who visit the facility may suffer severe harm or even die because of the lack of patient monitoring before drug administration by the care provider in the organization.


Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2020). Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System. European Journal of Hospital Pharmacy.

Barkell, N. P., & Snyder, S. S. (2021, January). Just culture in healthcare: An integrative review. In Nursing Forum (Vol. 56, No. 1, pp. 103-111).