Samples / NURS FPX 8022 / Assessment 3
Risk Mitigation Plan
NURS FPX 8022 · Assessment 3
Sample for study and reference. Ace My Assessment is an independent academic support service.
The risk mitigation plan table, found in the appendix, lists identified risks, their likelihood of occurrence, how they might harm the project, and what can be done to mitigate them. By using the Cleveland Clinic Application of the CPOE, combined with the CPOE's Decision Support and High Priority Practices SAFER Guides, four risks were identified. The revision of the SAFER Guide recommendations focus on high-severity/high-frequency risks and recommend that these be addressed first by organizations in terms of attention and allocation of resources (Sittig et al., 2025). This projected improvement is based on evidence that, over time, structured workflow redesign can significantly decrease safety events associated with scanning (Grailey et al.,x 2023). Likewise, there is expected to be a significant improvement in the absence of continuous monitoring after the analytics dashboard would be fully deployed. These forecast results will help the organization to measure mitigation success by providing measurable standards to compare to.
Ethical or Legal Issues
If the risks identified are not managed, there are significant ethical and legal implications for the patient, the practitioner and the organization. Ethically, uncertainties about medication administration are a breach of the nursing principle of nonmaleficence, which means "do no harm" and could lead to preventable and foreseeable harm. From a legal standpoint, if a healthcare organization or individual nurse has prevented a medication error from hurting a patient, they could potentially face negligence charges. In 2022, a nurse was convicted of a crime after a fatal medication error, which has resulted in serious personal liability associated with such incidents (Townley et al., 2022). These are important reminders of the risks of not taking a proactive approach to risk mitigation and why it is both an ethical and a legal responsibility.
In addition to the consequences of individual liability, the consequences of unsolved technology-related risks are significant institutional risks of the organization. Safety incidents that are repeated may lead to increased regulatory review requirements, lower Leapfrog and Medicare Compare ratings, and less confidence of the community in the organization. Additionally, practitioners can suffer from permanent, psychological injury, such as moral injury, after participating in an avoidable patient safety incident. Organizations have been found to be deterred from reporting errors that lead to high-profile prosecutions of clinician error, which hinders organizational learning (Townley et al., 2022). The proactive management of identified risks benefits patients, practitioners and the organization's sustainability.
HIPAA Compliance and Cybersecurity Measures
The proposed technology should also be 100 percent compliant with the Health Insurance Portability and Accountability Act of 1996. Authorized staff will only have access to patient data, through role-based access controls, in barcode medication administration and clinical decision support systems. All scanning and override information will be transmitted and stored encrypted, just as is required by the HIPAA Security Rule technical safeguards. Layered technological security measures are becoming even more critical for healthcare organizations to safeguard patient information, as they are often the target of hacking attacks (Dolezel et al., 2026). Together these steps guarantee that the technology enhances patient safety, while safeguarding data privacy and regulatory standards.
Justification of Proposed Actions
All proposed mitigation actions are based on existing scientific evidence and not on assumption or organizational convenience. The evidence for tiering clinical decision support alerts by severity is warranted because nuisance alerts lead to unsafe habits of overriding (Wang et al., 2022). Documenting override reasons helps to hold people accountable and provides information for future work on optimizing alerts. Real-time override reporting dashboards, when proven, have been known to maintain meaningfully reduced override rates in large, multi-unit healthcare systems (Boehme et al., 2022). These scientifically sound reasons help to guarantee that proposed actions will create tangible, lasting safety gains.
The other proposed actions are also evidence-based, based on information they shared about nursing and medication safety technology. Behavioral research indicates that over time, streamlined scanning workflows yield increased nursing adherence due to ergonomic workflow redesign (Grailey et al., 2023). There is evidence that compliance of scanning tends to wane over time when it is not being monitored, so the use of monitoring dashboards is justified (Williams et al., 2025). The national SAFER Guide (Sittig et al., 2025) continues to recommend monitoring as a key safety practice and suggests it should be done in a structured, evidence-based manner. This evidence base, when combined with other evidence, forms a strong basis for the actions for mitigation suggested throughout this plan.
