NUR 550 medication administration errors
NUR 550 medication administration errors
The occurrence of medication administration errors hinders effective attainment of quality and safe patient care and outcomes. Medication administration errors are significant safety issue in health care sector, especially when there are different crises affecting healthcare and quality outcomes. The susceptibility of patients to medication administration errors increase with reduced number of healthcare workers against an increase in demand for services due to several factors. Medication administration errors (MAEs) increase the length of stay for critically ill patients and cost of care. Studies demonstrate that leveraging health information technologies that include barcode scanning and other interventions can reduce and prevent the occurrence of these events, especially among the critically ill patients. The purpose of this literature review is to offer a comparison of the articles that supports the evidence-based practice project of using health information technology to reduce the occurrence of medication administration errors among the critically ill patients. The review also identifies the methods used to search the literature and synthesizes it for effective understanding and use for the selected eight articles.
When I think of this question about how to integrate appropriate information, I essentially think of having good advertising and marketing. You have to think of the populations you are trying to reach. I think it’s important to target two main populations younger people 30-45 that may need earlier screening because of high risk and then 45-75 that should be already getting regular screenings. Commercials are great. I am sure we have all heard of Cologuard because of their commercials. Cologuard is an additional way to screen for colorectal cancer but not a replacement for colonoscopies. Social media is also a great way to educate and advertise. But most importantly anytime you go to your primary care physician’s office the nurses, providers, and staff should be discussing regular screenings with the patients and have handouts around the offices with information that people can read while they wait. Also nurses or medical assistants pointing out to providers that a patient is a certain age and has not had a colonoscopy yet. Being the eyes and ears for patients is so important. Another thing for people to know is that insurance should cover these type of screenings at a 100%. This was one great thing about the Affordable Care Act. The Affordable Care Act requires both private insurers and Medicare to cover the costs of colorectal cancer screening tests, because these tests are recommended by the United States Preventive Services Task Force (USPSTF) (Centers for Disease Control and Prevention, 2022). The law stipulates that there should be no out-of-pocket costs for patients, such as co-pays or deductibles, for these screening tests (CDC, 2022). So for people with medical coverage, they should be taking advantage of these benefits.
PICOT Statement
The use of health information technology can reduce and prevent the prevalence of medication administration errors (MAEs) among critically ill patients. The use of interventions like barcode scanning and electronic dispensation ensures that human errors that occur during medication dispensation are reduced or minimized, especially the critically-ill patients in different health settings.
PICOT Question for the Evidence-Based Practice Project
Among the critically ill patients (P), does the integration of health information technology (I) compared to conventional medication administration process (C), lead to a reduction in medication administration errors (O) during patient’s stay (T)?
Search Methods of the Literature
Effective search of articles comprises of using appropriate approaches and terms that align with the topic of interest. In this assignment, I employed different yet related strategies to search for the articles that support the EBP project. These included using institutional library to get databases of journals and their published peer-reviewed articles. I used terms like “peer review” and “scholarly works” about medication administration errors. Through these approaches, I obtained the articles that I used in providing this literature review as they support my EBP project. I also ensured that the article meet the criteria of being published within the last five years and are relevant to the nursing context and use.
Synthesis of Literature
Article 1
The first article is by Alotaibi and Federico (2012) who discuss the impacts of health information technology on patient safety. Through a review of present scientific evidence on the effects of health information technologies on improving patient safety, the authors demonstrate the effectiveness of these interventions in reducing medication administration errors. Their findings support the implementation of health information technology to reduce medication errors and mitigate adverse events while increasing compliance to established guidelines in nursing practice. The article supports the PICOT as it shows the interventions that can be used to improve quality care and enhance overall patient safety. The article also supports the PICOT by showing the time frame that facilities can use to attain the benefits of these interventions.
Article 2
The second article by Barakat and Franklin (2020) focuses on the effects of using barcode medication administration (BCMA) on nursing practice activity and workflow. The authors use a qualitative study design in two surgical wards at a large acute facility in London. Through observations, the authors found that BCMA increased the nursing workflow, patient verification and efficiencies in medication administration. The authors are emphatic that the use of barcode and other health information technologies can enhance care delivery by minimizing occurrence of medication administration errors. The article supports the PICOT as it addresses how nurse practitioners handling critically ill patients can use technology-based interventions to enhance workflow and increase efficiencies aimed at mitigating MAEs.
