Improving Quality of Care and Patient Safety NURS-FPX4020

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Improving Quality of Care and Patient Safety NURS-FPX4020

Root-Cause Analysis and Safety Improvement Plan

Medication administration errors (MEAs) are among the leading causes of disabilities, mortalities, lengthy hospitalization, and increased costs of compensating care services. According to Tsegaye et al. (2020), the World Health Organization (WHO) estimates the annual global cost associated with medication errors to be approximately $42 billion, accounting for about 0.7% of healthcare expenditures. Despite such ramifications, health organizations face challenges in eliminating medication mistakes because they can occur at any stage of the medication management process. Healthcare professionals, especially nurses, must adhere to safety guidelines by observing various “rights,” including the right patient, doses, time, routes, and documentation during medication administration practices. Medical administrators must incorporate evidence-based practice and best strategies to safeguard patient safety and avert errors. Therefore, this paper describes a scenario of medication administration mistakes while elaborating root causes, evidence-based strategies, and organizational resources for preventing MEAs.

Analysis of the Root Cause

Medication administration errors are preventable acts that result in improper medication use in the treatment process, leading to multiple safety concerns such as adverse reactions, disability, and death (Tsegaye et al., 2020). In this sense, healthcare professionals responsible for administering regimens to patients fail to uphold the “medication rights” such as correct dosage, administration routes, documentation, and frequency due to the prevailing organizational, human, and technical factors. As a registered nurse operating in a skilled nursing facility (SNFs) in the cardiovascular care department, I have witnessed numerous scenarios where caregivers commit near misses or actual errors that lead to adverse medical outcomes.

In one instance, a registered nurse (RNs) tasked to administer digoxin doses to a 50-year-old male patient with arrhythmia episodes decided to delegate medication administration practices to unlicensed assistant personnel (UAP). Often, our organization allows registered nurses to delegate responsibilities to UAPs after conducting competency assessments and knowledge enhancement programs such as training and educational interventions. Although the nurse had fulfilled such guidelines, the delegate committed an error by administering incorrect dosage at the right time.

After observing the patient’s reactions, the nurse assistant detected the mistake that suggested potential digoxin toxicity, including nausea, vomiting, and irregular heart rhythms. After identifying the error, the nurse assistant did not communicate early or alert the delegator about the incident. Fortunately, one on-floor nurse saved the patient from the impending safety threats by administering an antidote. From such a scenario, l learned about the root causes of medication administration errors and possible ways to prevent mistakes.

Many scholarly studies provide evidence about the root causes of medication administration errors consistent with the case study. For instance, Vaismoradi et al. (2020) contend that various institutional factors facilitate medication mistakes. These factors include organizational patient-safety culture and environment, nurses’ workloads, the effectiveness of interprofessional collaboration and communication, the presence of education and training programs for nurses, and the availability of institutional guidelines for medication administration. In this sense, health organizations should provide opportunities that enable healthcare professionals to adhere to and comply with patient-safety principles. In our case study, timely incident reporting and effective communication between the nurse assistant and the delegator nurse would have prevented an error that almost claimed the patient’s life.

Other primary causes of medication administration mistakes are technical and human factors. In organizations where clinicians use computerized physician order entries (CPOEs) and automated medication administration technologies, incidences of technical glitches may compromise medication administration practices leading to errors of commission and omission. Although technical factors are often accidental and unanticipated, human factors are significant causes of medication errors. Tsegaye et al. (2020) argue that medication administration mistakes occur due to various human-related issues, including the level of knowledge and training on medication administration practices, work experience, familiarity with organizational guidelines, ability to communicate and report near misses or actual sentinel events, and competencies to adhere to safety guidelines. Since a human is to error, it is essential for healthcare organizations to invest massively in implementing evidence-based and best practices for enhancing employee competencies and knowledge of safe practices for medication administration.

