NR 451 Week 6 Assignment: EBP Change Process form

NR 451 Week 6 Assignment: EBP Change Process form

Name

Chamberlain University

NR-451: RN Capstone Course

Prof. Name

Date

Week 6 Assignment: EBP Change Process Form using the ACE Star Model of Knowledge Transformation

Star Point 1: Discovery (Identify Topic and Practice Issue)

The topic identified for this assignment is the reduction of errors made by nurses in healthcare institutions, with a focus on promoting a culture of safety. Errors are prevalent in hospital settings, often resulting in severe consequences that jeopardize patient health and, in some cases, lead to fatalities. These errors can stem from various factors, including recklessness, fatigue, and inattentiveness. Given their critical role in patient care, nurses are uniquely positioned to implement strategies that can significantly reduce or eliminate these errors.

The rationale for selecting this topic stems from the alarming frequency of errors reported in hospitals, which have contributed to the deaths of millions globally. The scope of the issue is broad, affecting not only individual patients but also overall healthcare quality and institutional credibility.

Star Point 2: Summary (Evidence to Support Need for a Change)

The primary practice problem revolves around the increasing incidence of errors in healthcare settings, which encompasses missed care, patient hand-offs, infections, falls, and medication errors. Despite the serious implications of these errors, efforts to foster a safety culture within healthcare environments remain insufficient. Consequently, there is a pressing need for research and interventions aimed at improving patient outcomes.

To formulate a guiding question, the PICOT framework is utilized. The relevant systematic review selected from the Cochrane Database of Systematic Reviews is:

• Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al Kindi, S. N. (2015). Patient safety culture among nurses. International Nursing Review, 62(1), 102-110.

Other scholarly sources consulted include:

1. Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical Care Nurse, 36(4), 19-35.
2. Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1).
3. Bush, P. A., Hueckel, R. M., Robinson, D., Seelinger, T. A., & Molloy, M. A. (2015). Cultivating a culture of medication safety in prelicensure nursing students. Nurse Educator, 40(4), 169-173.

The systematic review highlights that patient safety is crucial in enhancing healthcare quality. Key predictors of patient safety include effective communication about errors, continuous feedback, hospital management support, clear management expectations, and teamwork in addressing potential errors.

To address the identified issues, evidence-based solutions will be proposed. Hospital management should prioritize developing systems and practices that nurture a culture of patient safety while enhancing leadership capabilities to facilitate open communication, foster continuous organizational learning, and create a blame-free environment.

Star Point 3: Translation (Action Plan)

To support intervention planning, it is essential to identify existing care standards, practice guidelines, or protocols. A comprehensive, learner-centered training module can significantly enhance nurses’ skills, attitudes, and knowledge, while also raising awareness about various error-reduction strategies.

Key stakeholders involved in the change process include:

Nurses play a vital role in the change process by reporting errors or near misses to the appropriate authorities, allowing for analysis and subsequent preventive measures. They must also report unsafe conditions, such as faulty equipment, and utilize activity checklists to ensure comprehensive care.

Star Point 4: Implementation

To initiate the trial, the nurse leaders will formally seek permission from hospital management by submitting a detailed letter that outlines the problem, its implications, and the proposed intervention measures, including anticipated benefits. Educating staff about the change process is critical for its success; training sessions will emphasize the importance of reducing errors and enhancing patient safety.

The proposed implementation timeline is as follows:

Measurable outcomes based on the PICOT framework include:

• P (Population): Number of medication errors.
• I (Intervention): Promotion of patient safety.
• C (Comparison): Application of checklists during interventions.
• O (Outcome): Mortality rate.
• T (Time): Six months.

To record data during the pilot process, individual error types will be documented against the nurses involved. Available resources include checklists, posters, and flashcards to aid staff throughout the trial. Weekly meetings will be scheduled for stakeholders to evaluate the intervention’s effectiveness and make necessary adjustments.

Star Point 5: Evaluation

Outcomes of the trial will be reported using frequency tables to illustrate changes in error rates pre- and post-intervention. The findings will serve as a foundation for determining the effectiveness of the implemented changes and will offer insights for further improvement efforts aimed at reducing medication errors in the facility.

References

Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al Kindi, S. N. (2015). Patient safety culture among nurses. International Nursing Review, 62(1), 102-110.

Bush, P. A., Hueckel, R. M., Robinson, D., Seelinger, T. A., & Molloy, M. A. (2015). Cultivating a culture of medication safety in prelicensure nursing students. Nurse Educator, 40(4), 169-173.

Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1).

NR 451 Week 6 Assignment: EBP Change Process form

Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical Care Nurse, 36(4), 19-35.