NURS-FPX4020 Assessment 1: Medication Safety Quality Paper
NURS-FPX4020 Assessment 1
Enhancing Quality and Safety
Capella University — BSN FlexPath | Improving Quality of Care and Patient Safety | 2025–2026
Assessment Overview
Healthcare organisations and the professionals who work within them are consistently working toward one central goal — keeping patients safe. And yet, the complexity of modern healthcare means that maintaining safety is never automatic. Systems fail, communication breaks down, and individual nurses often find themselves at the intersection of institutional pressure and patient vulnerability. Quality improvement measures and safety improvement plans exist precisely to address this reality, and baccalaureate-prepared nurses are expected to understand and drive them.
In this first assessment for NURS-FPX4020, you will develop a 3- to 5-page paper that examines a specific patient safety risk related to medication administration. You will analyse the factors that contribute to this risk, identify evidence-based and best-practice solutions from the literature, explain the nurse’s coordinating role in addressing the problem, and identify the stakeholders whose involvement is necessary to sustain any meaningful improvement.
Your starting point should be either a real situation from your current or previous clinical practice or a well-developed hypothetical scenario grounded in a healthcare setting you know. Either approach is acceptable, but the analysis must be specific — not generic. Broad discussions of “medication errors in general” will not satisfy the rubric at the Distinguished level. Specificity in both the problem and the solution is what distinguishes a proficient response from an exceptional one.
Why This Assessment Matters
Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission’s National Patient Safety Goals (NPSGs) programme have each been instrumental in reshaping how the nursing profession approaches patient safety. A foundational understanding of these organisations — what they stand for, what standards they set, and what evidence they have generated — is prerequisite knowledge for this assessment. Before you begin writing, review the Identifying Safety Risks and Solutions activity available in your NURS-FPX4020 courseroom. Learners who complete courseroom activities prior to their first submission are consistently more successful in reaching Distinguished on their initial attempt.
Assessment Instructions
As a baccalaureate-prepared nurse, you are responsible for identifying and implementing quality improvement and patient safety measures in your healthcare setting. For this assessment, you will analyse a current issue or clinical experience surrounding a medication administration safety risk and identify a quality improvement (QI) initiative that would address it. Your paper must address all of the following required content areas.
Scenario Context
Consider a previous experience or a well-developed hypothetical situation involving a medication error or medication administration safety risk, and examine how the error could have been prevented or reduced through evidence-based guidelines. Choose a specific medication administration safety risk as the central focus of your paper — for example, wrong-patient dosing, high-alert medication protocols, look-alike/sound-alike drug confusion, barcode scanning non-compliance, or nurse interruptions during medication preparation — and use that specific risk to anchor your entire analysis.
Required Content Area 1 — Factors Contributing to the Medication Administration Safety Risk
Identify and explain the specific factors that lead to the patient safety risk you have chosen. Your analysis must go beyond simply naming the problem. Address the following:
- Patient-level factors that increase vulnerability to the identified risk (e.g., polypharmacy, cognitive impairment, inability to self-advocate)
- Nurse- and provider-level factors that contribute to the risk (e.g., fatigue, skill-mix gaps, inadequate training on high-alert medications, communication failures during handoff)
- Organisational and systems-level factors that create or sustain the risk (e.g., inadequate staffing ratios, absence of clinical decision support systems, workflow interruptions, poor EHR usability)
- Support your analysis with peer-reviewed evidence — do not rely solely on anecdote or personal observation
This section maps to Competency 2: Analyse factors that lead to patient safety risks.
