NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment

NURS FPX 4020 Assessment Enhancing Quality and Safety Example AssignmentAssignment Brief: NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment

Course: NURS FPX 4020 Improving Quality of Care and Patient Safety

Assignment Title: Assessment 1: Assessment Enhancing Quality and Safety


This assignment focuses on improving quality and safety in healthcare, specifically addressing patient falls as a significant safety concern. Students will explore the risk factors associated with patient falls, look into practical solutions to mitigate this issue, understand the vital role of nurses in fall prevention, and identify key stakeholders for effective collaboration.

Understanding Assignment Objectives:

The primary goals of this assignment are to:

  1. Analyze Patient Fall Risk Factors: Investigate and understand both internal and external factors contributing to the safety risk of patient falls. Utilize relevant literature and resources to gain insights into these risk elements.
  2. Explore Evidence-Based Solutions: Examine practical practices and solutions aimed at preventing patient falls. This includes assessing the effectiveness of interventions, such as minimizing psychoactive drug use, conducting gait and balance training, and providing vitamin D supplementation.
  3. Understand the Role of Nurses in Fall Prevention: Recognize and articulate the essential role of nurses in addressing patient falls. This involves assessing their involvement in fall risk assessment, patient education, and effective communication within the healthcare team.
  4. Identify Stakeholders for Collaboration: Identify and discuss stakeholders essential for collaborative efforts in fall prevention. Understand the importance of working together involving patients, doctors, pharmacists, and other healthcare professionals.

The Student’s Role:

As a student undertaking this assignment, your role involves:

  • Research and Analysis: Conduct in-depth research to understand the complexities of patient fall risk factors and evidence-based solutions. Utilize academic journals, textbooks, and reputable sources to gather information.
  • Critical Thinking: Apply critical thinking skills to evaluate the effectiveness of evidence-based solutions. Consider the practicality of each intervention in real-world healthcare settings.
  • Nursing Perspective: Embrace the role of a nurse by exploring how they contribute to fall prevention. Analyze their responsibilities, including fall risk assessment, patient education, and communication, to comprehend the comprehensive nature of nursing involvement.
  • Stakeholder Identification: Identify and discuss key stakeholders involved in collaborative efforts for fall prevention. Emphasize the importance of effective communication and teamwork among healthcare professionals.

Detailed Assessment Instructions for the NURS FPX 4020 Assessment Enhancing Quality and Safety Assignment

For This Assessment, You Will Develop A 3-5 Page Paper That Examines A Safety Quality Issue In A Health Care Setting. You Will Analyze The Issue And Examine Potential Evidence-Based And Best-Practice Solutions From The Literature As Well As The Role

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.    

Explain evidence-based and best-practice solutions to improve patient safety related to a specific patient safety risk and reduce costs.

Competency 2: Analyze factors that lead to patient safety risks.    

Explain factors leading to a specific patient safety risk.

Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.    

Explain how nurses can help coordinate care to increase patient safety and reduce costs.

Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements.

Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.    

Communicate using writing that is clear, logical, and professional with correct grammar and spelling using current APA style.


Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.


Consider the hospital-acquired conditions that are not reimbursed under Medicare/Medicaid, some of which are specific safety issues such as infections, falls, medication errors, and other concerns that could have been prevented or alleviated with the use of evidence-based guidelines.

Choose a specific condition of interest and incorporate evidence-based strategies to support communication and ensure safe and effective care.

For this assessment, consider using one of the following approaches:

Expand on the scenario presented in Vila Health: Identifying Patient Safety Concerns and analyze a quality improvement (QI) initiative.

Analyze a current issue in clinical practice and identify a quality improvement (QI) initiative in the health care setting.


The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.

Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.

Explain factors leading to a specific patient-safety risk.

Explain evidence-based and best-practice solutions to improve patient safety related to a specific patient-safety risk and reduce costs.

Explain how nurses can help coordinate care to increase patient safety and reduce costs.

Identify stakeholders with whom nurses would coordinate to drive safety enhancements.

Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Additional Requirements

Length of submission: 3–5 pages, plus title and reference pages.

Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.

APA formatting: References and citations are formatted according to current APA style

NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment

Administration-related errors

Patient safety and the quality of care are paramount goals in healthcare, directly impacting treatment outcomes and patient satisfaction. Continuous quality improvement is integral to enhancing the overall efficiency of healthcare services. However, challenges persist in achieving quality enhancement, with a notable concern being medication errors, defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, n.d) as “any preventable event that may cause or lead to inappropriate medication use or patient harm.” Medication errors (M.E.s) occurring during drug administration are often attributed to nurses. Although these errors can happen throughout the healthcare system, this paper specifically addresses the gravity of the issue within acute care settings.

Acute hospitals, providing short-term yet critical treatment services, such as emergency or intensive care, are prone to distractions and require quick decision-making. This setting increases the likelihood of medication administration errors (MAEs), posing a threat to patient safety. To address this, nurses need to implement effective strategies and solutions to minimize administration-related errors and improve care quality.

Overview of Medication Errors

Medication errors (M.E.s) constitute a significant healthcare issue, resulting in both minor and severe harm to patients. According to the U.S. Food and Drug Administration (FDA, 2019), there are over 100,000 reported presumed cases of M.E.s annually. Additionally, up to 9,000 people in the U.S. die each year due to these errors (Tariq et al., 2021). The associated costs are substantial, exceeding $40 billion per year in total care costs for patients affected by M.E.s (Tariq et al., 2021). Beyond financial implications, M.E.s contribute to perceptions of negligence, carelessness, or inexperience among healthcare staff, eroding trust in healthcare services.

Factors Leading to Medication Administration Errors

While medication errors (M.E.s) can occur at any stage of medication use, they are particularly prevalent during administration, accounting for up to 25% of drug administration instances (Koyama et al., 2020). Inattention and distraction are leading causes of MAEs, often resulting in errors such as administering the wrong drug, dose, or to the wrong patient. Nursing inattentiveness is linked to factors like high workload, multitasking, and increased patient flow (Bucknall et al., 2019). Distractions, common in healthcare facilities, especially in acute care settings, contribute to the most frequent administration-related M.E.s.

Competence or skill flaws, insufficient drug knowledge, misunderstandings related to abbreviations or poor handwriting, similar drug names, packaging, incorrect routes of administration, and non-compliance with recommendations and protocols further contribute to MAEs (Tariq et al., 2021). These factors elevate the risk of patient harm. However, the majority of these factors are preventable human errors that can be mitigated through the implementation of appropriate strategies.

Strategies to Improve Patient Safety

Improving patient safety and care quality necessitates a reduction in M.E. rates. Adherence to the “five-rights” rule, ensuring the right patient receives the right drug at the right time, dose, and route, is a fundamental strategy (Martyn et al., 2019). However, recent studies suggest the need for new frameworks, emphasizing the importance of managing workflow, avoiding interruptions, and implementing patient-centered strategies to contribute to safe and prompt medication administration (Martyn et al., 2019). The introduction of new teaching strategies, such as reflection and remediation educational models, can raise awareness of proper drug administration and reduce MAEs (McCabe & Ea, 2016). Computerizing and automating the medication preparation and administration process is another strategy endorsed by research, as it significantly reduces the occurrence of medication errors (Risør et al., 2018).

Nurse Roles

Nurses play a pivotal role in healthcare, particularly in acute care settings, where they are involved in various aspects, including medication prescribing, preparation, dispensing, and administration. Educated, experienced, and attentive nurses contribute to the prevention of medication errors through their high level of competence. Nurses are crucial in the medication use process, serving as the last line of defense to prevent MAEs by double-checking the correctness of medication, dose, patient, time, and route before administration.