Article 3
The third article is by Alomari et al. (2020) which evaluates the effectiveness of nurse-based interventions in reducing medication errors in pediatric wards. The authors investigate the effects of using bundled interventions to reduce medication administration errors. The author also focused on enhancing nurses’ perspective of medication administration process. Using a quantitative research approach in their selected settings, the authors shows through phased action research that these interventions, including use of health information technology, can reduce medication errors by over 60%. The authors emphasize that these benefits are not impacted by tan increase in the number of patients and prescribed medications. The article supports the PICOT question and statement as it shows the duration and interventions that can be implemented by nursing staff and other professionals to reduce and prevent the occurrence of medication administration errors.
Article 4
The fourth study by Devin et al. (2020) focuses on the effects of health information technologies in reducing prescribing errors in hospitals. The authors also focus on behavioral change techniques linked to HIT implementation that can reduce occurrence of medication errors. using a qualitative approach in different settings, the authors show that HIT prescribing reduces medication errors, especially prescribing errors. The authors’ findings emphasize the need for providers to integrate different approaches to ensuring that medication errors do not occur during the entire medication process. The article supports the EBP PICOT statement as it integrates the use of health information technology as a critical intervention to reducing medication administration errors.
Article 5
The fifth article by Zadvinski et al. (2018) explores the experience of nurses working with health information technology over time in their facilities. Using a longitudinal qualitative study design, the authors demonstrate the effects of nurses embracing technologies in a medical-surgical unit for a period of 18 months. The findings show that personal and organizational issues impact the adoption of HIT. The findings show that change of perception of these technologies is essential in attaining their intended benefits to the organization and patient safety goals. The article supports the PICOT statement as it shows that implementing health information technologies requires time for quality outcomes. Leveraging organizational policies and enhances the ability of nurses to adopt and use these technologies to enhance patient safety and quality outcomes.
Article 6
The study by Naidu and Alicia (2019) aims at evaluating the use of barcode medication administration and electronic medication administration records (e-MAR), outcomes, practice and policies and their effects on nurses in the medication administration duties in their nursing practice areas. Through an annotated literature review, the authors’ findings demonstrate that compliance to these interventions enhance patient safety and reduces reported medication administration errors. The use of these practices and policies also improves the efficiency of the BCMA system. The article is essential as it supports the PICOT by discussing the use of the health information technologies as interventions to reducing and preventing the prevalence of medication administration errors.
Article 7
The study by Jheeta and Franklin (2017) focuses on the how hospital electronic prescribing and medication administration system can enhance medication administration safety. Through an observational design, the authors show that implementation of these interventions encourages the occurrence of certain errors but also mitigates others. The implication is that using these interventions helps in reducing errors and enhancing patient safety. The article supports the PICOT statement as it emphasizes the need to use effective interventions and encourage their applications among all stakeholders in healthcare systems.
Article 8
The article by Härkänen et al. (2019) provides an analytical perspective of reported medication errors and their associated mortality in England and Wales for a period of nine years. The authors analyze medication errors in acute care that lead to death, identify the used drugs and describe the associated characteristics of the medication administration errors. Their findings show that most of deaths occurring due to medication administration errors happen in inpatients and among patients aged over 75 years with errors of omission being the most common form. The article supports the PICOT as it shows that medication errors occur due to several factors and should be addressed through integration of health information technologies.
Comparison of the Articles
The most prevalent issue in all these articles is the adoption of different health information technologies in mitigating and reducing the occurrence of medication administration errors (MAEs). Using an evidence-based practice approach, most of the articles demonstrate the effectiveness of having protocols and policies that supplement the use of technology in healthcare settings among healthcare workers. A majority of these articles use systematic reviews as they are considered the best level of evidence, especially in EBP projects. These reviews provide different interventions that healthcare providers can use to integrate health information technologies and reduce and prevent the occurrence of medication administration errors.