Required Content Area 2 — Evidence-Based and Best-Practice Solutions
Identify and explain evidence-based and best-practice solutions that directly address the medication administration safety risk you described. Your discussion must:
- Identify at least two specific, evidence-based strategies or interventions — not generalisations — that are supported by peer-reviewed literature
- Explain how each solution addresses the specific factors you identified in Content Area 1
- Address cost reduction where applicable — quality improvement that fails to consider resource sustainability will not be adopted at the organisational level
- Reference QSEN competencies, IOM standards, Joint Commission NPSGs, or comparable professional frameworks where relevant
- Cite all sources with in-text APA 7th edition citations; do not rely on unsupported claims
This section maps to Competency 1: Analyse the elements of a successful quality improvement initiative.
Required Content Area 3 — The Nurse’s Role in Care Coordination
Explain how nurses, in their role as coordinators of patient care, can increase patient safety with respect to medication administration and contribute to cost reduction. Address the following specifically:
- What direct care coordination activities can BSN-prepared nurses lead or participate in to reduce the identified safety risk?
- How does the nurse’s position at the point of care make them uniquely placed to identify and report safety gaps?
- What organisational mechanisms — safety huddles, incident reporting systems, shared governance structures, interdisciplinary rounds — should nurses leverage to sustain the improvement?
- How does effective nurse-led coordination reduce unnecessary costs associated with adverse events, extended length of stay, or preventable readmissions?
This section maps to Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
Required Content Area 4 — Stakeholder Identification
Identify the specific stakeholders with whom nurses would need to coordinate to drive safety enhancements related to medication administration. For each stakeholder group identified, explain:
- Their role in contributing to or perpetuating the current safety risk
- Their role in implementing or sustaining the proposed improvement
- How nurses should approach collaboration with that group
Stakeholders typically include, but are not limited to: prescribing physicians and advanced practice providers, pharmacists, unit managers and nursing administration, informatics and EHR support teams, patients and families, and risk management or quality improvement officers. Do not simply list stakeholders — explain each relationship with specificity.
This section also maps to Competency 4: Identify stakeholders with whom nurses would coordinate to drive safety enhancements.
Submission Requirements
- Length: 3–5 pages of written content, not counting the APA title page or reference list
- Font and spacing: Times New Roman or Calibri, 12-point, double-spaced throughout, 1-inch margins on all sides
- APA title page: Required — include learner name, Capella University, course code, course title, instructor name, and date
- In-text citations: All paraphrased or quoted content must be cited in APA 7th edition format
- References: Minimum of 4 peer-reviewed or scholarly sources, all published within the last 5 years; formatted in APA 7th edition with DOI links where available
- APA headings: Use APA Level 1 or Level 2 headings to organise the four content sections of your paper
- File format: Submit as a Microsoft Word (.docx) file through the Assessment area of your NURS-FPX4020 FlexPath courseroom
- Writing standard: Clear, logical, professional academic writing with minimal grammatical errors and consistent APA adherence throughout
Before submitting, study the scoring guide below carefully. Knowing exactly what each performance level requires for each criterion allows you to self-assess your draft and target Distinguished across all criteria on your first attempt.
Competencies Assessed
This assessment maps directly to the following NURS-FPX4020 course competencies:
- Competency 1: Analyse the elements of a successful quality improvement initiative — addressed through the identification and application of evidence-based, cost-aware solutions to the medication administration safety risk
- Competency 2: Analyse factors that lead to patient safety risks — addressed through the systematic examination of patient, provider, and systems-level contributors to the identified risk
- Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs — addressed through the discussion of care coordination strategies and stakeholder identification
- Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care — assessed through writing quality, logical organisation, and APA formatting adherence throughout the paper
Scoring Rubric — NURS-FPX4020 Assessment 1
Each criterion below aligns with a course competency and is assessed at Distinguished (100%), Proficient (85%), Basic (75%), or Non-Performance (0%). A minimum Proficient rating across all criteria is required to pass this assessment. Resubmissions within your FlexPath subscription term carry no grade penalty.