Nurse Coordination with Stakeholders

Interdisciplinary collaboration is crucial to preventing medication administration errors. Nurses often require additional information from clinicians, physicians, pharmacists, or other nurses to ensure safe drug administration. Effective communication with patients is also essential, as missing patient information, failure to obtain medical and allergy histories, or not being aware of side effects can lead to MAEs. Nurses act as intermediaries, connecting healthcare professionals with patients, coordinating communication, and ensuring safe medication use.


Medication errors related to drug administration pose significant risks to patient safety, ranging from minor harm to potential fatality. While various factors contribute to these errors, they are preventable incidents requiring diligent efforts to explore and implement effective strategies. Reducing the rate of MAEs is crucial to providing patients with safe and quality care. The skills, knowledge, and attitudes of nursing staff are instrumental and should be maintained at a high level to ensure the prevention of medication errors.


Bucknall, T., Fossum, M., Hutchinson, A. M., Botti, M., Considine, J., Dunning, T., Hughes, L., Weir-Phyland, J., Digby, R. & Manias, E. (2019). Nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in an acute hospital setting. Journal of Advanced Nursing, 75(6), 1316-1327. Web.

Food and Drug Administration (2019). Working to reduce medication errors. Web.

Koyama, A. K., Maddox, C. S., Li, L., Bucknall, T., & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality & Safety, 29(7), 595–603. Web.

Martyn, J., & Paliadelis, P. (2019). Nurses’ decision-making and the Five Rights of medication administration. Contemporary Nurse, 55(1), 116–126. Web.

McCabe, B., & Ea, E. (2016). Medication administration error reduction efforts in nursing homes: A systematic review and synthesis of quantitative evidence. International Journal of Nursing Studies, 62, 92-103. Web.

Risør, B. W., Lisby, M., Sørensen, J., & Bro, L. (2018). Two strategies for introducing barcoding of drug administration to an electronic medication administration record. Journal of Patient Safety, 14(4), 459-465. Web.

Tariq, R. A., Rai, A. B., Tai, Y. H., & Raouf, M. (2021). Medication administration errors in pediatrics: A systematic review. Journal of Pediatric Nursing, 59, 25–33. Web.

NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment Two


Patient safety is a critical aspect of healthcare delivery, and medication administration errors (MAEs) pose a significant threat to patient well-being. This paper aims to explore the factors contributing to MAEs and present evidence-based strategies to enhance the quality of patient care while minimizing costs. By analyzing a specific incident involving a medication error and employing professional guidelines, this paper elucidates the role of baccalaureate-prepared nurses in coordinating care to drive safety enhancements.

Factors Leading to Patient Safety Risks

One illustrative incident involves Nurse Ella, who inadvertently administered rapid-acting insulin instead of long-acting insulin to a diabetic patient, Mr. Wallace. Several factors contribute to such medication errors:

Lack of Knowledge and Training: Inadequate knowledge about drug doses, interactions, and contraindications is a leading factor of medication administration errors. Research indicates that 78.7% of medication errors result from poor training of nurses (Hassen et al., 2022). Nurses possessing advanced pharmaceutical knowledge and subsequent training are less likely to make medication administration errors.

Communication Gap Between Healthcare Professionals: Insufficient communication and collaboration among healthcare staff contribute to medication errors. A study suggests a higher incidence of medication administration errors in settings with communication gaps (Ghasemi et al., 2022).

Prescribing Errors: Inaccurate prescriptions leading to incorrect dosages and inappropriate instructions are another significant factor. Incompletely written prescriptions contribute to 71% of prescription-related errors (White et al., 2019).

Stress, Burnout, and Mental Health Challenges: Elevated stress levels among nurses due to excessive workloads and long shifts contribute to psychological distress, burnout, and ultimately, medication errors. Burnout is linked to a fivefold increase in patient care and medication errors (White et al., 2019).

Evidence-Based Best Practices Solutions

To address these challenges, evidence-based and best practice solutions are crucial. Some effective strategies include:

QSEN Competencies: Implementation of Quality and Safety Education for Nurses (QSEN) competencies in nursing education has been shown to improve nurses’ quality and safety education by up to 75% (Watanabe et al., 2021).