The main themes in these articles include use of medication administration processes, medication administration errors’ occurrence, the role of healthcare workers in embracing these interventions, and the effectiveness of the approaches to reduce medication administration errors. Some of the articles like the one by Jheeta and Franklin (2017) don not emphasize the effectiveness of health information technology in mitigating MAEs. However, the article emphasizes the need to have a multifaceted approach to the use of technologies to enhance care delivery. Each of the article has its unique shortcomings and areas not addressed. However, a common theme also emerges about the need to conduct further research to validate the outcomes and effectiveness of health information technology approaches to reduce and prevent medication administration errors, especially in acute care settings. Each of the article does not contain any controversy as the researchers complied with established guidelines to enhance validity and reliability.
Suggestions for Future Research
A majority of these articles recommend the need for further research on different aspects of the topic. The authors are categorical that while their studies offer evidence based on their research, it is imperative to conduct more studies on different aspects of these technologies to ascertain their overall effectiveness in addressing the issue under consideration (Alomari et al., 2020; Alotaibi & Federico, 2017). Gaps in effective research illustrating the interactions among various interventions and outcomes may require more approaches for better implementation of suggested approaches.
Conclusion
Medication administration errors (MAEs) remain a core concern in attaining better patient safety levels in different care settings. These events affect the quality of care and safety, especially for critically ill patients in hospitals who die for other causes other than their afflicted conditions. Therefore, stakeholders need interventions that leverage the best practices to reduce and prevent the occurrence of these events. The findings from these articles demonstrate the need for nurses and other healthcare workers to implement evidence-based practice interventions to reduce medication administration errors (MAEs). The selected articles show the need for enhance patient care and safety for better outcomes.
References
Alomari, A., Sheppard-Law, S., Lewis, J. & Wilson, V. (2020). Effectiveness of Clinical Nurses’
interventions in reducing medication errors in a pediatric ward. The Journal of Clinical Nursing, 29(17-18): 3403-3413. https://doi.org/10.1111/jocn.15374
Alotaibi, Y. K. & Federico, F. (2017). The impact of health information technology on patient
safety. Saudi Medical Journal, 38(12):1173-1180. doi: 10.15537/smj.2017.12.20631
Barakat, S. & Franklin, B. D. (2020). An Evaluation of the Impact of Barcode Patient and
Medication Scanning on Nursing Workflow at a UK Teaching Hospital. Pharmacy (Basel), 8(3):148. doi: 10.3390/pharmacy8030148
Devin, J., Cleary, B. J. & Cullinan, S. (2020). The impact of health information technology on
prescribing errors in hospitals: a systematic review and behavior change technique analysis. BMC Systematic Reviews, 9(275). https://doi.org/10.1186/s13643-020-01510-7
Jheeta, S. & Franklin, B. D. (2017). The impact of a hospital electronic prescribing and
medication administration system on medication administration safety: an observational study. BMC Health Services Research, 17(547). https://doi.org/10.1186/s12913-017-2462-2
Härkänen, M., Vehviläinen-Julkunen, K., Murrells, T., Rafferty, A. M., & Franklin, B. D.
(2019). Medication administration errors and mortality: Incidents reported in England and Wales between 2007 ̶ 2016. Research in Social and Administrative Pharmacy, 15(7), 858-863. https://doi.org/10.1016/j.sapharm.2018.11.010
Naidu, M. and Alicia, Y.L.Y. (2019). Impact of Bar-Code Medication Administration and
Electronic Medication Administration Record System in Clinical Practice for an Effective Medication Administration Process. Health, 11, 511-526. https://doi.org/10.4236/health.2019.115044
Zadvinskis, I. M., Smith, J. G., & Yen, P. Y. (2018). Nurses’ experience with health information
technology: Longitudinal qualitative study. JMIR medical informatics, 6(2), e38. doi: 10.2196/medinform.8734
Description:
The purpose of this assignment is to write a review of the research articles you evaluated in your Topic 5
“Evidence-Based Practice Project: Evaluation of Literature” assignment. If you have been directed by your instructor to select different articles in order to meet the requirements for a literature review or to better support your evidence-based practice project proposal, complete this step prior to writing your review.