Application of Evidence-Based Strategies

Health organizations must incorporate the best evidence and implement proven interventions for preventing medication administration errors. In our case study, communication breakdown and human factors facilitated an administrative error that adversely affected the patient. Manias et al. (2020) support the possibility of preventing causal factors for medication errors by implementing scientifically proven interventions, including interprofessional collaboration, prescriber education, technological advancements to incorporate computerized physician order entry (CPOE), and pharmacist-led medication reconciliation. On the other hand, Reeves et al. (2017) suggest effective communication and reporting systems as ideal approaches for reducing medication mistakes. Implementing these recommendations requires institutions to embrace contingency plans and consolidate resources for enacting quality improvement initiatives.

Improvement Plan with Evidence-Based and Best-Practice Strategies

Undoubtedly, health organizations must implement quality improvement initiatives and evidence-based strategies to prevent medication administration errors. In this sense, these steps include educating and training prescribers about safe medication administration practices, enhancing reporting and communication systems, installing advanced technologies to replace the traditional documentation steps, and encouraging interprofessional collaboration by transforming workplace cultures. According to Yousef & Yousef (2017), an ideal plan for preventing medication errors must contain educational workshops for physicians, process automation and technological advancement, setting standardized general guidelines, creating suitable workplace environments to eliminate blame, and punishment for error perpetrators, and empowerment programs. Institutions should consistently implement these recommendations because eliminating medication errors requires continuous quality improvement initiatives.

Existing Organizational Resources

Health organizations and quality improvement implementation teams should leverage the existing institutional resources to guarantee plan sustainability and realize strategic goals. In this sense, it is possible to utilize employees’ competencies, experience, and skills when implementing training and educational programs for newly registered nurses and prescribers. Reputable physicians, IT experts, and informaticists can input these initiatives by sharing information, educating novice nurses about safety guidelines, and ensuring smooth operations of technological infrastructures. Also, organizations should utilize the existing health record systems and information frameworks to promote interprofessional collaboration and effective communication. In this sense, the presence of electronic health records (EHRs), automated alert systems, and other technologies provide ideal opportunities for healthcare organizations to prevent medication errors. When leveraging the existing organizational resources, it is essential to conduct need assessments to identify resource strengths, opportunities, weaknesses, and threats.

Conclusion

Medication administration errors (MAEs) are among sentinel events that result in multiple patient safety concerns, including adverse reactions to medications, disabilities, mortalities, lengthy hospitalization, and increased economic burden of compensating care. From the case study, it is valid to contend that human, technical, and organizational factors combine to determine the likelihood of error occurrence. In this sense, issues like ineffective communication and timely reporting systems, time pressure, prescriber experience, familiarity with guidelines, and technological advances significantly determine organizational susceptibility to medication administration errors. While many scholarly studies propose training and educational programs for prescribers, among other strategies, it is essential to embrace the evidence-based practice and implement the best interventions that are consistent with the need to prevent medication errors. Also, it is vital to align and leverage the existing resources when implementing these prevention approaches.

References

Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11, 204209862096830. https://doi.org/10.1177/2042098620968309

Reeves, S., Clark, E., Lawton, S., Ream, M., & Ross, F. (2017). Examining the nature of interprofessional interventions designed to promote patient safety: A narrative review. International Journal for Quality in Health Care, 29(2), 144–150. https://doi.org/10.1093/intqhc/mzx008

Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication administration errors and associated factors among nurses. International Journal of General Medicine, Volume 13, 1621–1632. https://doi.org/10.2147/ijgm.s289452

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health, 17(6), 2028. https://doi.org/10.3390/ijerph17062028

Yousef, N., & Yousef, F. (2017). Using a total quality management approach to improve patient safety by preventing medication error incidences. BMC Health Services Research, 17(1), 1-16. https://doi.org/10.1186/s12913-017-2531-6

NURS-FPX4020 Assessment 1 Instructions: Enhancing Quality and Safety

  • 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:

      • 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.
    • Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Additional Requirements

    • Length of submission: 3–5 pages, plus title and reference pages.
    • Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
    • APA formatting: References and citations are formatted according to current APA style.

