Quality Risk Management Assignment

Case Study Evaluation

1. Area of Improvement in the Case Study

The quality improvement project focused on reducing medication administration errors in the Pediatric Intensive Care Unit (PICU). Medication safety is a high-risk area in pediatric settings because:

• Children require weight-based medication dosing

• Narrow therapeutic ranges increase harm risk

• Communication gaps often occur during care transitions

• Nurses frequently manage multiple high-alert drugs

The area of improvement specifically targeted:

• Wrong dose administration

• Timing deviations

• Omission and duplication errors

• Documentation and transcription gaps

The project aimed not only to reduce error frequency but to build a sustainable safety culture through structured process improvement, multidisciplinary engagement, and continuous monitoring using the PDCA framework.

2. Tools Used to Identify Causes & Common Types of Errors

The improvement team used a combination of Root Cause Analysis tools, including:

• Fishbone (Ishikawa) diagram

• Process mapping

• Observation audits

• Incident reports

• Staff feedback discussions

These tools helped reveal multiple contributing dimensions — human factors, workload, documentation practices, communication gaps, and system-level barriers.

Most Common Types of Medication Errors Identified

The most frequently reported errors included:

• Wrong dose administration

• Wrong time or delayed dose

• Omission or missed medications

• Incorrect infusion rates

• Documentation discrepancies

Several of these errors were attributed to:

• Calculation mistakes during weight-based dosing

• Poor legibility of medication charts

• Inconsistencies between orders and administration records

• High workload during peak shifts

Main Causes Addressed Across PDCA Cycles

Across multiple PDCA cycles, the hospital primarily addressed:

• Lack of standardized medication preparation procedures

• Limited staff awareness regarding double-checking protocols

• Inadequate orientation of new staff and trainees

• Insufficient monitoring of near-miss incidents

• Lack of visual prompts for high-alert drug administration

The consistent use of data across cycles ensured that interventions were evidence-driven and clinically relevant.

3. Number of PDCA Cycles & Value of Incremental Interventions

The improvement project was conducted through several sequential PDCA cycles, with each cycle addressing a specific priority area. Rather than implementing one large change, the team adopted incremental interventions, allowing improvement outcomes to be monitored and refined progressively.

Examples of PDCA intervention themes included:

• Standardizing medication labeling and calculation charts

• Introducing mandatory double-checking for high-risk medications

• Implementing medication administration checklists

• Strengthening reporting of near-miss errors

• Enhancing staff training and safety awareness

Advantages of Using Multiple PDCA Cycles

Implementing changes in smaller iterative cycles enabled:

• Early identification of ineffective solutions

• Reduced disruption to ongoing clinical workflows

• Real-time learning and adaptation

• Enhanced staff participation and ownership

• Safer change management in a critical care setting

Small-scale improvement cycles ensured that corrective actions were:

• Practical

• Operationally feasible

• Clinically sustainable

This approach strengthened the reliability and continuity of patient-safety practices.

4. Results of the Quality Improvement Project

The project led to a significant reduction in medication administration errors across the PICU. Key outcomes included:

• Marked decrease in wrong-dose and timing-related errors

• Improvement in documentation accuracy

• Better compliance with double-checking policy

• Stronger reporting culture for near-miss incidents

• Increased staff confidence in medication safety protocols

The results also demonstrated:

• Improved interdisciplinary collaboration

• Standardization of medication preparation workflows

• Enhanced monitoring of safety indicators

Over time, the organization observed movement toward a culture of zero-tolerance for preventable medication harm, aligning with patient-safety goals.

5. Challenges Faced & Strategies to Overcome Them

The implementation team encountered several challenges during the improvement journey, including:

• Resistance to change among experienced staff

• Time constraints during high-workload shifts

• Variation in skill levels of new nursing staff

• Limited familiarity with quality improvement tools

• Under-reporting of near-miss incidents due to fear of blame

Strategies Used to Overcome Challenges

To address these barriers, the team implemented:

• Regular training workshops on medication safety

• Orientation sessions for new staff

• Non-punitive error reporting culture

• Continuous communication through meetings & reminders

• Engagement of nursing leadership as project champions

The adoption of a supportive learning environment promoted:

• Shared responsibility

• Trust in the improvement process

• Sustained staff participation

Ultimately, the project not only reduced medication errors but also strengthened team learning, transparency, and safety-oriented thinking within the PICU.

Part B PDCA Quality Improvement Project

Project Theme: Reducing Delays in Medication Administration During Shift Transitions in a Hospital Ward

Area of Improvement

The selected improvement area focuses on reducing medication administration delays occurring during nursing shift handovers.

Review of ward medication logs showed:

• High frequency of delayed doses during change-of-shift periods

• Communication gaps between outgoing and incoming nurses

• Incomplete medication task handovers

• Workload clustering immediately after shift start

Delayed doses are particularly risky for:

• Antibiotics

• Cardiac medications

• Insulin and critical-care drugs

Therefore, improving medication timeliness supports both:

• Patient safety

• Clinical outcome reliability

Data-Driven Observation Summary

Baseline audit (four weeks) showed:

• 23% of scheduled medications were delayed beyond acceptable window

• Most delays occurred within 30 minutes of shift transition

• Documentation of reasons for delay was inconsistent

Stakeholder interviews revealed contributing factors such as:

• Overlapping clinical priorities during shift change

• Lack of structured medication handover checklist

• Inconsistent prioritization of critical medications

SMART Objective

To reduce medication administration delays during shift transitions by 40% within eight weeks, through structured handover standardization, double-check verification, and monitoring of compliance using performance indicators.