Evidence-Based Rationale
The short explanation of the actions is that technology cannot overcome safety problems without a proper structure of human-based monitoring. Every mitigation matches a technical enhancement, such as: dashboards or tiers of alerts, with the accompanying accountability system. This is an integrated approach, as evidenced by current research that both system design and consistent behavioral reinforcement are important to creating sustained safety improvement (Lindsay, 2023). This rationale allows these actions to be technically adequate, but practically feasible within the day to day nursing practice.
Change Management Strategies
For these mitigation actions to be implemented successfully, an evidence-based and structured approach to change management within the organization is needed. The eight step change model by Kotter provides a practical tool for helping the nursing staff to implement the change as a technology. Building initial buy-in from staff by creating a sense of urgency using Leapfrog and override data from their own organisation will help. A similar shared governance model and Kotter's model were successfully implemented to decrease nursing documentation burden in a large academic health system (Lindsay, 2023). Doing so with the same structure provides a realistic approach to lasting adoption of the recommended mitigation actions.
In addition to Kotter's initial actions, ongoing frontline nursing engagement and feedback is a deliberate focus to sustain change. Unit-based charge nurses and/or pharmacy leaders should be identified as the ‘face' of the change/reinforcement of new scanning and override expectations. Improved unit level scanning rates (short-term success) should be recognized to keep staff motivated and moving. Cultural change initiatives are much more likely to be successful if frontline staff are involved in them from start to finish (Lindsay, 2023). The below strategies are to ensure the mitigation plan becomes a practice and not a one-off compliance task.
Applying Change Management for Sustained Implementation
Finally, it is important to embed these changes in the wider organisational culture of safety if they are to be sustained. Scanning and override measures should be part of a formal organizational process through regular safety huddles and quality committee reviews. As the last step in Kotter's work, an anchoring step helps keep people away from previous unsafe workflows after initial enthusiasm for the change fades. By taking this methodical change management strategy, Cleveland Clinic can now maintain the safety improvements as outlined in this plan.
Conclusion
This risk mitigation plan is the product of the findings in the SAFER Guide and provides a structured, evidence-based plan for improving patient safety. Specific, justifiable and measurable mitigation actions are taken to address identified risks in alert management and barcode scanning compliance. This plan will consider the ethical, legal, and HIPAA-related responsibilities, to ensure that patients, practitioners, and the organization are all protected. Using Kotter's change management model provides a realistic and evidence-based change management approach to support these improvements on a sustained basis across nursing practice. These actions will continue to be critical for maintaining the improvements in patient safety outcomes in a sustainable manner.
References
Boehme, S., Wohlt, P., Valentine, J., & Ensign, R. (2022). Sustained barcode medication administration rates less than 2 percent in a large healthcare system. Journal of Patient Safety and Risk Management, 27(6), 268–274. https://doi.org/10.1177/25160435221137145
Dolezel, D., Kruse, C. S., & Pradhan, R. (2026). Cybersecurity in healthcare: Ensuring patient safety and data privacy. Journal of Multidisciplinary Healthcare, 19, e609209. https://doi.org/10.2147/JMDH.S609209
Grailey, K., Hussain, R., Wylleman, E., Ezzat, A., Huf, S., & Dean Franklin, B. (2023). Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks: A mixed methods study. BMC Nursing, 22, e378. https://doi.org/10.1186/s12912-023-01382-x
Lindsay, M. (2023). A shared governance approach to nursing documentation redesign using Kotter's change management model. Nursing Management, 54(3), 14–20. https://doi.org/10.1097/01.NUMA.0000919064.29246.6b
Sittig, D. F., Flanagan, T., Sengstack, P., Cholankeril, R. T., Ehsan, S., Heidemann, A., Murphy, D. R., Salmasian, H., Adelman, J. S., & Singh, H. (2025). Revisions to the Safety Assurance Factors for Electronic Health Record Resilience (SAFER) Guides to update national recommendations for safe use of electronic health records. Journal of the American Medical Informatics Association, 32(4), 755–760. https://doi.org/10.1093/jamia/ocaf018
