Place order now

NURS FPX4020 Improving Quality of Care Assessment Essay Paper

NURS FPX4020 Improving Quality of Care Assessment Essay Paper

NURS FPX4020 Improving Quality of Care Assessment Essay Paper

For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue.

Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses.

Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).

The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care.

You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement.

Demonstration of Proficiency.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

    • Competency 1: Analyze the elements of a successful quality improvement initiative.
      • Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
    • Competency 2: Analyze factors that lead to patient safety risks.
      • Explain factors leading to a specific patient-safety risk focusing on medication administration.
    • Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
      • Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
      • Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration.
    • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
      • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling.
      • Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

References

Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.

Scenario

Consider a previous experience or hypothetical situation pertaining to medication errors, and consider how the error could have been prevented or alleviated with the use of evidence-based guidelines. Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care.   For this assessment:

    • Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting.

Instructions

The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.

Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting.

Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.

    • Explain factors leading to a specific patient-safety risk focusing on medication administration.
    • Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs.
    • Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs.
    • Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration.

Root-Cause Analysis Sample Paper on Medication Errors

Medication errors account for many sentinel and adverse events. While most of these events occur in a hospital setting (Poder & Maltais, 2020), the likelihood of an event in a school setting is also possible. This assessment will address the event of a substitute school nurse administering the wrong dosage of medication to a student. The root-cause analysis being a lack of communication within the transfer of care from the primary school nurse to the substitute will be discussed.

The following topics will be addressed in this assessment: an analysis of the root cause, application of evidence-based strategies, an improvement plan with evidenced-based and best- practice strategies, and existing organizational resources.

Analysis of the Root Cause

NURS FPX4020 Improving Quality of Care Assessment Essay Paper

To protect privacy, the names of those involved have been changed. The student will be referred to as John; the substitute nurse, Ann; and the primary school nurse, Kate. John is a six- year-old first-grade student who recently prescribed Adderall 10mg PO daily at 8 am for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). John has been coming to the health room each morning and receiving his medication from Nurse Kate for the past two weeks.

One Friday morning, John came back to the health room one hour after receiving his medication and complained to Kate that his heart “felt funny”. Kate assessed John and noted an increased pulse, a common side effect of Adderall. Kate notified John’s parent and prescribing physician of his complaint. Kate dismissed John from school, and his parent made an appointment with the physician for him to be seen that day.

That same afternoon, Kate received a fax from the prescribing physician indicating a change to the dosage of his current medication. John was to take Adderall 5mg (half of a 10mg tablet) beginning the following Monday morning. Kate intended to change the dosage of the medication in the Electronic Health Record (EHR) and add the new order to the Medication Administration Record (MAR) in the substitute notebook, but on that particular Friday, she was much busier than normal. At dismissal time, she realized she still needed to change the dosage in the EHR, but she was tired from her busy day and had a scheduled appointment outside the school setting. She decided to leave the new order on her desk until the following Monday morning, as she planned to come in early and add it to the EHR system.

Over the weekend, Kate’s daughter became sick, and Kate had to call out of work on Monday. The nursing director was able to secure a substitute nurse, Ann, to fill in for Kate. The two nurses communicated briefly via text message, but Kate had been awake most of the night with her sick daughter, causing Kate to feel fatigued and forgetful. Kate did not communicate to Ann that John’s Adderall dosage had changed as of Friday afternoon, nor was the new order in the substitute MAR notebook or the EHR. Ann was unaware of the dosage change, and therefore, administered Adderall 10mg (instead of 5mg) to John at 8 am.

Approximately 1 to 2 hours later, John came to the health room and stated his heart “felt funny” like it did on Friday. Ann became concerned and as she assessed John, she noticed he had an increased pulse. John told Ann about his visit to the doctor on Friday for the same complaint, and he suddenly remembered that his doctor changed something with his medicine. Ann looked through the EHR and the MAR, but only noted an order for the Adderall 10mg. She texted Kate to inform her of John’s complaint and to inquire about a possible change to the medication.