Root Cause Analysis Using Fishbone Diagram

Major cause categories:

• People: new staff unfamiliar with handover protocols

• Process: no standardized shift-handover checklist

• Environment: high workload peaks at shift start

• Communication: incomplete medication status reporting

• Equipment: dispersed medication charts and MAR sheets

Underlying root causes identified:

• Absence of clear prioritization of time-sensitive medications

• Limited accountability during medication transfer of responsibility

• Dependency on verbal handover without checklist validation

Pareto Analysis Identifying Key Root Causes

Pareto findings indicated that two primary contributors accounted for most delays:

1. Lack of structured medication handover checklist

2. Unclear prioritization of critical and time-sensitive medications

Therefore, improvement strategies were directed toward:

• Checklist introduction

• Clear medication priority marking

• Staff engagement and monitoring

PDCA Implementation Framework

PLAN

• Develop standardized Medication Handover Checklist

• Mark time-critical medications with visual alerts

• Train nursing staff on checklist-based transitions

• Define delay threshold and reporting protocol

DO

• Implement checklist during two pilot shifts for four weeks

• Assign medication coordinator during handover period

• Conduct weekly monitoring audits

• Collect staff feedback for refinement

CHECK

Outcome evaluation after pilot:

• Delays reduced from 23% to 11%

• Improved documentation clarity

• High compliance with checklist usage

Feedback suggested:

• Need for digital checklist integration

• Additional induction training for new staff

ACT

Final implemented actions:

• Checklist integrated into electronic MAR system

• Mandatory training during staff onboarding

• Monthly performance review dashboards

• Appointment of shift safety champions

This ensured intervention sustainability and continuous monitoring.

Key Performance Indicators 

KPI metrics used to evaluate improvement:

• Percentage of delayed medication doses

• Number of shift-handover checklist compliance events

• Rate of near-miss or timing-related safety incidents

• Staff adherence to documentation standards

Post-implementation results indicated:

• Sustained reduction in medication delays

• Standardized handover communication

• Improved nursing team coordination and accountability

Conclusion

Both the case study review and PDCA project emphasize that systematic quality improvement, data-driven analysis, and iterative PDCA cycles play a vital role in enhancing patient safety and minimizing medication-related risks. Combining structured tools such as fishbone diagrams, Pareto analysis, KPI monitoring, and incremental interventions results in:

• Stronger safety culture

• Improved clinical reliability

• Sustainable operational efficiency

This approach demonstrates how Quality Risk Management can effectively transform healthcare processes and outcomes.

Summary of Assessment Requirements

This assessment focuses on Quality Risk Management within a healthcare context and is divided into two key parts:

Part A Case Study Evaluation (Maximum 2000 Words)

Students are required to critically analyse the article:

“Targeting zero medication administration errors in the pediatric intensive care unit: A Quality Improvement project” (Ghezaywi et al., 2024)

The key expectations include:

• Identifying the area of improvement discussed in the case study

• Describing the quality improvement tools used to identify causes of medication errors

• Explaining the most common types and causes of medication errors

• Analysing the PDCA cycles implemented and the advantage of using multiple cycles

• Summarising the project outcomes and improvements achieved

• Discussing the challenges faced and strategies used to overcome them

The intent of this section is to evaluate the learner’s ability to interpret real-world healthcare risk-management initiatives through a structured quality improvement lens.

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Part B Independent PDCA Project (Maximum 1200 Words)

Students must design and present an original PDCA improvement project in the healthcare setting of their choice. The project must:

• Identify a clear process improvement problem area

• Present data-driven observations

• Develop a SMART objective

• Conduct root-cause analysis using Fishbone diagram

• Identify key causes using a Pareto chart

• Propose targeted improvement interventions

• Define suitable Key Performance Indicators (KPIs)

• Demonstrate all four PDCA stages
  (Plan – Do – Check – Act)

This section tests the student’s capability to apply quality improvement methodologies in practice and demonstrate analytical, evaluative, and reflective problem-solving skills.

How the Academic Mentor Guided the Student

The Academic Mentor adopted a structured and supportive guidance approach to ensure the student understood both the academic expectations and the practical application of quality risk-management concepts.

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Step 1 Understanding Assessment Scope & Academic Expectations

The mentor first guided the student through:

• Interpreting assignment instructions

• Understanding plagiarism tolerance & APA 7th requirements

• Clarifying outcome-based learning expectations

The mentor emphasised:

• Critical analysis rather than descriptive writing

• Evidence-based arguments

• Logical organisation of sections

• Integration of Quality Risk Management principles

This ensured that the student approached the task with clarity, academic integrity, and focus.

Step 2 Structuring Part A: Case Study Evaluation

The mentor helped the student structure Part A into logically aligned sections:

1. Area of Improvement in the Case Study

   • Highlighting medication safety as a high-risk area in PICU

   • Focusing on wrong-dose, timing errors, omissions, and documentation gaps

2. Tools Used to Identify Causes of Errors

   • Fishbone diagram

   • Process mapping & audits

   • Incident reporting & staff feedback

3. Common Types & Causes of Medication Errors

   • Weight-based dosing miscalculations

   • Documentation inconsistencies

   • High workload during peak periods

4. PDCA Cycles and Incremental Interventions

   • Standardisation of procedures

   • Double-checking protocols

   • Training and awareness initiatives

5. Project Results & Improvements Achieved

   • Reduced wrong-dose and timing errors

   • Stronger reporting culture

   • Improved documentation practices

6. Challenges Faced & Strategies Adopted

   • Resistance to change & workload constraints

   • Skill variation among new staff

   • Shift toward non-punitive safety culture

The mentor guided the student to maintain:

• Analytical tone

• Evidence-based reasoning

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