A literature review provides a concise comparison of the literature for the reader and explains how the research demonstrates support for your PICOT. You will use the literature review in this assignment in NUR-590, during which you will write a final paper detailing your evidence-based practice project proposal.
In a paper of 1,250-1,500, select eight of the ten articles you evaluated that demonstrate clear support for your evidence-based practice and complete the following for each article:
- Introduction – Describe the clinical issue or problem you are addressing. Present your PICOT statement.
2. Search methods – Describe your search strategy and the criteria that you used in choosing and searching for your articles.
3. Synthesis of the literature – For each article, write a paragraph discussing the main components (subjects, methods, key findings) and provide rationale for how the article supports your PICOT.4. Comparison of articles – Compare the articles
(similarities and differences, themes, methods, conclusions, limitations, controversies).
5. Suggestions for future research: Based on your analysis of the literature, discuss identified gaps and which areas require further research.
6. Conclusion – Provide a summary statement of what you found in the literature.
7. Complete the “APA Writing Checklist” to ensure that your paper adheres to APA style and formatting criteria and general guidelines for academic writing. Include the completed checklist as an appendix at the end of your paper.
Refer to the “Evidence-Based Practice Project Proposal – Assignment Overview” document for an overview of the evidence-based practice project proposal assignments.
You are required to cite eight peer-reviewed sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
Benchmark Information
This benchmark assignment assesses the following programmatic competencies:
MBA-MSN; MSN-Nursing Education; MSN Acute Care Nurse Practitioner-Adult-Gerontology; MSN Family Nurse Practitioner; MSN-Health Informatics; MSN-Health Care Quality and Patient Safety; MSN-Leadership in Health Care Systems; MSN-Public Health Nursing
3.2: Analyze appropriate research from databases and other information sources to improve health care practices and processes.
Patient safety and improved quality of care requires providers and organization to use evidence-based practice (EBP) interventions to tackle issues that may cause adverse events like patient falls. Patients in medical-surgical units are susceptible to falls because of their delicate nature. The Centers for Medicare and Medicaid Services (CMS) considers falls as never events since they are preventable (Melnyk et al., 2022). Falls lead to increased stay in hospitals, poor patient outcome and serious fractures and head injuries that can lead to death. The use of bundled care approach through TIPS (tailoring interventions for patient safety) is considered one of the most effective ways to reduce and prevent falls in medical-surgical settings. The purpose of this literature review paper of the EBP project is to compare articles on the use of TIPS toolkit to reduce and prevent falls in medical-surgical settings.
PICOT Statement and Question
Nationwide, patient falls while in hospitals, particularly in medical-surgical units, are a leading cause of permanent disability and even death. Further, hospitalization increases one’s fall risk as close to three percent of patients fall while in hospitals. Nearly 30% of those who experience falls sustain injuries with a rise in the number of days in hospitals by close to 7 days. Again, under Medicare, the CMS does not reimburse falls and hospitals cannot get a Magnet designation when their fall rates are not below the national average (Khasnabish et al., 2020). The implication is that hospital managers and leaders must seek ways, through the use of evidence-based practice, to reduce the occurrence of falls. The use of TIPS toolkit is considered one of the most effective ways to reduce and mitigate falls and their occurrences as well as effects on patients in medical-surgical units.
PICOT Question
Among hospitalized adult patients in medical-surgical units (P) does the use of TIPS toolkit as a bundled care approach (I) compared to normal falls prevention approach (C) reduce the prevalence of falls (O) within 6 months (T)?
Search Methods
The evidence-based practice process implores researchers to seek evidence from previous research articles when doing their literature to obtain findings that support their proposed projects or interventions. The use terms, phrases and words associated with the topic under investigation and exploring databases to generate scholarly sources are some of the standard search strategies that one can deploy to attain relevant evidence. The study employed these strategies, starting with key terms and words in different databases. These included PubMed, Cochrane and Google Scholar as well as CINAHL. The strategy also entailed the use of CRAAP approach that involves searching for articles which are current, relevant, accurate, authoritative and purposeful to the area or topic under investigations (Melnyk et al., 2022). Using this criteria, the paper identified the reviewed articles and describes how they support the proposed EBP project to reduce and prevent the occurrence of falls in medical-surgical settings.
