Portfolio PLP3
Ensuring quality and safety
Author: Naomi Majoor
Student number: 432186
Education: Nursing bachelor training
Study section: PLP3
Course code: KVVB18MBKV
Academic year: 2024-2025
Group: PLG Moshi/Turiani
Tutor: Anne-Geertje Hoekema
Supervisor: Costancia Ndunguru
Internship place: Turiani Hospital, Female Ward
Date: 16-01-2024
Period: Semester 1
,Table of contents
Introduction............................................................................................................................... 4
H1 Problem definition .............................................................................................................. 7
1.1 Reason ............................................................................................................................. 7
1.2 Problem statement ........................................................................................................... 7
1.3 Objective........................................................................................................................... 8
H2 Research design ................................................................................................................. 9
H3 Practical research ............................................................................................................. 10
H4 Discussion, conclusion, advice ...................................................................................... 12
4.1 Discussion ...................................................................................................................... 12
4.2 Conclusion ...................................................................................................................... 13
4.3 Advice ............................................................................................................................. 13
H5 Implementation plan ......................................................................................................... 14
5.1 Plan................................................................................................................................. 14
5.2 Do ................................................................................................................................... 16
5.3 Check ............................................................................................................................. 17
5.4 Act ................................................................................................................................... 18
H6 Legislation and regulation ............................................................................................... 20
Literature list ........................................................................................................................... 23
Annexes ................................................................................................................................... 27
Annex A Format baseline survey ......................................................................................... 27
Annex B Baseline survey responses ................................................................................... 30
Annex C Presentation and feedback ................................................................................... 35
Annex C1 Presentation .................................................................................................... 35
Annex C2 Feedback ......................................................................................................... 36
Annex D Implementation in practice .................................................................................... 37
2
, Annex D1 Presentation .................................................................................................... 38
Annex D2 Poster .............................................................................................................. 38
Annex D3 Syringe implementation................................................................................... 38
Reflections .............................................................................................................................. 39
Ensuring quality and safety 1 ............................................................................................... 39
Ensuring quality and safety 2 ............................................................................................... 41
Working on health ................................................................................................................ 45
Directing care ....................................................................................................................... 47
Promoting self-management ................................................................................................ 49
Competence plan ................................................................................................................. 51
Valuation forms ...................................................................................................................... 53
Ensuring quality and safety 1 ............................................................................................... 53
Ensuring quality and safety 2 ............................................................................................... 58
Working on health ................................................................................................................ 64
Directing care ....................................................................................................................... 67
Promoting self-management ................................................................................................ 71
Competence scans................................................................................................................. 75
Competence scan student ................................................................................................... 75
Competence scan supervisor .............................................................................................. 81
Anti-plagiarism ....................................................................................................................... 87
3
, Introduction
Medication safety is an important concept within healthcare. Medication safety is about the
quality of medicines, but also their proper use by healthcare providers and institutions that
apply or prescribe them (Ministerie van Volksgezondheid, Welzijn en Sport, z.d.-b). This term
refers to all activities aimed at the correct prescription, delivery and use of medicines. The
ultimate goal of this is: the right client gets the right medicine at the right date and time in the
right amount and administered in the right way (Zorg voor Beter, 2024). Maintaining
medication safety is essential for patients' health. Thus, errors in it can put health harm at
risk (VMSzorg, z.d.). A medication error is any error that occurs in the process of prescribing,
compounding/dispensing, storing/managing, preparing, administering/recording or
evaluating. This is irrespective of whether harm has occurred. Causes may include: no
administration list, making a medication list yourself, no clear agreements in the care file,
malfunctions while working with medication, unclear instruction or no proper administration
registration (Zorg voor Beter, 2024). Parenteral medication errors are globally recognised as
a high-priority healthcare problem. Parenteral drugs are all drugs that are not administered
via the gastrointestinal system, such as injections and infusions. Errors are associated with
increased morbidity and mortality in patients (who are already seriously ill). The National
Patient Safety Agency in the United Kingdom revealed that more than 14,000 incident reports
on injectable drugs were reviewed. This represents more than 4,107 cases, or 28.9% of the
total number of incidents. The most common medication error here is an incorrect dose,
strength or frequency of the prescribed drug. In addition, studies show that treatment costs
were higher in patients with medication errors than in patients without medication errors.
Treatment costs attributable to medication errors range from $8,439 to $8,898 per case. Cost
per medication error can be as high as 111,727 euro. It was found that 19% of adverse
events lead to moderate physical impairment, 6% to permanent impairment and 8% even to
death (B. Braun, z.d.).
Obtaining exact data on the rate of medication errors in Tanzania is difficult, due to limited
reporting systems and the lack of comprehensive studies in this area. A study from Jakaya
Kikwete Cardiac Institute in Dar es Salaam shows that this has several causes, including fear
of disciplinary action, such as dismissal and the like. In addition, there are no public
databases or websites that provide detailed statistics on medication errors in Tanzania
(Ndamayape et al., 2023).