Medication Reconciliation: Implementing medication reconciliation procedures during care transitions, contrasting a patient’s present pharmaceutical regimen with prescribed medications, improves patient safety (Koprivnik et al., 2020).

Computerized Physician Order Entry (CPOE): Electronically submitting medicine orders through CPOE systems reduces the chance of adverse drug events and improves patient safety (Skalafouris et al., 2022).

Barcode Medication Administration (BCMA) Systems: Using BCMA systems for correct medication delivery enhances patient safety by preventing drug errors through patient identification and barcoded labels (Ye, 2023).

Clinical Decision Support System (CDSS): Offering suggestions based on research to healthcare practitioners at the point of care, CDSS can notify healthcare professionals about possible medication combinations, dosage mistakes, or allergies (Manias et al., 2020).

Value-Based Formulary Management: Choosing medicines based on clinical potency, cost-effectiveness, and safety helps maintain high healthcare quality while cutting expenditures related to pharmaceuticals (Weinmeyer et al., 2021).

Nurse-Led Coordination to Optimize Patient Safety

Effective coordination among healthcare professionals, especially nurses, plays a pivotal role in optimizing patient safety. In the case of medication administration errors, nurses can collaborate with various stakeholders:

Coordination with Physicians and Pharmacists: Clear communication between nurses and physicians regarding treatment regimens, along with collaborative efforts with pharmacists, can reduce prescription transcribing and filling errors (Koprivnik et al., 2020).

Collaboration with IT Personnel: Mutual collaboration with IT personnel for the effective utilization of technology tools ensures the proper functioning of systems like CPOE, BCMA, and CDSS to prevent MAEs (Ye, 2023).

Interdisciplinary Collaboration: A holistic care approach by working with interdisciplinary teams and adherence to regulatory requirements reduces the risk of errors, ensuring patient safety and cost-effectiveness (Alrabadi et al., 2021).

Nurses’ Coordination with Other Stakeholders

Nurses play a crucial role in collaborating with various stakeholders to improve medicine delivery and enhance patient safety:

Collaboration with Physicians and Pharmacists: Nurses collaborate with physicians and pharmacists to ensure accurate medication administration. Quality improvement teams and nursing staff can work together to evaluate challenges and implement suitable strategies (Manias et al., 2020).

Involvement of Patients and Families: Better adherence and patient satisfaction can be achieved by involving patients and their families actively in the medication administration process.

Involvement of Medication Safety Officers and Administrators: Organizational prioritization of patient safety through the involvement of medication safety officers and administrators is crucial. Professional associations offer tools for the continuous advancement of medical practices (Manias et al., 2020).


Medication administration errors pose a significant threat to patient safety and contribute to increased treatment costs. However, employing evidence-based best practices and fostering effective coordination among healthcare professionals, especially nurses, can significantly reduce the occurrence of MAEs. The integration of QSEN competencies, medication reconciliation, and advanced technological tools, along with interdisciplinary collaboration, creates a holistic approach to patient care, ensuring safety and cost-effectiveness.

NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment Three

Quality improvement initiatives are widespread across health organizations, emphasizing patient safety and quality care. Patient safety remains a top priority for interdisciplinary teams, particularly as medication errors pose common and recurring threats to healthcare, contributing to increased patient harm and mortality (Alotaibi & Federico, 2017). Medication errors are preventable and can result from various factors such as communication gaps, disturbances during medication retrieval and administration, missing patient information, poor labeling, inadequate medication reconciliation, and lack of knowledge.

Factors Leading to Patient Safety Risks

Medication errors can occur at any time and place, often during prescription and drug monitoring. Resolving this issue necessitates collective responsibility, involving interdisciplinary collaboration. Evidence-based practices play a crucial role in raising awareness among healthcare professionals. While medication errors can happen in diverse settings, home environments pose risks, especially for children due to negligent drug storage. Adherence to the five rights of medication administration — ensuring the right drug, patient, dosage, time, and route — is critical in preventing errors. Factors contributing to negligence include increased workloads, fatigue, and insufficient pharmacologic knowledge.