Kate called Ann at the school and apologized for not updating the EHR or MAR on Friday afternoon when she received the faxed order. She proceeded to tell Ann her intentions of coming in early that morning to complete the task, which was the reason for leaving the faxed order on her desk. Ann informed Kate she did not see a faxed order on her desk, only a stack of immunization records with a post-it note from the school secretary indicating those records needed filing. Kate was unaware of the immunization records, as the school secretary had put them on her desk after Kate left Friday afternoon. Ann looked through the stack of papers and found the faxed medication order at the bottom.

Ann and Kate notified the nursing director, John’s parent, the principal, and the prescribing physician. They detailed the chain of events leading up to the medication administration error (MAE) and completed a medication incident report with signatures from all parties involved.

Thankfully, John’s symptoms were only temporary and he fully recovered once the medication’s peak subsided. The physician instructed the nurses and parent that John could be monitored at home with restricted activity and with increased fluids and rest.

Kate experienced uncontrollable factors such as a busier than normal Friday, a sick child of her own over the weekend, decreased sleep causing fatigue and forgetfulness the following Monday morning, and unknown immunization records being placed on top of a faxed medication order. These uncontrollable factors prevented Kate from updating the EHR and MAR promptly, but one controllable factor that Kate failed to utilize was effective communication during the report between her and Ann. Had Kate notified Ann of the changed order and her intentions of updating the EHR and MAR, Ann could have found the faxed order and updated the records herself, while also administering the correct dose to John when the time came.

Application of Evidence-Based Strategies

Implementing evidence-based practice (EBP) among nurses in a healthcare setting requires adequate knowledge, training, skills, management support, effective communication, and a positive attitude (Rahmayanti, Kadar, & Saleh, 2020). Kate should have utilized the best practice strategies of updating the EHR and MAR Friday afternoon before leaving work, as this would have likely prevented an MAE, but multiple interruptions that day prevented her from doing so. Research states interruptions are often one of the many factors causing MAEs (Poder & Maltais, 2020). By limiting the number of students in the health room at a given time, would allow Kate more time to focus on imperative tasks such as updating the EHR and MAR.

Another evidence-based strategy would have been for Kate to effectively communicate with Ann on Monday morning using a checklist system of topics to discuss during report hand- off. While the exact content of the text messages between the two nurses is unknown, it is evident this was not an effective way to communicate the continuity of care for these students, especially the changed medication dose for John.

A predominant result of the root-cause analysis is ineffective communication between two sources, particularly when pediatric patients are involved (Stang, Thomson, Hartling, Shulhan, Nusple, & Ali, 2018). While John was involved in both situations on Friday and Monday, the fact remains that, he is still a 6-year-old child and unable to grasp the concept of the situation, even though he eventually remembered something had changed.

Fatigue caused by burnout and high patient ratios is also a leading factor in MAEs (Dykstra, Sendelbach, & Steege, 2016). Kate had experienced fatigue on Friday afternoon due to a high volume of students, then again on Monday morning due to lack of sleep while caring for her sick child the night before. Research suggests having systems in place to improve fatigue at an individual unit level, not just at an organizational level (Dykstra, et. Al, 2016).

Improvement Plan with Evidence-Based and Best-Practice Strategies

Ineffective communication is a primary source of MAEs (Stang, et. al, 2018) in which improvement plans are needed to prevent further MAEs. This would include the presence of the primary and substitute school nurses at monthly professional development (PD) sessions. During PD sessions, a checklist system will be created for nurses to use during report handoff (Stang, et. al, 2018). This will include a list of students with chronic medical conditions in which they come to the health room for nursing services. It will also include a section for any updates or changes that have occurred within the last 72 hours. There will also need to be effective communication between the nurses and parents to alert the school nurse of any changes, and between the nurse and the front office staff, educating them not to place papers on top of a medication order.

Research indicates most nurses approve of using EBP to improve patient care, but familiar routines, limited resources, and lack of knowledge prevent them from doing so (Rahmayanti, et. al, 2020). Adequate technology, training, and support staff also prevent MAEs (Stang, et. al, 2018). Improving the nurse to student ratio by hiring additional nurses or nurse aids would prevent one medical professional from bearing the burden of all necessary duties.

If additional healthcare staff had been present on Friday, Kate would likely have time to enter the updated order in the EHR and MAR. Additional training on the importance of updating a MAR and EHR in a reasonable timeframe will also be addressed at the monthly PD sessions (Poder & Maltais, 2020). School nurses will be required to update the EHR and MAR by the end of the school day when receiving any new or changed orders.

