Student Name
Capella University
NURS FPX 4010 Leading in Intrprof Practice
Prof. Name
Date
Interview Summary
Organizational Background and Interview Context
The interview was conducted at Gifford Medical Center, a 27-bed critical access hospital located in Vermont. The facility is recognized for delivering comprehensive community-based healthcare services, including 24-hour emergency care, inpatient services, outpatient treatments, and preventive health programs (Gifford Health Care, n.d.). The hospital’s infrastructure integrates modern clinical technologies designed to enhance patient safety and care coordination.
The interviewee was a senior registered nurse with ten years of experience at the institution. Her responsibilities included medication administration, monitoring patient outcomes, supervising clinical documentation, and collaborating with interdisciplinary professionals to ensure continuity of care. The discussion focused primarily on patient safety challenges, particularly medication-related errors within the organization.
A key question addressed during the interview was: What factors contribute most significantly to medication errors within the facility? The nurse identified communication breakdowns, high patient-to-nurse ratios, workflow interruptions, and the complexity of medication administration systems as principal contributors. Although the organization has implemented electronic Medication Administration Records (eMAR) and conducts periodic staff training, these interventions have only partially reduced errors.
Another central question explored was: What strategies could further reduce medication errors? The interviewee emphasized the necessity of a structured interdisciplinary approach involving nurses, pharmacists, and physicians to improve medication reconciliation, verification processes, and real-time communication.
Two primary interviewing techniques facilitated the depth of responses. First, open-ended questioning encouraged detailed explanations and minimized response bias (Karnehed et al., 2024). Second, active listening strengthened rapport and allowed clarification of subtle concerns, thereby enhancing the credibility and richness of the data collected (Ozavci et al., 2022).
Summary of Key Interview Insights
| Question Explored | Interview Response | Implications for Practice |
|---|---|---|
| What are the leading causes of medication errors? | Communication failures, high workload, complex medication workflows | Indicates systemic and process-based deficiencies |
| Are current interventions effective? | eMAR and training help but do not eliminate errors | Suggests need for broader systemic reform |
| What improvements are necessary? | Stronger interdisciplinary coordination and accountability | Supports team-based safety model |
Issue Identification
Scope and Significance of Medication Errors
Medication errors remain a persistent patient safety issue both nationally and locally. In the United States, approximately 1.4 million individuals are affected annually, with at least one medication-related fatality occurring each day (Naseralallah et al., 2023).
Within the organization, errors arise from multifactorial causes, including communication gaps among healthcare professionals, excessive workloads, and fragmented medication management processes. A critical question emerges: Why do medication errors persist despite technological interventions? The answer lies in the complexity of healthcare systems, where technological tools alone cannot compensate for human factors and communication failures.
Medication administration requires coordinated actions across multiple disciplines. From prescribing to dispensing to bedside administration, each step introduces potential vulnerabilities. Therefore, addressing this issue demands structured interdisciplinary collaboration (Gregory et al., 2021).
An interdisciplinary framework promotes shared accountability, standardized protocols, and improved medication reconciliation processes. By fostering collective problem-solving and transparent communication, healthcare teams can reduce variability in practice and enhance patient outcomes.
Change Theory That Could Lead to an Interdisciplinary Solution
Application of Lewin’s Change Theory
Kurt Lewin’s Change Theory provides a systematic model for implementing organizational transformation. The framework consists of three phases: Unfreezing, Changing, and Refreezing (Barrow et al., 2022).
During the Unfreezing phase, leadership acknowledges medication errors as a systemic safety concern requiring structured reform. Data transparency, incident reporting, and stakeholder engagement create readiness for change.
The Changing phase involves implementing interdisciplinary interventions such as standardized communication protocols, medication reconciliation audits, and collaborative safety rounds. Interprofessional education programs would reinforce shared responsibilities among physicians, nurses, and pharmacists.
Finally, the Refreezing phase institutionalizes new practices by embedding them into policy, performance metrics, and organizational culture. Continuous quality monitoring ensures sustainability of improvements.
Arabi et al. (2022) emphasize that structured change management models significantly enhance communication during health information system implementation. Applying Lewin’s framework reduces resistance, strengthens interdisciplinary engagement, and supports long-term medication safety improvements.
Leadership Strategy That Could Lead to an Interdisciplinary Solution
Transformational Leadership as a Catalyst for Change
Transformational leadership is particularly effective in complex healthcare environments requiring cultural shifts. This leadership style motivates teams through shared vision, empowerment, and professional development (Deveaux et al., 2021).
A critical question addressed is: How can leadership influence medication safety outcomes? Transformational leaders cultivate psychological safety, encourage reporting of near-misses, and promote innovation in safety practices. By modeling collaborative behaviors and recognizing interdisciplinary contributions, leaders enhance team cohesion.
Research demonstrates that transformational leadership correlates with reduced burnout, improved team performance, and enhanced patient safety metrics (Chen et al., 2022). Leaders who prioritize communication clarity, resilience, and accountability create environments conducive to safe medication administration.
Through inspirational motivation and individualized consideration, this leadership model supports the interdisciplinary integration necessary to mitigate medication errors.
Collaboration Approach for Interdisciplinary Teams
Establishment of a Medication Safety Committee
A structured Medication Safety Committee represents a practical interdisciplinary solution. This committee would include nurses, pharmacists, physicians, and quality improvement personnel. Its core responsibilities would encompass monitoring medication-related incidents, reviewing reconciliation processes, and implementing evidence-based safety interventions (Chiewchantanakit et al., 2020).
