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Enhancing Quality and Safety: Health System

Despite the fact that in the context of present-day developments, medicine is constantly progressing and supplies the most effective treatment options, there is still a likelihood of patient safety risks and health providers’ mistakes. In some cases, such errors may cost patients’ lives. Kohn et al. (2000) report: “experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals” (para. 1).

For this reason, healthcare organizations are extremely interested in finding an appropriate solution and minimizing these risks and attempt to implement the latest innovations in this field. Therefore, the purpose of this paper is to cover the factors leading to patient safety risks, elements of successful quality improvement incentives, the role of nurses in this regard, applying the practical case.

The Description of The Case

In order to cover the aforementioned questions, a practical case should be applied. Florence is an elderly woman aged 84 years old and diagnosed with hypertension and rheumatoid arthritis (NICE, 2015). She lives alone and visits her daughter every week, who resides 50-60 kilometers far from her.

The patient is provided essential support from a care worker on an everyday basis. The list of prescribed medications for her contained bendroflumethiazide, lisinopril, simvastatin, methotrexate, folic acid, and paracetamol (NICE, 2015). After some time, Florence felt the symptoms of urinary frequency, dysuria, and urge incontinence. She was diagnosed with a urinary tract infection (UTI) and prescribed trimethoprim (NICE, 2015). However, her condition deteriorated, and a hospital doctor changed the medication to co-amoxiclav (NICE, 2015). Therefore, it was a prescribing mistake, as trimethoprim cannot be combined with methotrexate due to life-threatening risks for the health state.

Factors Leading to Patient Safety Risks

There are multiple factors, which are highly likely to lead to patient safety risks in the situation described earlier. One of them implies some problems or the lack of communication between the health care providers (Kohn et al., 2000; NICE, 2015). The mistake can be prevented in case the doctor, who prescribed trimethoprim, contacted the care worker or Florence’s daughter (NICE, 2015). The possibility of discussing the treatment plan may contribute to the successful solution of the patient’s health problem without medication errors.

In addition, it may be assumed that there are no appropriate standards in the medical setting in this regard, which regulate the actions of doctors in similar situations. It is highly likely that in case there were precise rules, which determine the behavior of workers, a doctor would double-check his or her prescriptions (Kohn et al., 2000; NICE, 2015). Therefore, he or she would be able to compare them with Florence’s treatment plan and provide a more patient-centered approach.

It should be admitted that some human factors may lead to medical errors as well. It is a widely known fact that nurses have to fulfill a variety of duties and their workload is high. Consequently, there is a likelihood that it was a stressful day when health care providers were required to helped a great number of clients (Kohn et al., 2000). In this context, it is evident that nurses could be exhausted and could not provide medical service of high quality. In these situations, people cannot be concentrated and consider all the details (Kohn et al., 2000). They did not have time to be attentive, which might present the reason for the medication mistake.

Furthermore, there is a likelihood of numerous interruptions while consulting the patients, which also result in the lack of attention. Occasionally, nurses are required to fulfill multiple duties at the same time, which prevents them from focusing on the client’s problems (Allen, 2013; Kohn et al., 2000). Therefore, high workload and a range of responsibilities may aggravate the situation and bother nurses delivering competent and attentive care for the patients.

Elements of a Successful Quality Improvement Incentive

These factors determine the most effective improvement incentives, which will contribute to avoiding these types of mistakes in the future. First of all, it is essential to address the issue of communication between health care providers, the patients, and her relatives (NICE, 2015). They should be asked about the specialties of the health condition of the patient with multiple problems before prescribing additional medications (Allen, 2013). It should become an integral part of appointments in case doctors have to find a solution for the patients with a range of health problems (Allen, 2013). This action also implies reviewing the current treatment plan and its discussion with the care worker and the daughter of Florence.

This strategy should be adhered by the specialists as well. For instance, both nurses and pharmacists should contact each other while choosing appropriate medication for the patient. In addition, physicians should participate in decision-making in this regard too (Allen, 2013; NICE, 2015). This way, it is possible to provide a patient-centered care and comprehensive approach for solving all the problems without the likelihood of medical errors.

Furthermore, the health care organization should be interested in addressing these issues. It is essential to establish appropriate standards, which determine the actions of health care providers in these situations (NICE, 2015). The medical setting should supply its staff members with precise practical steps, which will involve considering all the specialties about the particular case and the patient (Allen, 2013). These requirements may include the necessity to discuss the treatment plan with necessary health care providers or double check the prescribed medication. This measure will be helpful for contributing to delivering patient-centered care.

The described measures contribute to cost reduction due to medical errors. It is apparent that these mistakes not only lead to deterioration of the patient’s health state, but also impacts the price. The lack of proper attention in this regard may result in bankruptcy of the medical setting in case of serious problems (Sheik et al., 2017). Therefore, despite investments associated with the aforementioned incentives, they will helpful for reducing the expenditures in the long run and benefit the organization.

The Role of Nurses

It is apparent that the role of nurses in providing quality and safety enhancements with medication administration should not be underestimated. They may supply essential help by ensuring whether a patient was asked about the current treatment plan and other conditions (Sheik et al., 2017). Nurses may inform clients, such as Florence, about the probable side effect of the prescribed medication and combination with other medications (Sheik et al., 2017).

In addition, they may inquire about additional social care and support for the patient, in case it is needed while the patient has health problems (NICE, 2015). Moreover, nurses may be responsible for conducting conversations with the care worker and the daughter of Florence in order to be aware of additional information about her treatment and general health condition (Sheik et al., 2017). Therefore, it is vital for nurses to coordinate their work with doctors and contribute to providing patient-centered care using possible options. Doctors should be aware of this issue and check the prescriptions.

In addition, directors of medical settings can be noted as stakeholders, who are interested in enhancing quality and increasing patient safety. As medical errors are associated with additional expenditures and reduction of organization profit, the owners of clinics will be definitely willing to help nurses to address this issue (NICE, 2015). They are capable of addressing all the factors leading to medication mistakes. For instance, they may establish appropriate standards in the company, which will contribute to better medication control (NICE, 2015). Furthermore, directors of medical setting may provide a sufficient solution for high workload among nurses by employing more specialists (NICE, 2015).

Although this measure is highly likely to be connected with additional expenditures, these investments will be beneficial for cost reduction in the long run (Sheik et al., 2017). Thus, it is essential to nurses to coordinate their works with them in order to avoid or minimize this problem in the future.


In conclusion, it should be mentioned that mistakes in the field of delivering medical services are inevitable, as doctors and nurses are humans, who cannot perform ideally on a constant basis. However, the percentage of error can and should be reduced in order to avoid serious health condition deterioration. In this context, it is essential to analyze the factors leading to patient safety risks and implement appropriate improvements.


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

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

NICE (National Institute for Health and Care Excellence). (2015). Case scenarios for health and social care practitioners. Web.

Sheikh, A., Dhingra-Kumar, N., Kelley, E., Kieny, M. P., & Donaldson, L. J. (2017). The third global patient safety challenge: tackling medication-related harm. Bulletin of the World Health Organization, 95(8), 546–546A. Web.

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