Existing Organizational Resources

Our local school district is fortunate in that one full-time nurse, either an LPN or RN is assigned to each school. Due to the variation of school sizes, some have a nurse-to-student ratio of 1:700 or as high as 1:1900. This creates fatigue and burnout among full-time nurses, constant interruptions, and causes miscommunication in the transfer of care to our limited number of substitute nurses. Our district created a new position for a full-time float nurse to assist the busiest schools, but one float nurse can only be present at one school at a time. Hiring additional healthcare staff and providing monthly training would improve interdisciplinary communication and overall outcomes (Stang, et. al, 2018).

Our district currently uses an EHR specific to school nurses, which is great for documentation, setting schedules or alerts for medications, and creating student profiles for medical history, but it is not linked to any EHR used by local physicians or hospitals. It would be beneficial for the school system to utilize the same EHR system, as it would provide an immediate implementation of doctor’s orders versus the current process of nurses having to manually add the order into our system. Computerized physician order entry (CPOE) helps eliminate MAEs (Poder & Maltais, 2020).

Conclusion

School nurses are at a disadvantage when it comes to available resources often provided to those in a normal health care setting such as clinics and hospitals. Adequate staffing, advanced technology, and electronic medication ordering systems require substantial budgets that a school district often lacks. Interdisciplinary collaboration with evidenced-based practice and strategies can improve the overall safety of students.

References

Dykstra, J. G., Sendelbach, D., & Steege, L. M. (2016). Fatigue in float nurses: Patient, nurse, task, and environmental factors across unit work systems. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 60(1), 623–627. https://doi.org/10.1177/1541931213601142

Poder, T. G., & Maltais, S. (2020). Systemic analysis of Medication Administration Omission Errors in a tertiary-care hospital in Quebec. Health Information Management Journal, 49(2–3), 99–107. https://doi.org/10.1177/1833358318781099

Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). Readiness, Barriers and Potential Strength of Nursing in Implementing Evidence-Based Practice. International Journal of Caring Sciences, 13(2), 1203–1211.

Stang, A., Thomson, D., Hartling, L., Shulhan, J., Nuspl, M., & Ali, S. (2018). Safe Care for Pediatric patients: A Scoping Review across Multiple Health Care Settings. Clinical Pediatrics, 57(1), 62–75. https://doi.org/10.1177/0009922817691820

NURS-FPX4020 Assessment 2

As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety improvement measures and plans. Often root-cause analyses are conducted, and safety improvement plans are created to address sentinel or adverse events such as medication errors, patient falls, wrong-site surgery events, and hospital-acquired infections.

Performing a root-cause analysis offers a systematic approach for identifying causes of problems, including process and system-check failures. Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care professionals to protect patients and improve outcomes.

As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety Improvement Plan Knowledge Base activity and to review the various assessment resources, all of which will help you build your knowledge of key concepts and terms related to quality and safety improvement. The terms and concepts will be helpful as you prepare your Root-Cause Analysis and Safety Improvement Plan. Activities are not graded and demonstrate course engagement.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Analyze the elements of a successful quality improvement initiative.
    • Apply evidence-based and best-practice strategies to address a safety issue or sentinel event pertaining to medication administration. ;
    • Create a viable, evidence-based safety improvement plan for safe medication administration.
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Professional Context

Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality improvements.

Scenario

For this assessment, you may choose from the following options as the subject of a root-cause analysis and safety improvement plan:

  • The specific safety concern identified in your previous assessment pertaining to medication administration safety concerns.
  • The readings, case studies, or a personal experience in which a sentinel event occurred surrounding an issue or concern with medication administration.

Instructions

The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Please utilize the template

Use the Root-Cause Analysis and Improvement Plan [DOCX] template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

  • Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration.
  • Create a feasible, evidence-based safety improvement plan for safe medication administration.
  • Identify organizational resources that could be leveraged to improve your plan for safe medication administration.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on safe medication administration.