Evidence-based Practices

High-quality care aligns with evidence-based research, emphasizing patient-centered care and proper communication among staff. Involving patients and caregivers in medication education and ensuring clear instructions can enhance care quality. Best practices to enhance patient safety encompass double-checking procedures, using name alerts, planning medication administration to avoid disruptions, and leveraging available technologies.

The Nurse’s Role in Coordinating Care

Nurses, integral to hospital quality improvement, engage in various roles, including patient care, data collection, and medication management. Medication errors pose financial burdens, and nurses play a vital role in coordinating care to alleviate these challenges. Coordination involves assessing the work environment, implementing safety technologies, educating patients, and exercising caution with high-alert medications. Nurses share knowledge, ensure seamless care transitions, and collaborate with interdisciplinary teams to develop personalized care plans, contributing to cost efficiency.

Stakeholder Coordination for Quality and Safety Enhancements

Effective coordination involves collaboration with stakeholders such as society, administrators, patients, families, researchers, technicians, nursing educators, and physicians. Patients and families actively contribute to quality patient safety by providing essential information and seeking clarification on medications.


Patient safety remains paramount, necessitating a focus on preventing medication errors. Factors contributing to these errors are diverse, emphasizing the need for strict adherence to the five rights of medication administration. Coordination by nurses, evidence-based practices, and stakeholder collaboration are essential elements in enhancing quality and safety in healthcare.

NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment Four


Ensuring patient safety and delivering quality care stand out as paramount challenges in healthcare, involving healthcare facilities, nurses, physicians, and various professionals. Suboptimal quality and compromised patient safety result in adverse outcomes such as morbidity, mortality, increased care costs, prolonged hospital stays, diminished patient and job satisfaction, among other issues. This paper aims to examine the patient safety issue of medication administration, analyze evidence-based practices, and scrutinize the coordination among nurses and stakeholders.

Patient-safety risk focusing on medication administration

Medication administration, a pivotal process predominantly managed by nurses, involves multiple stakeholders, including physicians, pharmacists, and informatics nurses. Errors at any stage of this process can lead to medication administration errors (MAEs) and subsequent adverse events. Research indicates varying rates of prescription, dispensing, and dosage errors, emphasizing the substantial contribution of human errors, particularly by nurses. Interferences during medication administration, whether from patients, families, or distractions, further elevate the risk of errors. Factors like nurse-to-patient ratio, poor communication, and inadequate training are additional contributors, with the potential consequences ranging from mortality and morbidity to adverse effects.

Evidence-based and best practice solutions

Implementing evidence-based practices (EBPs) is crucial to address medication administration challenges. Training and educating healthcare staff based on guidelines from the Institute of Medicine (IOM) and the Quality and Safety Education for Nurses (QSEN) is a primary EBP. This includes vigilant verification of medication with electronic health records (EHRs), allergy checks, pre-administration assessment, accurate dosage calculation, and the avoidance of workarounds and abbreviations. Another EBP involves the implementation of a physician order entry system with error reporting and communication capabilities, aiming to reduce prescription, dispensing, and administration errors. Technological interventions, such as bar-code-based medication administration and voice-tagged dosage calculation, prove effective in preventing errors. Strategies like using color-coded tabards and checklists, along with interprofessional collaboration, contribute to reducing interruptions and enhancing communication during medication administration.

Coordinated care among nurses to improve quality and patient safety

Nurses play a crucial role in coordinating care to address burnout and create supportive work environments. Collaborative efforts during medication administration, such as sharing responsibilities and supporting each other during interruptions, contribute to error reduction. Effective communication among nurses to identify patient allergies and educate colleagues about EHRs and technology usage enhances skills and knowledge. Nurse leaders manage resources and conflicts, ensuring a coordinated approach to resolve practice issues. Shared decision-making and coordinated care further contribute to efficient workflow and decreased medication errors.