Townley, J. N., Pogue, C. A., & McHugh, M. D. (2022). Criminal prosecution of clinician errors: A setback to the progress toward safe hospital work environments. Journal of Hospital Medicine, 17(10), 850–853. https://doi.org/10.1002/jhm.12952
Wang, L., Goh, K. H., Yeow, A., Poh, H., Li, K., Yeow, J. J. L., Tan, G., & Soh, C. (2022). Habit and automaticity in medical alert override: Cohort study. Journal of Medical Internet Research, 24(2), e23355. https://doi.org/10.2196/23355
Williams, R., Kantilal, K., Man, K. K. C., Blandford, A., & Jani, Y. (2025). Barcode medication administration system use and safety implications: A data-driven longitudinal study supported by clinical observation. British Medical Journal Health Care Informatics, 32(1). https://doi.org/10.1136/bmjhci-2024-101214
Appendix A: Risk Mitigation Plan
Risk Identified by SAFER Guides | Possibility of Occurrence (Frequent, Sometimes, Never) | Potential for Harm (Severe, Mild, None) | Mitigation to Address Risks | Possibility of Occurrence (Frequent, Sometimes, Never) | Potential for Harm (Severe, Mild, None) |
Clinical decision support (CDS) alerts within the CPOE system are routinely overridden by nursing and physician staff without documented clinical justification (CPOE with Decision Support SAFER Guide). | Frequent | Severe | Configure the CDS engine to tier alerts by clinical severity so that only high-risk warnings (e.g., allergy conflicts, lethal dosing) interrupt workflow, reducing nuisance alerts implicated in habitual dismissal (Wang et al., 2022). Require a structured override reason to be selected before an alert can be bypassed, creating an auditable data trail for every override event. Establish a joint pharmacy-informatics committee to review override reports monthly and recalibrate alert thresholds based on override patterns. Provide targeted nurse and physician education on high-risk alert types during onboarding and annual competency review. | Sometimes | Mild |
Barcode scanning compliance is inconsistent across high-acuity nursing units due to scanner malfunction, weak wireless connectivity, and unreadable medication or wristband labels (High Priority Practices SAFER Guide). | Frequent | Severe | Replace aging handheld scanners and strengthen wireless network coverage on units with the highest override rates, directly targeting the equipment failures nurses report as the leading cause of manual overrides. Implement a real-time override reporting dashboard, modeled on evidence showing sustained reductions in override rates when units receive individualized feedback (Boehme et al., 2022). Assign charge nurses to review daily override logs and provide brief, non-punitive coaching to staff with recurring overrides. Schedule preventive maintenance and battery replacement for scanning equipment on a fixed monthly cycle. | Sometimes | Mild |
Dual scanning of both the patient wristband and medication label is inconsistently performed on busy units, increasing the risk of wrong-patient or wrong-medication administration events (High Priority Practices SAFER Guide). | Sometimes | Severe | Redesign medication cart ergonomics and workflow sequencing so that scanning is the path of least resistance rather than an extra step, addressing the ergonomic and time-pressure barriers identified in behavioral research on scanning adherence (Grailey et al., 2023). Engage patients directly by asking them to confirm their identity and remind staff to scan, reinforcing a second layer of verification. Use unit-level scanning-rate data, disaggregated by shift, to identify and remediate specific time periods with the lowest compliance. Reinforce expectations through unit safety huddles and visible unit-level scanning-rate postings. | Never | Mild |
No structured, ongoing monitoring or feedback loop currently exists to detect drift in scanning compliance or alert-override rates over time, delaying identification of emerging safety risks (CPOE with Decision Support SAFER Guide). | Frequent | Mild | Deploy an integrated analytics dashboard that aggregates scanning and override data in real time and flags units whose compliance falls below an established threshold, consistent with longitudinal evidence that unmonitored scanning rates decline over time (Williams et al., 2025). Designate an accountable pharmacy-nursing safety lead to review dashboard trends weekly and escalate persistent declines to unit leadership. Integrate scanning and override metrics into existing quality dashboards already reviewed at monthly patient safety committee meetings. Set a formal annual review cycle to reassess thresholds and mitigation effectiveness against updated SAFER Guide recommendations. | Never | None |