Additional Requirements

  • Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan pertaining to medication administration.
  • Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
  • APA formatting: Format references and citations according to current APA style.
  • SCORING GUIDE

Root-Cause Analysis and Safety Improvement Plan Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Analyze the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. Does not identify the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. Identifies the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization. Analyzes the root cause of a patient safety issue or a specific sentinel event pertaining to medication administration in an organization, noting the degree to which various elements contributed to the safety issue or sentinel event pertaining to medication administration.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration. Does not describe evidence-based and best-practice strategies pertaining to medication administration. Describes evidence-based and best-practice strategies but their relevance to the safety issue or sentinel event pertaining to medication administration is unclear. Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration. Applies evidence-based and best-practice strategies to address the safety issue or sentinel event pertaining to medication administration, detailing how the strategies will address the safety issue or sentinel event pertaining to medication administration.
Create a viable, evidence-based safety improvement plan for safe medication administration. Does not create a viable, evidence-based safety improvement plan for safe medication administration. Creates a safety improvement plan for safe medication administration that lacks appropriate, convincing evidence of its viability. Creates a viable, evidence-based safety improvement plan for safe medication administration. Creates a viable, evidence-based safety improvement plan for safe medication administration that makes explicit reference to scholarly or professional resources to support the plan.
Identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. Does not identify existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. Identifies existing organizational resources, but their relevance and usefulness to quality and safety improvement for safe medication administration are unclear. Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration. Identifies existing organizational resources that could be leveraged to improve a safety improvement plan for safe medication administration, prioritizing them according to potential impact.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling. Does not organize content for ideas. Lacks logical flow and smooth transitions. Organizes content with some logical flow and smooth transitions. Contain errors in grammar or punctuation, word choice, and spelling. Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar or punctuation, word choice, and spelling. Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar or punctuation, word choice, and free of spelling errors.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format. Does not apply APA formatting to headings, in-text citations, and references. Does not use quotes or paraphrase correctly. Applies APA formatting to in-text citations, headings and references incorrectly or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes or paraphrasing. Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format. Exhibits strict and flawless adherence to APA formatting of headings, in-text citations, and references. Quotes and paraphrases correctly.

Evidence-Based Practice

  • Hande, K., Williams, C. T., Robbins, H. M., & Christenbery, T. (2017). Leveling evidence-based practice across the nursing curriculum. The Journal for Nurse Practitioners, 13(1), e17–e22.
    • Abstract: Evidence-based practice (EBP) competencies represent essential components of nursing education at all levels. The transition of EBP learning goals from the baccalaureate to the Master of Science in nursing and Doctor of Nursing Practice levels provides a blueprint for the development and advancement of student knowledge, skills, and attitudes. The purpose of this article is to describe 3 nursing curricula related to EBP competencies at the baccalaureate, master’s, and Doctor of Nursing Practice levels (Hande, Williams, Robbins, & Christenbery, 2017).
  • Sukkarieh-Haraty, O., & Hoffart, N. (2017). Integrating evidence-based practice into a Lebanese nursing baccalaureate program: Challenges and successes. International Journal of Nursing Education Scholarship, 14(1), 441–442.
    • Abstract: Evidence-based practice (EBP) is defined as “the conscientious use of current best evidence in making clinical decisions about patient care.” This paper describes how we have developed the evidence-based practice concept and integrated it into two courses at two different levels of the BSN curriculum. Students apply EBP knowledge and process by using the PICO clinical question (Population, Intervention, Comparison and Outcome), whereby they observe a selected clinical skill, and then compare their observations to hospital protocol and against the latest evidence-based practice guidelines. The assignment for the second course requires students to pick a more complex clinical skill and to support proposed changes in practice with scholarly literature. Assessment of student learning and course evaluation has shown that the overall experience of integrating EBP projects into the curriculum is fruitful for students, clinical agencies, and faculty (Sukkarieh-Haraty & Hoffart, 2017).
  • Rahmayanti, E. I., Kadar, K. S., & Saleh, A. (2020). Readiness, barriers and potential strength of nursing in implementing evidence-based practice. International Journal of Caring Sciences, 13(2), 1203–1211.
    • This article provides methods for identifying the readiness, barriers, and potential strengths of implementing evidence-based practice.
  • Lee, S. K. (2016). Implementing evidence-based practices improves neonatal outcomes. Evidence-Based Medicine, 21(6), 231.
    • This journal article provides a framework for identifying and appraising research, as well as implementing change and practices based on research.