Research Synthesis
Article 1
The first article by Dykes et al. (2020) evaluates the use of a patient-centered fall prevention TIPS to lower falls and their associated injuries. Using non-randomized controlled trials with the study set in 14 medical units in Boston and New York, the researchers show a positive link between the intervention and a decline in number of falls. The researchers are categorical that nurse-led interventions can reduce injurious falls through providing information to families on fall management and prevention. The article demonstrates the efficacy of using TIPS as an intervention as depicted by the PICOT question.
Article 2
The second article by Tzeng et al. (2021) focuses on the impact of using TIPS program in reducing falls among older adults in nursing homes. Using a mixed method approach in a 15-bed nursing unit, the findings from the study shows that fall TIPS can reduce the rate of falls, especially injurious falls among older patients or adults. The TIPS program entails different approaches that include patient education and creating awareness about the harmful effects of falls. The article is critical to the EBP proposed project as it illustrates the increased role of TIPS initiative to reduce falls as depicted in the PICOT question. The article supports the EBP project since it shows that TIPS as an intervention is effective.
Article 3
In this article by Morris et al. (2022) the researchers conduct a systematic review of literature and meta-analysis on diverse interventions that can reduce falls. The researchers identify a host of interventions based on the data collected from the 43 studies that met their inclusion criteria. The findings show that tailoring or customization of interventions leads to reduced rates of falls for patients in such facilities. These interventions are effective when they consider the different components and factors impacting patient situations. As such, the article supports the EBP proposed project by demonstrating the effectiveness of diverse and tailored interventions for patients based on their level of acuity.
Article 4
The fourth article by Heng et al. (2020) is a scoping review of how hospitals can use patient education as a strategy to prevent falls. The researchers focused on 43 articles when analyzing the different approaches in patient education that confer benefits to patients to reduce their susceptibility to falls. The analysis shows that patient educational interventions can reduce falls that lead to injuries and bruises as well as lacerations and fractures. The study recommends the need to deploy TIPS as an effective approach to reducing and mitigating falls among patients. The article supports the EBP proposed project as it shows the need for diverse interventions like different approaches to educating patients on fall risks that they may be exposed to in their activities of daily living.
Article 5
In their article, LeLaurin et al. (201) aim at familiarizing different stakeholders about the benefits as well as the cons of various types of research studies on testing fall prevention interventions. The researchers opine that organizations and providers should focus on diverse interventions, one point at a time, to attain their efficacy and impact on patient fall management. The study’s findings are categorical that the effectiveness of each type of interventions depends on a host of factors. Therefore, customizing or tailoring these interventions is essential to attaining quality outcomes and helping patients avoid and reduce their susceptibility to falls. The article is important in the EBP project as it shows the need for tailoring each intervention to suit patient needs and situations.
Article 6
The article by Dykes et al. (2019) focuses on the effectiveness of tailoring interventions through a collaborative approach among providers. Using a qualitative approach or design, the article demonstrates that fall TIPS program is effective in reducing and preventing falls in diverse patient settings. The study is emphatic that TIPS model is important for providers to reduce and prevent falls. The article supports the EBP proposed project as it illustrates the importance of customizing interventions to meet patient needs and reduce susceptibility to falls.
Article 7
In this article by Cuttloer et al. (2018), the researchers aim at reducing inpatient falls in medical-surgical settings through technology-enabled TIPS initiative. The researchers use a four-minute video to provide patient education and collect their views on the implementation based on their situation. The findings are consistent that TIPS initiatives reduce and prevent falls. Therefore, the article supports the EBP project by showing that tailoring interventions is essential in addressing patient falls in medical-surgical settings.
Article 8
In their study, Bargmann et al. (2020) evaluates the effects of implementing a multicomponent fall prevention program to improve patient safety because of risks associated with falls. Set in a 26-bed medical surgical telemetry unit, the study shows that these interventions are effective in reducing falls and risks associated with falling for fragile patients. The article supports the EBP project since it is categorical that TIPS model reduce and prevents the occurrence of falls.