In Turiani hospital, medication errors are not reported, so it is not clear how many incidents of
this occur annually. However, the student noted that medication errors do occur in Turiani
4
Ensuring quality and safety
Author: Naomi Majoor
Student number: 432186
Education: Nursing bachelor training
Study section: PLP3
Course code: KVVB18MBKV
Academic year: 2024-2025
Group: PLG Moshi/Turiani
Tutor: Anne-Geertje Hoekema
Supervisor: Costancia Ndunguru
Internship place: Turiani Hospital, Female Ward
Date: 16-01-2024
Period: Semester 1
,Table of contents
Introduction............................................................................................................................... 4
H1 Problem definition .............................................................................................................. 7
1.1 Reason ............................................................................................................................. 7
1.2 Problem statement ........................................................................................................... 7
1.3 Objective........................................................................................................................... 8
H2 Research design ................................................................................................................. 9
H3 Practical research ............................................................................................................. 10
H4 Discussion, conclusion, advice ...................................................................................... 12
4.1 Discussion ...................................................................................................................... 12
4.2 Conclusion ...................................................................................................................... 13
4.3 Advice ............................................................................................................................. 13
H5 Implementation plan ......................................................................................................... 14
5.1 Plan................................................................................................................................. 14
5.2 Do ................................................................................................................................... 16
5.3 Check ............................................................................................................................. 17
5.4 Act ................................................................................................................................... 18
H6 Legislation and regulation ............................................................................................... 20
Literature list ........................................................................................................................... 23
Annexes ................................................................................................................................... 27
Annex A Format baseline survey ......................................................................................... 27
Annex B Baseline survey responses ................................................................................... 30
Annex C Presentation and feedback ................................................................................... 35
Annex C1 Presentation .................................................................................................... 35
Annex C2 Feedback ......................................................................................................... 36
Annex D Implementation in practice .................................................................................... 37
2
, Annex D1 Presentation .................................................................................................... 38
Annex D2 Poster .............................................................................................................. 38
Annex D3 Syringe implementation................................................................................... 38
Reflections .............................................................................................................................. 39
Ensuring quality and safety 1 ............................................................................................... 39
Ensuring quality and safety 2 ............................................................................................... 41
Working on health ................................................................................................................ 45
Directing care ....................................................................................................................... 47
Promoting self-management ................................................................................................ 49
Competence plan ................................................................................................................. 51
Valuation forms ...................................................................................................................... 53
Ensuring quality and safety 1 ............................................................................................... 53
Ensuring quality and safety 2 ............................................................................................... 58
Working on health ................................................................................................................ 64
Directing care ....................................................................................................................... 67
Promoting self-management ................................................................................................ 71
Competence scans................................................................................................................. 75
Competence scan student ................................................................................................... 75
Competence scan supervisor .............................................................................................. 81
Anti-plagiarism ....................................................................................................................... 87
3
, Introduction
Medication safety is an important concept within healthcare. Medication safety is about the
quality of medicines, but also their proper use by healthcare providers and institutions that
apply or prescribe them (Ministerie van Volksgezondheid, Welzijn en Sport, z.d.-b). This term
refers to all activities aimed at the correct prescription, delivery and use of medicines. The
ultimate goal of this is: the right client gets the right medicine at the right date and time in the
right amount and administered in the right way (Zorg voor Beter, 2024). Maintaining
medication safety is essential for patients' health. Thus, errors in it can put health harm at
risk (VMSzorg, z.d.). A medication error is any error that occurs in the process of prescribing,
compounding/dispensing, storing/managing, preparing, administering/recording or
evaluating. This is irrespective of whether harm has occurred. Causes may include: no
administration list, making a medication list yourself, no clear agreements in the care file,
malfunctions while working with medication, unclear instruction or no proper administration
registration (Zorg voor Beter, 2024). Parenteral medication errors are globally recognised as
a high-priority healthcare problem. Parenteral drugs are all drugs that are not administered
via the gastrointestinal system, such as injections and infusions. Errors are associated with
increased morbidity and mortality in patients (who are already seriously ill). The National
Patient Safety Agency in the United Kingdom revealed that more than 14,000 incident reports
on injectable drugs were reviewed. This represents more than 4,107 cases, or 28.9% of the
total number of incidents. The most common medication error here is an incorrect dose,
strength or frequency of the prescribed drug. In addition, studies show that treatment costs
were higher in patients with medication errors than in patients without medication errors.
Treatment costs attributable to medication errors range from $8,439 to $8,898 per case. Cost
per medication error can be as high as 111,727 euro. It was found that 19% of adverse
events lead to moderate physical impairment, 6% to permanent impairment and 8% even to
death (B. Braun, z.d.).
Obtaining exact data on the rate of medication errors in Tanzania is difficult, due to limited
reporting systems and the lack of comprehensive studies in this area. A study from Jakaya
Kikwete Cardiac Institute in Dar es Salaam shows that this has several causes, including fear
of disciplinary action, such as dismissal and the like. In addition, there are no public
databases or websites that provide detailed statistics on medication errors in Tanzania
(Ndamayape et al., 2023).
In Turiani hospital, medication errors are not reported, so it is not clear how many incidents of
this occur annually. However, the student noted that medication errors do occur in Turiani
4
