Patient safety is an integral part of value-based healthcare. Ensuring patient safety can lead to faster recovery times, which, in turn, leads to lower costs of care. When combined, these factors result in improved patient satisfaction. Ensuring patient safety requires professional nurses to be proactive in identifying potential safety concerns and proposing evidence-based solutions to mitigate those concerns across the healthcare continuum.

Your goal for this task is to clearly and concisely propose a recommendation that addresses an identified systems-level safety issue that affects patients within a healthcare setting, such as your practice or a colleague’s practice, using convincing evidence to promote the necessity for change.
A. Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the following:

1. Describe a healthcare-related situation (S) prompting a systems-level patient safety concern that has the potential to impact multiple patients.
2. Analyze background (B) information about the concern by doing the following:
a. Describe the data that support or would support the need for change.
b. Explain how one or more national patient safety standards apply to this situation.
3. Assess (A) the impact of the safety concern on the patient(s), staff, and the organization as situated in the identified healthcare setting.
a. Explain how the safety concern affects value for the patient(s) and the healthcare setting.
4. Recommend (R) an evidence-based practice change that addresses the safety concern.
a. Discuss how this recommendation aligns with the principles of a high-reliability organization.
b. Describe two potential barriers to the recommended practice change.
c. Identify two potential interventions to minimize the barriers from part A4b to the recommended practice change.
d. Discuss the significance of shared decision-making among the healthcare setting’s relevant stakeholders in implementing this recommendation.
e. Describe an outcome measure that could be used to evaluate the results of the recommendation.
f. Describe the care delivery model currently being used in the healthcare setting.
i. Explain how the current care delivery model in the healthcare setting identified in part A4f would be impacted by the recommended change in part A4.
B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.


Sample Answer

Sample Answer




Addressing Systems-Level Patient Safety Concern in Healthcare Settings

In healthcare settings, ensuring patient safety is paramount to providing high-quality care and improving patient outcomes. One significant systems-level safety concern that requires attention is medication errors, which can have detrimental effects on multiple patients within a healthcare facility. By applying the Situation, Background, Assessment, Recommendation (SBAR) format, this proposal will outline the importance of addressing medication errors and provide evidence-based recommendations for practice change.

Situation (S):

Medication errors are a prevalent issue in healthcare settings, often stemming from factors such as miscommunication, inadequate training, and system failures. These errors have the potential to impact multiple patients, leading to adverse drug reactions, treatment delays, and compromised patient safety.

Background (B):

– Data Supporting the Need for Change: Studies have shown that medication errors are a leading cause of preventable harm in healthcare, affecting millions of patients annually. The Institute of Medicine estimates that medication errors result in over 7,000 deaths each year in the United States alone.

– National Patient Safety Standards: The Joint Commission’s National Patient Safety Goals emphasize the importance of improving medication safety by implementing processes to reduce the likelihood of errors, including accurate medication reconciliation and standardizing medication administration protocols.

Assessment (A):

The impact of medication errors extends beyond individual patients to affect healthcare staff and the organization as a whole. These errors compromise the value for patients by jeopardizing their safety and well-being. Additionally, healthcare settings face increased costs associated with managing the consequences of medication errors, such as prolonged hospital stays and legal repercussions.

Recommendation (R):

An evidence-based practice change to address medication errors involves implementing barcode medication administration (BCMA) systems. BCMA systems utilize technology to verify patient identity, medication accuracy, and dosage before administration, reducing the risk of errors significantly. This recommendation aligns with high-reliability organization principles by emphasizing a proactive approach to error prevention.

– Barriers to Practice Change:

1. Resistance to change among staff members accustomed to traditional medication administration methods.
2. Financial constraints related to acquiring and implementing BCMA systems.

– Interventions to Minimize Barriers:

1. Providing comprehensive training and support for staff transitioning to BCMA systems.
2. Securing funding through grant opportunities or cost-sharing agreements with vendors.

– Significance of Shared Decision-Making:
Engaging stakeholders, including frontline staff, administrators, and IT specialists, in shared decision-making is crucial for successful implementation. Involving relevant parties in the planning and execution of practice changes fosters buy-in and promotes a culture of collaboration.

– Outcome Measure:
The reduction in medication error rates following the implementation of BCMA systems can serve as an outcome measure to evaluate the effectiveness of the recommendation. Tracking error rates, adverse drug events, and patient outcomes will provide valuable data on the impact of the practice change.

– Impact on Care Delivery Model:
The current care delivery model in the healthcare setting may shift towards a more technology-driven approach with the introduction of BCMA systems. This change will streamline medication administration processes, enhance patient safety, and promote a culture of continuous improvement in medication management practices.

In conclusion, addressing systems-level patient safety concerns such as medication errors requires a proactive and evidence-based approach to ensure optimal care delivery and patient outcomes. By implementing technological solutions like BCMA systems and fostering shared decision-making among stakeholders, healthcare settings can enhance patient safety and quality of care.


1. Author Last Name, First Initial. (Year). Title of Source. Publisher.
2. Author Last Name, First Initial. (Year). Title of Source. Publisher.


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