and System Analysis

NURS FPX 6424 Assessment 4 Tool Kit for Critical Analysis of System Vulnerabilities, Data Validity Management, and System Analysis Student Name Capella University NURS-FPX6424 Data Mining to Advance Healthcare Professor Name Submission Date   Tool Kit for Critical Analysis of System Vulnerabilities, Data Validity Management, and System Analysis An audit of potential system vulnerabilities of the medical-surgical unit (MSU) with 40 beds showed significant shortcomings in compliance with CDSS. It did not perform medication reconciliation, and the nurse was not well-versed in electronic health records. This toolkit includes evidence-based policies, guidelines, and actionable recommendations to address these vulnerabilities and enhance health informatics data to improve patient safety outcomes. Evidence-Based Policy The person who is responsible for complying with this policy is all (RN, charge RN, pharmacists, unit managers) registered nurses, charge nurses, pharmacists, and unit managers on the 40-bed medical-surgical unit. All staff will investigate all CDSS alerts, carry out medication reconciliation at each patient change of care, and report all of the near misses within 24 hours of occurrence. All told, these activities will help to reduce the number of medication-related errors if they are consistently carried out across all health care professions. At the start of January 2026, the medical-surgical unit had a rate of 8.2 errors for every 1,000 doses, had 54% compliance with the CDSS alerts, and had a total of 12 near-misses during the calendar month (January). The specific outcomes that will be measured for this policy are: error rates of ≤5.0, compliance with CDSS and medication reconciliation procedure ≥90%, no more than 4 near-misses reported per month, and nurses gaining their EHR competency level of ≥85%, which is based on the TIGER framework. All data gathered under this policy by the law is protected under HIPAA (Health Insurance Portability and Accountability Act) and can only be accessed by those with authorization. The Joint Commission NPSG 03.06.01 requires that nurses complete a medication reconciliation at each “transition of care. Medication reconciliation must be documented by the nurse at each “transition of care” per the Joint Commission NPSG 03.06.01. Nurses will be accountable for not properly completing this medication reconciliation or documenting an override of an alert by CDSS. As a consequence, data about students’ IQ collected under this policy will be used solely to inform quality improvement processes. Guidelines for Applying the Policy in Practice Within 15 minutes of an alert override/overrides the Registered Nurse is required to document their clinical reasoning about the override(s) in the CDSS. Staff will be required to have a 48-hour learning session if there is a shift that is more than a 30% override. At the end of each shift, charge nurses will discuss and record any override(s) that occurred during their shift with their unit manager. The medication reconciliation process must be performed at patient admission, discharge, and transfers, and it is built right into the workflow of the electronic health record (EHR) so that it is a required task for all staff to perform. Medication reconciliation is done within 2 hours of admission to the facility to check the accuracy of medications in the pharmacy. Any discrepancies will have to be resolved prior to giving a medication. Any event that is a near-miss medication is to be reported via the hazard reporting system within 24 hours. The average of unit near misses will be calculated monthly by the charge nurses, who will summarise this to the unit manager by the third business day of the next month. The unit manager, charge nurses, and pharmacists’ safety dashboard review meeting is held on the first Monday of every month to review how they are doing in relation to the service-wide benchmarks: number of medication errors, CDSS compliance, CDSS reconciliation completeness, near misses, competency of staff in using EHR, and CDSS override percentage. If an organisation does not meet any of its benchmarks, then action plans need to be created and put into place within 72 hours. Practical Recommendations All registered nurses need to attend a required orientation of two hours that includes active involvement in hands-on activities using an electronic health record (EHR) and procedures and policies for reconciliation and CDSS. Tip sheets defining end-user questions about EHRs are readily available in the nursing station, and quarterly, through team manager reviews, data is gathered from each unit to assess trends and outcomes. In addition to this information from these reviews, the units have 15 minutes each month for a safety huddle, which is completed during shift changes, whereby the units can discuss a few key performance indicators (KPIs). It outlines ways in which improvement could be achieved, and communicates any changes in protocol, ensuring that no time is lost and that all staff are aligned and accountable. The data monitoring is in four levels. Nurse staff supervisors will audit medication administration record (MAR) overrides on an ongoing, nightly basis and will immediately re-educate anyone who has exceeded the 30% override rate for administering medication. Once a month, the unit will consider how it is doing on each of the 6 metrics in its safety dashboard review meeting (SDRM) and reflect on these metrics in relation to the benchmark. The unit will have a policy review quarterly, to confirm the metrics and discuss any vulnerabilities that may have occurred. Unit data will be compared with the national data on an annual basis to assess the need for any changes in policy and/or EHRs. Specific Example: Medication Safety Initiative on the 40-Bed Medical-Surgical Unit There were three issues found in the EHR during an audit report in January 2026; they were related to an audit trail and dispensing from the EHR by a pharmacy. They were also much higher than the 30% Joint Commission’s benchmark, with an alert override percentage of 38%, lower than the benchmark on completing medication reconciliation processes with 61% (below the 90% completion rate expected by Joint Commission), and the lower than expected 48% of nurses who completed competency training with EHR. During the one-month period,