Key guiding question: What mechanisms ensure sustained interdisciplinary collaboration? The answer lies in formalized governance structures combined with technological integration.
Integrating Electronic Health Records (EHR), automated dispensing systems, and Barcode Medication Administration (BCMA) strengthens oversight and reduces human error (Jessurun et al., 2021). Regular interdisciplinary review meetings would evaluate error trends, assess root causes, and refine protocols.
The Collaborative Care Model (CCM) further enhances coordination by clarifying roles, establishing accountability structures, and promoting continuous quality improvement cycles. Through real-time alerts and standardized documentation, technological systems support accurate medication dispensing and administration.
Proposed Interdisciplinary Framework
| Component | Purpose | Expected Outcome |
|---|---|---|
| Medication Safety Committee | Oversight and governance | Reduced systemic medication risks |
| EHR & eMAR Integration | Real-time documentation | Improved accuracy and transparency |
| BCMA Technology | Verification at bedside | Fewer administration errors |
| Interdisciplinary Rounds | Collaborative review | Enhanced communication |
Conclusion
Medication errors at Gifford Medical Center stem from communication breakdowns, excessive workloads, and the inherent complexity of medication management systems. Although eMAR implementation and staff education have produced incremental improvements, these measures alone are insufficient.
The interview findings underscore the necessity of a coordinated interdisciplinary strategy supported by Lewin’s Change Theory and transformational leadership principles. Establishing a Medication Safety Committee, strengthening communication protocols, and leveraging health information technologies provide a comprehensive pathway toward sustained improvement.
Through structured collaboration, accountable leadership, and systematic change management, healthcare organizations can significantly reduce medication errors and improve patient safety outcomes.
References
Arabi, Y. M., Al Ghamdi, A. A., Al-Moamary, M., Al Mutrafy, A., AlHazme, R. H., & Al Knawy, B. A. (2022). Electronic medical record implementation in a large healthcare system from a leadership perspective. BMC Medical Informatics and Decision Making, 22(1). https://doi.org/10.1186/s12911-022-01801-0
Barrow, J. M., Toney-Butler, T. J., & Annamaraju, P. (2022). Change management. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459380/
Chen, J., Ghardallou, W., Comite, U., Ahmad, N., Ryu, H. B., Ariza-Montes, A., & Han, H. (2022). Managing hospital employees’ burnout through transformational leadership: The role of resilience, role clarity, and intrinsic motivation. International Journal of Environmental Research and Public Health, 19(17), 10941. https://doi.org/10.3390/ijerph191710941
NURS FPX 4010 Assessment 2 Interview and Interdisciplinary Issue Identification
Chiewchantanakit, D., Meakchai, A., Pituchaturont, N., Dilokthornsakul, P., & Dhippayom, T. (2020). The effectiveness of medication reconciliation to prevent medication error: A systematic review and meta-analysis. Research in Social and Administrative Pharmacy, 16(7), 886–894. https://doi.org/10.1016/j.sapharm.2019.10.004
Deveaux, D., Kaplan, S., Gabbe, L., & Mansfield, L. (2021). Transformational leadership meets innovative strategy: How nurse leaders and clinical nurses redesigned bedside handover to improve nursing practice. Nurse Leader, 20(3), 290–296. https://doi.org/10.1016/j.mnl.2021.10.010
Gifford Health Care. (n.d.). Gifford Medical Center. https://giffordhealthcare.org/location/gifford-medical-center/
Gregory, L. R., Lim, R., MacCullagh, L., Riley, T., Tuqiri, K., Heiler, J., & Peters, K. (2021). Intensive care nurses’ experiences with the new electronic medication administration record. Nursing Open, 9(3), 1895–1901. https://doi.org/10.1002/nop2.939
Jessurun, J. G., Hunfeld, N. G. M., Rosmalen, J., Dijk, M., & Bemt, P. M. L. A. (2021). Effect of automated unit dose dispensing with barcode scanning on medication administration errors: An uncontrolled before-and-after study. International Journal for Quality in Health Care, 33(4), 1–8. https://doi.org/10.1093/intqhc/mzab142
Karnehed, S., Pejner, M. N., Erlandsson, L.-K., & Petersson, L. (2024). Electronic medication administration record (eMAR) in Swedish home healthcare—Implications for nurses’ and nurse assistants’ work environment: A qualitative study. Scandinavian Journal of Caring Sciences, 38(2), 347–357. https://doi.org/10.1111/scs.13237
NURS FPX 4010 Assessment 2 Interview and Interdisciplinary Issue Identification
Naseralallah, L., Stewart, D., Price, M. J., & Paudyal, V. (2023). Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: A systematic review. International Journal of Clinical Pharmacy, 45(6), 1359–1377. https://doi.org/10.1007/s11096-023-01626-5
Ozavci, G., Bucknall, T., Kron, R., Hughes, C., Jorm, C., & Manias, E. (2022). Creating opportunities for patient participation in managing medications across transitions of care through formal and informal modes of communication. Health Expectations, 25(4), 1807–1820. https://doi.org/10.1111/hex.13524
Worafi, Y. M. (2020). Medication errors. In Drug Safety in Developing Countries (pp. 59–71). https://doi.org/10.1016/b978-0-12-819837-7.00006-6