Quality and Safety

Root-Cause Analysis

  • Institute for Healthcare Improvement. (n.d.). Cause and effect diagram [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard16.aspx
    • Cause and effect (or fishbone) diagrams are often used in root-cause analyses; this video shows how to create them.
  • Institute for Healthcare Improvement. (n.d.). Introduction to trigger tools for identifying adverse events. http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx
    • Tools to identify adverse events and determine their causes are provided on this resource page.
  • Galatzan, B. J. (2019). Exploring the content of the nurse-to-nurse change of shift hand-off communication (Publication No. 27666610) [Doctoral dissertation, University of Arizona]. http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdocview%2F2336369734%3Faccountid%3D27965
    • Abstract: An estimated 250,000 deaths occur annually are attributed to preventable medical errors. Approximately 100,000 of those deaths are related to miscommunication between healthcare providers. Miscommunication between healthcare providers during the transfer of care accounts for 80% of sentinel events occurring in the hospital setting. The hand-off communication continues to be one of the primary causes of sentinel events in healthcare in spite of the continued research focus over the past 10 years. The transfer of care communication between providers is called the “hand-off,” “change of shift report,” or “handover.” The hand-off for purposes of this study is defined as the process of transferring patient care, responsibility, and authority from one nurse to another at the change of shift. Specifically, we are concerned about the communication of clinical events (CE) experienced by the patient because CEs are precursors to a sentinel event. A CE is defined as a change in the patient’s condition in the following areas: bleeding, pain, fever, and changes in output, respiratory status, or level of consciousness (Galatzan, 2019).
  • Minnesota Department of Health. (n.d.). Root cause analysis toolkit. https://www.health.state.mn.us/facilities/patientsafety/adverseevents/toolkit/
    • The Minnesota Department of Health offers an extensive collection of resources related to root-cause analysis.
  • The Joint Commission. (n.d.). Framework for conducting a root cause analysis and action plan. http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/
    • With resources for conducting a root-cause analysis and creating an action plan to address the results, this Web page will help you understand the steps and processes of RCAs and improvement plans for this assessment.

Sentinel Events

  • The Joint Commission. (n.d.). Sentinel event policy and procedures. https://jointcommission.org/sentinel_event_policy_and_procedures
    • This web page provides definitions, policies, and procedures related to Sentinel events that may help you to complete your assignment.
  • The Joint Commission. (2017). The essential role of leadership in developing a safety culture [PDF]. Sentinel Event Alert, 57, 1–8. https://www.jointcommission.org/sea_issue_57/
    • According to The Joint Commission, “Competent and thoughtful leaders…understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.” This issue of Sentinel Event Alert discusses ways that effective leaders foster the development of a safety culture.

Safety and Sentinel Event Case Studies

  • Institute for Healthcare Improvement. (n.d.). One dose, fifty pills (AHRQ). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/AHRQCaseStudyOneDoseFiftyPills.aspx
  • Institute for Healthcare Improvement. (n.d.). Josie King – What happened to Josie? [Video]. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WhatHappenedtoJosieKing.aspx

NURS-FPX4020 Assessment 3 Improvement Plan

https://courserooma.capella.edu/webapps/osv-kaltura-BBLEARN/LtiMashupPlayIframeWrapperResponsive?playUrl=/browseandembed/index/media/entryid/1_0m2xsxo9/showDescription/false/showTitle/false/showTags/false/showDuration/false/showOwner/false/showUploadDate/false/playerSize/608×402/playerSkin/43969931/&course_id=_344730_1&content_id=@X@content.pk_string@X@

!!!Please click the link above for video instructions!!!

For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.

As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.

The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the health care environment (Patel & Wright, 2018).

As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.

Instructions

The final deliverable for this assessment will be a PowerPoint presentation with detailed presenter’s notes representing the material you would deliver at an in-service session to raise awareness of your chosen safety improvement initiative focusing on medication administration and to explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.

Be sure that your presentation addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

  • List the purpose and goals of an in-service session focusing on safe medication administration for nurses.
  • Explain the need for and process to improve safety outcomes related to medication administration.
  • Explain to the audience their role and importance of making the improvement plan focusing on medication administration successful.
  • Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
  • Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.