Comparison of the Articles
The reviewed articles share certain aspects in their research findings and also differ in other areas. for instance, all the articles agree that tailoring interventions on falls is an effective strategy that all providers and facilities should leverage in their settings. Again, the article agree that the TIPS model gives hospitals and providers increased leeway to implement interventions that are appropriate to their facilities based on their cost and other components. Thirdly, all the articles demonstrate that multiple interventions are complementary to the efforts and policies developed by organizations to reduce and prevent falls in their articles.
None of the article demonstrates controversies but all agree conclusively that more studies are required to provide significant outcomes. The articles also share limitations like timelines to conduct the studies, use of same settings and need for beet support from management and other stakeholders (Khasnabish et al., 2020). The articles do not have significant differences as they are emphatic that these diverse interventions are necessary in reducing falls, especially injurious falls among older patients.
Suggestions for Future Research
An analytical perspective of the eight articles and others demonstrate the need for more research to tackle some of the gaps. For instance, the articles do not offer a standard TIPS approach that can be used across all facilities, irrespective of their patient’s acuity and needs. As such, it is important to have more studies on the development of a standardized tool or approach to falls based on the nature of the respective setting, from medical-surgical units to outpatient facilities.
Conclusion
Falls are a major health issue that impact overall quality of care and life for patients, especially the elderly admitted to medical-surgical units. The use of TIPS toolkit; either patient-centered or nurse-driven, is critical to reducing these falls because of their adverse effects like injuries and long-term fractures and disabilities. The articles are emphatic that using TIPS allows providers to offer the most effective interventions to reduce and prevent their occurrence. The review illustrates that sufficient evidence exists to support the proposed interventions based on the TIPS framework to reduce falls.
References
Bargmann, A. L., & Brundrett, S. M. (2020). Implementation of a multicomponent fall
prevention program: Contracting with patients for fall safety. Military medicine, 185(Supplement_2), 28-34. https://doi.org/10.1093/milmed/usz411
Cuttler, S. J., Barr-Walker, J., & Cuttler, L. (2018). Reducing medical-surgical inpatient falls and
injuries with videos, icons and alarms. BMJ open quality, 6(2), e000119.
DOI: 10.1136/bmjoq-2017-000119
Dykes, P. C., Adelman, J. S., Alfieri, L., Bogaisky, M., Carroll, D., Carter, E., … & Spivack, L.
- (2019). The fall TIPS (tailoring interventions for patient safety) program: A collaboration to end the persistent problem of patient Falls. Nurse Leader, 17(4), 365-370. https://doi.org/10.1016/j.mnl.2018.11.006
Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., Ergai, A., Lindros,
- E., Lipsitz, S. R., Scanlan, M., Shaykevich, S., & Bates, D. (2020). Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries. JAMA Network Open, 3(11), e2025889. https://doi.org/10
Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital
falls prevention with patient education: a scoping review. BMC geriatrics, 20, 1-12. DOI: https://doi.org/10.1186/s12877-020-01515-w
Khasnabish, S., Burns, Z., Couch, M., Mullin, M., Newmark, R., & Dykes, P. C. (2020). Best
practices for data visualization: creating and evaluating a report for an evidence-based fall prevention program. Journal of the American Medical Informatics Association, 27(2), 308-314. DOI: 10.1093/jamia/ocz190.
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: state of the
science. Clinics in geriatric medicine, 35(2), 273-283. DOI: 10.1016/j.cger.2019.01.007
Melnyk, B. M., & Fineout-Overholt, E. (2022). Evidence-based practice in nursing &
healthcare: A guide to best practice. Lippincott Williams & Wilkins.
Morris, M. E., Webster, K., Jones, C., Hill, A. M., Haines, T., McPhail, S., … & Cameron, I.
(2022). Interventions to reduce falls in hospitals: a systematic review and meta-analysis. Age and Ageing, 51(5), afac077. https://doi.org/10.1093/ageing/afac077
Tzeng, H.-M., Jansen, L. S., Okpalauwaekwe, U., Khasnabish, S., Andreas, B., & Dykes, P. C.
(2021). Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) Program to Engage Older Adults in Fall Prevention in a Nursing Home. Journal of Nursing Care Quality, https://doi.org/10.1097/ncq.0000000000000547