| Criterion / Competency | Distinguished (100%) | Proficient (85%) | Basic (75%) | Non-Performance (0%) |
|---|---|---|---|---|
| Competency 2: Explain factors leading to a specific patient-safety risk focusing on medication administration | Explains patient, provider, and systems-level factors with analytical precision and specificity. All claims are supported by current (within 5 years) peer-reviewed evidence. The risk is clearly defined and distinguishable from generic medication error discussions. The connection between identified factors and the downstream safety impact is explicitly and logically developed. | Identifies and explains the main factors contributing to the medication administration safety risk, supported by at least one peer-reviewed source. The risk is specific rather than generic. Some factors may receive less development than others, but the overall analysis is substantive and evidence-linked. | Factors are identified but described in broad or surface-level terms. Evidence is present but may not be from peer-reviewed sources or may fall outside the five-year currency window. The safety risk itself may not be clearly or specifically defined, reducing the analytical value of the section. | No meaningful analysis of contributing factors is provided. The discussion is entirely anecdotal, draws on non-credible sources, or addresses a topic unrelated to medication administration safety. The safety risk is not identified. |
| Competency 1: Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs | Identifies at least two specific, evidence-based solutions that are directly matched to the factors identified in the preceding section. Each solution is described in enough depth that its mechanism is clear, and the cost-reduction dimension is addressed with specificity — not as an afterthought. References to QSEN, IOM, NPSG, or equivalent frameworks are integrated naturally and correctly. All solutions are current and peer-reviewed. | Identifies at least two evidence-based solutions with adequate explanation of their relevance to the identified risk. At least one source is peer-reviewed and within the five-year window. Cost reduction is mentioned, though it may not be fully developed. QI frameworks may be referenced but not deeply integrated. | At least one solution is identified, but it may be described in generic terms (e.g., “improve communication”) without specificity about mechanism, evidence base, or cost impact. Peer-reviewed support is present but insufficient or not clearly matched to the identified safety risk. | No evidence-based solutions are provided, or all solutions are drawn from non-credible sources. Cost-reduction considerations are absent. The section does not address medication administration safety in any meaningful way. |
| Competency 4a: Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs | Provides a detailed, practice-specific explanation of how BSN-prepared nurses coordinate care to reduce the identified medication safety risk. The discussion connects nurse-led coordination directly to patient safety outcomes and cost reduction, with reference to real mechanisms (huddles, incident reporting, EHR workflows, interdisciplinary collaboration). Evidence is used to support the coordination approach described. | Explains the nurse’s coordinating role in patient safety improvement with reasonable specificity. The connection between nurse coordination and cost reduction is present. At least one mechanism of coordination is described. The section is supported by evidence or professional literature. | The nurse’s role in coordination is mentioned but described in abstract or idealistic terms rather than practice-specific ones. The cost-reduction dimension is absent or tangential. The discussion could apply to any safety risk rather than being matched to the specific medication administration context. | The nurse’s coordinating role is not addressed, or the discussion focuses solely on individual clinical tasks rather than coordination, quality improvement, or cost impact. No connection to the identified safety risk is present. |
| Competency 4b: Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration | Identifies at least three specific stakeholder groups with a distinct explanation of each group’s role in contributing to the current risk and in implementing or sustaining the proposed improvement. The nurse-stakeholder relationship is described specifically for each group. The stakeholder analysis is evidence-informed and tailored to the specific clinical context of the paper. | Identifies at least two stakeholder groups with explanation of their relevance to medication administration safety improvement. Each group’s coordinating role is described, though some entries may lack the specificity or depth of a Distinguished response. The relationship to the identified safety risk is present for each stakeholder. | Stakeholders are listed by name or category without substantive explanation of their roles. The discussion reads as a checklist rather than an analysis. The connection between stakeholder involvement and the specific safety risk described in the paper is weak or implied rather than explicit. | No stakeholders are identified, or only a single stakeholder is mentioned without explanation. The section is absent, irrelevant, or contains no connection to quality improvement or medication administration safety. |