There are various ways to structure an in-service session; below is just one example:

  • Part 1: Agenda and Outcomes.
    • Explain to your audience what they are going to learn or do, and what they are expected to take away.
  • Part 2: Safety Improvement Plan.
    • Give an overview of the current problem focusing on medication administration, the proposed plan, and what the improvement plan is trying to address.
    • Explain why it is important for the organization to address the current situation.
  • Part 3: Audience’s Role and Importance.
    • Discuss how the staff audience will be expected to help implement and drive the improvement plan.
    • Explain why they are critical to the success of the improvement plan focusing on medication administration.
    • Describe how their work could benefit from embracing their role in the plan.
  • Part 4: New Process and Skills Practice.
    • Explain new processes or skills.
    • Develop an activity that allows the staff audience to practice and ask questions about these new processes and skills.
    • In the notes section of your PowerPoint, brainstorm potential responses to likely questions or concerns.
  • Part 5: Soliciting Feedback.
    • Describe how you would solicit feedback from the audience on the improvement plan and the in-service.
    • Explain how you might integrate this feedback for future improvements.

Remember to account for activity and discussion time.

Additional Requirements

  • Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the presenter’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be 10–15 slides.
  • Speaker notes: Speaker notes should reflect what you would actually say if you were delivering the presentation to an audience. Another presenter would be able to use the presentation by following the speaker notes.
  • APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation.
  • Number of references: Cite a minimum of 3 sources of scholarly or professional evidence to support your assertions. Resources should be no more than 5 years old.

Improvement Plan In-Service Presentation Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses. Does not list the purpose and goals of an in-service session focusing on safe medication administration for nurses. Lists with insufficient clarity the purpose and goals of an in-service session on safe medication administration for nurses. Lists clearly the purpose and goals of an in-service session on safe medication administration for nurses. Lists clearly the purpose and goals of an in-service session on safe medication administration for nurses, with purpose and goals that are relevant and achievable within the in-service session.
Explain the need and process to improve safety outcomes related to medication administration. Does not describe the need and process to improve safety outcomes related to medication administration. Describes a safety improvement outcome for medication administration, but the described need for the improvement or process to achieve improvement is unclear or irrelevant. Explains the need and process to improve safety outcomes related to medication administration. Explains the need and process to improve safety outcomes related to medication administration, with reference to specific data, evidence, or standards to support the explanation.
Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful. Does not describe the audience’s role in and importance of making the improvement plan focusing on medication administration successful. Describes the audience’s role in the improvement plan focusing on medication administration but does not clearly address how the audience is important to the success of the improvement plan. Explains audience’s role and importance of making the improvement plan focusing on medication administration successful. Explains audience’s role and importance of making the improvement plan focusing on medication administration successful, using persuasive and transparent communication to improve buy-in.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration. Does not list resources or activities related to safe medication administration. Lists resources or activities related to safe medication administration, but their relevance to skill development or process understanding related to a safety improvement initiative is unclear. Creates resources or activities to encourage skill development and process understanding related to a safety improve initiative on medication administration. Creates resources or activities to encourage skill development and process understanding related to a safety improve initiative on medication administration, explaining their value.
Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented. Slides are difficult to read with multiple editing errors. No speaker notes provided. Slides are easy to read with few editing errors. Speaker notes are sufficient to support the slides. Slides are easy to read and error free. Detailed speaker notes are provided. Slides are easy to read and clutter free. Slide background is “visually” pleasing with a contrasting color for the text and may utilize graphics. Detailed speaker notes are provided.
Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years). Does not organize content with clear purpose or goals. PowerPoint slides do not support main points, assertions, arguments, conclusions, or recommendations. Sources are not relevant or evidence-based (published within 5 years). Organizes content with clear purpose or goals. PowerPoint slides do not consistently support main points, assertions, arguments, conclusions, or recommendations with relevant and evidence-based sources (published within 5 years). Organizes content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years). Organizes content with clear purpose or goals. PowerPoint slides support main points, assertions, arguments, conclusions, or recommendations with relevant and evidence-based sources (published within 5 years).

 

× Chat with us