Stakeholders and safety enhancement

Coordination among various stakeholders, including informatics nurses, pharmacists, physicians, therapists, nurse leaders, and patients, is essential for safety enhancement. Patients’ active involvement in treatment decisions and their contribution to health history and allergy information are critical. Informatics nurses play a vital role in data management, error reporting, and correction processes within EHRs. Physicians, pharmacists, and nurse leaders collaborate to prevent and correct medication errors, while therapists and specialists provide valuable insights into patient conditions. Effective communication and coordination among stakeholders help in resolving conflicts and ensuring patient safety.


Abukhader, I., & Abukhader, K. (2020). Effect of medication safety education program on intensive care nurses’ knowledge regarding medication errors. Journal Of Biosciences And Medicines, 08(06), 135-147.

Armstrong, G. (2019). QSEN safety competency: the key ingredient is just culture. The Journal Of Continuing Education In Nursing, 50(10), 444-447.

Bradley, C., Luder, H., Beck, A., Bowen, R., Heaton, P., & Kahn, R. et al. (2016). Pediatric asthma medication therapy management through community pharmacy and primary care collaboration. Journal Of The American Pharmacists Association, 56(4), 455-460.

Hammoudi, B., Ismaile, S., & Abu Yahya, O. (2017). Factors associated with medication administration errors and why nurses fail to report them. Scandinavian Journal Of Caring Sciences, 32(3), 1038-1046.

Huckels-Baumgart, S., Niederberger, M., Manser, T., Meier, C., & Meyer-Massetti, C. (2017). A combined intervention to reduce interruptions during medication preparation and double-checking: a pilot-study evaluating the impact of staff training and safety vests. Journal Of Nursing Management, 25(7), 539-548.

Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal Of Medical Informatics, 111, 112-122.

Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opinion On Drug Safety, 17(3), 259-275.

Montgomery, A., Azuero, A., Baernholdt, M., Loan, L., Miltner, R., & Qu, H. et al. (2020). Nurse burnout predicts self-reported medication administration errors in acute care hospitals. Journal For Healthcare Quality, Publish Ahead of Print.

Palese, A., Ferro, M., Pascolo, M., Dante, A., & Vecchiato, S. (2019). “I am administering medication—please do not interrupt me”: red tabards preventing interruptions as perceived by surgical patients. Journal Of Patient Safety, 15(1), 30-36.

Pop, M., & Finocchi, M. (2016). Medication errors: a case-based review. AACN Advanced Critical Care, 27(1), 5-11.

Tariq, R., Vashisht, V., Sinha, A., & Scherbak, y. (2021). Medication dispensing errors and prevention. Retrieved 17 March 2021, from

Thomas, L., Donohue-Porter, P., & Stein Fishbein, J. (2017). Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. Journal Of Nursing Care Quality, 32(4), 309-317.

Thompson, K., Swanson, K., Cox, D., Kirchner, R., Russell, J., & Wermers, R. et al. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(4), 342-351.

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal Of General Medicine, Volume 13, 1621-1632.

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NURS FPX 4020 Assessment Enhancing Quality and Safety Example Assignment Five


Patient safety is a major concern in healthcare, with patient falls being a significant safety issue. A fall is described as “an unplanned descent to the floor (or extension of the floor [e.g., trash can or other equipment]) with or without injury to the patient and with or without assistance” (Tucker et al., 2019, p. 113). Falls can lead to various injuries, including fractures, functional decline, traumatic brain injury, and nursing home placement, making them the “leading cause of accidental death in people over 65 years old” (Lasater et al., 2016, p. 545). In addition to the human cost, falls increase healthcare expenses due to the need to treat preventable injuries. Healthcare organizations are thus focused on falls prevention to enhance patient safety and reduce healthcare costs. This paper examines the risk factors of patient falls and evidence-based solutions. It also explores the role of nurses in falls prevention and identifies stakeholders with whom nurses should collaborate to address this safety concern.