| Competency 5: Communicate using writing that is clear, logical, and professional with correct grammar and spelling; apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format | Writing is professional, clear, and logically organised throughout. Ideas transition smoothly between sections. Grammar, spelling, and punctuation are correct throughout with no distracting errors. APA 7th edition in-text citations and reference list entries are nearly flawless — hanging indents, alphabetical order, correct DOI formatting, and consistent italics are all present. Paper length falls within 3–5 pages. At least 4 peer-reviewed sources within 5 years are cited. | Writing is clear and professionally organised with only minor errors that do not impede reading. APA formatting is applied consistently with only occasional minor lapses (e.g., one missing DOI, one inconsistent heading level). Paper meets the minimum length requirement. At least 4 sources are cited, most within the five-year window. | Writing contains recurring grammatical or mechanical errors that distract the reader. Organisation is inconsistent — some sections are underdeveloped relative to others. APA formatting errors are present across multiple reference entries or in-text citations. Paper may fall below minimum length or cite fewer than four sources. | Writing is disorganised, unclear, or substantially below professional standard. APA citations and references are absent, consistently incorrect, or formatted in a non-APA style. Fewer than two sources are cited. Paper is substantially below the minimum length requirement. |
FlexPath Grading Note: NURS-FPX4020 uses a competency-based pass/fail model. Assessments are rated Distinguished, Proficient, Basic, or Non-Performance per criterion. You must achieve at minimum a Proficient rating on all five criteria to pass. Resubmissions carry no penalty within your current subscription term, but delays caused by multiple resubmission cycles can affect your course completion timeline.
Sample Answer Guide NURS-FPX4020 Assessment 1: Enhancing Quality and Safety
Medication administration errors represent one of the most preventable categories of patient harm in acute care settings, yet they continue to occur at rates that reflect deep systemic problems rather than individual lapses in nursing attentiveness. At the unit level, nurses preparing and administering medications are routinely interrupted, working under staffing ratios that exceed safe thresholds, and operating electronic health record systems whose usability has not kept pace with clinical demand — a convergence of environmental stressors that the literature consistently associates with increased error rates. One of the most evidence-supported interventions for reducing interruption-related medication errors is the implementation of a Medication Safety Zone (MSZ), a designated physical and policy-protected space in which nurses cannot be non-urgently interrupted during medication preparation, a strategy that has demonstrated measurable reductions in distraction-related errors in multiple acute care trials. Nurse-led safety huddles conducted at shift change provide an additional coordination mechanism that allows the oncoming team to flag high-alert medication patients, recent near-miss events, and pending pharmacist consults before care begins — rather than discovering risk mid-shift when the window for prevention has already narrowed. Involving pharmacists as active members of interdisciplinary rounding teams, rather than consultants engaged only after an error occurs, addresses the stakeholder coordination gap that underlies many preventable adverse drug events. According to Rodziewicz, Houseman, and Hipskind (2024, StatPearls), the majority of serious medication errors are traceable to system vulnerabilities rather than individual nurse error, which means that sustainable quality improvement must be directed at the system rather than the individual clinician.
Reading Materials Resources (APA 7th Edition Format)
- Rodziewicz, T.L., Houseman, B. & Hipskind, J.E. (2024). Medical error reduction and prevention. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
- Tariq, R.A., Vashisht, R., Sinha, A. & Scherbak, Y. (2023). Medication dispensing errors and prevention. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519065/
- Bell, T., Sprajcer, M., Flenady, T. & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17–18), 5445–5460. https://doi.org/10.1111/jocn.16620
- Westbrook, J.I., Li, L., Hooper, T.D., Raban, M.Z., Middleton, S. & Lehnbom, E.C. (2021). Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: A cluster randomised controlled feasibility study. BMJ Quality & Safety, 30(7), 588–597. https://doi.org/10.1136/bmjqs-2020-011773
- Manias, E., Kusljic, S. & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 1–29. https://doi.org/10.1177/2042098620968309