Factors Leading to Patient-Safety Risk

Patient fall risk factors can be categorized as intrinsic and extrinsic. Intrinsic factors include patient characteristics such as age, sex, previous falls, balance impairment, gait, activities of daily living (ADL) disabilities, stroke, cognitive impairments, Parkinson’s disease, and incontinence (Kwan et al., 2016). The risk of falls increases with age, with those aged 65-74 years having a 32% probability and those over 80 years having a 37% probability (Kwan et al., 2016). Extrinsic factors related to the environment include home hazards, use of assistive devices, and inappropriate footwear (Morone et al., 2018; Kwan et al., 2016). The Morse scale assesses risk factors such as history of falls, secondary diagnosis, walk assistance, parenteral therapy, mental status, and gait to determine an individual’s risk of falls (Nadia & Permanasari, 2018).

Evidence-Based Solutions

Addressing patient falls begins with identifying at-risk patients and conducting a multifactorial fall risk assessment for older patients (Morone et al., 2018). Assessment should include factors like gait, balance, mental status, reflexes, and various functions (Morone et al., 2018). Analyzing the type of fall is crucial for selecting preventive strategies, categorizing falls as accidental, unanticipated physiological, anticipated physiological, or intentional (Morone et al., 2018). Evidence-based practices include minimizing psychoactive drug use, engaging in gait and balance training, and providing vitamin D supplementation (Morone et al., 2018). Managing conditions identified during risk assessment, such as visual impairment or a hazardous home environment, is also critical. Effective fall prevention involves interventions addressing both clinical assessment findings and individual risk assessment outcomes (Morone et al., 2018).

The Role of Nurses in Addressing Patient-Safety Risk

Nurses play a central role in addressing the safety issue of patient falls due to their extensive patient interaction and involvement in the care team (Nadia & Permanasari, 2018). Nurses contribute to fall risk assessment using tools like the Morse scale, inform patients about fall risks, and provide necessary assistance. Effective communication among nurses is vital for ensuring patient safety, as poor communication can jeopardize care coordination (Tucker et al., 2019).


Collaboration with various stakeholders is essential for implementing evidence-based solutions for patient falls. Nurses should educate patients and families on fall risks and prevention strategies. Cooperation with doctors and pharmacists is crucial for adjusting medications and administering vitamin D. Nurses should also work with social workers and doctors to implement strategies like exercise programs, motivational interviewing, and environmental assessment. Effective communication among nurses is necessary for sharing information about safety issues and addressing them (Lasater et al., 2016; Tucker et al., 2019).


Kwan, E., Straus, S., & Holroyd-Leduc, J. (2016). Risk factors for falls in the elderly. In A. Huang & L. Mallet (Eds.), Medication-related falls in older people (pp. 91-101). Adis.

Lasater, K., Cotrell, V., McKenzie, G., Simonson, W., Morgove, M. W., Long, E. E., & Eckstrom, E. (2016). Collaborative falls prevention: Interprofessional team formation, implementation, and evaluation. The Journal of Continuing Education in Nursing, 47(12), 545-550.

Morone, G., Federici, A., Tramontano, M., Annicchiarico, R., & Salvia, A. (2018). Strategies to prevent falls. In G. Sandrini, V. Homberg, L. Saltuari, N. Smania, & A. Pedrocchi (Eds.), Advanced technologies for the rehabilitation of gait and balance disorders (pp. 149-158). Springer.

Nadia, P., & Permanasari, V. Y. (2018). Compliance of the nurse for fall risk assessment as a procedure of patient safety: A systematic review. KnE Life Sciences, 4(9), 207-219.

Tucker, S., Sheikholeslami, D., Farrington, M., Picone, D., Johnson, J., Matthews, G., Evans, R., Gould, R., Bohlken, D., Comried, L., Petrulevich, K., Perkhounkova, E., & Cullen, L. (2019). Patient, nurse, and organizational factors that influence evidence‐based fall prevention for hospitalized oncology patients: An exploratory study. Worldviews on Evidence-Based Nursing, 16(2), 111-120.

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