Enhancing Quality and Safety Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Explain factors leading to a specific patient-safety risk focusing on medication administration. Does not identify factors leading to a specific patient-safety risk focusing on medication administration. Identifies factors leading to a specific patient-safety risk focusing on medication administration. Explains factors leading to a specific patient-safety risk focusing on medication administration. Explains factors leading to a specific patient-safety risk focusing on medication administration. Makes reference to specific data, evidence, or standards to illustrate the safety risk.
Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs. Does not identify evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs. Identifies evidence-based and best-practice solutions to improve patient safety focusing on medication administration and/or discusses reducing costs but not both. Explains evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs. Explains evidence-based and best practice solutions to improve patient safety focusing on medication administration and reducing costs. Makes explicit reference to scholarly or professional resources to support explanation.
Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs. Does not identify how nurses can help coordinate care to increase patient safety with medication administration and reduce costs. Identifies how nurses can help coordinate care to increase patient safety with medication administration and/or how to reduce costs but not both. Explains how nurses can help coordinate care to increase patient safety with medication administration and reduce costs. Explains how nurses can help coordinate care to increase patient safety with medication administration and reduce costs, providing specific examples related to a patient safety risk.
Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration. Does not identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration. Identifies stakeholders, but their relevance to collaboration with nurses or their ability to drive quality and safety enhancements with medication administration is unclear. Identifies stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration. Identifies stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration, noting the relevance and potential importance of the stakeholders.
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. Contains 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.

Collaboration and Leadership

    • This article discusses the importance of creating a unit-specific patient safety culture that is tailored to the competencies of the unit’s RNs in patient safety practice.
    • Evidence-based practice is a problem-solving approach in which the best available and useful evidence is used by integrating research evidence, clinical expertise, and patient values and preferences to improve health outcomes, service quality, patient safety and clinical effectiveness, and employee performance.
    • This article provides recommendation to promote quality and safety education with a focus on systems thinking awareness among direct care nurses. A key point is error prevention, which requires a shared effort among all nurses.
    • This research study may be helpful in identifying traits and qualities of new registered nurses that are helpful in coordinating and leading quality and safety measures related to this assessment.
    • This research analyzes attributes and best practices of leadership and nursing staff that help aid in patient care quality and job satisfaction.
    • This article examines competencies that may help nurses collaborate more effectively to improve patient outcomes.
    • This examination of underlying systemic causes of medication errors may be useful as you consider QI vest practices and ways to coordinate care to increase safety and quality.
    • This article examines competencies that may help health care professionals collaborate more effectively to improve patient outcomes.
    • This examination of underlying systemic causes of medication errors may be useful as you consider QI best practices and ways to coordinate care to increase safety and quality.

Quality and Safety Education

    • This article attempts to align the language used in three quality and safety standards and reduce confusion for health care professionals.
    • This article discusses the needs for quality and safety education in nursing and how the Journal of Continuing Education in Nursing supports QSEN competency implementation in practice.
    • This article discusses educating nursing students about patient safety early within their learning journey and how it has shown to have a compelling positive impact on each individual’s knowledge, skills, and behavior growth surrounding the concept of patient safety.
    • Abstract: It is recognized worldwide that the skills of nursing students concerning patient safety is still not optimal. The role of clinical instructors is to instill in students the importance of patient safety. Therefore, it is important to have competent clinical instructors. Their experience can be enhanced through the application of quality circles.
    • This study identifies the effect of quality circles on improving the safety of patients of nursing students. Patient safety is inseparable from the quality of nursing education. Existing research shows that patient safety should be emphasized at all levels of the healthcare education system.
    • In hospitals, the ratio between nursing students and clinical instructors is disproportionately low. In Indonesia, incident data relating to patient safety involving students is not well documented, and the incidents often occur in the absence of a clinical instructor (Wieke Noviyanti, Handiyani, & Gayatri, 2018).
    • This study examines components of nursing care delivery and the mode of nursing care delivery. This may be helpful in seeing safety and quality education and best practices.
    • This wire feed examines evidence-based and best-practice strategies for improving the care offered by school nurses, may help you identify useful strategies for your assessment.

Quality and Safety Case Studies

Consider reviewing the following case studies as you complete your assessment:

  • 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 2: Root-Cause Analysis and Safety Improvement Plan

For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue pertaining to medication administration in a health care setting of your choice as well as a safety improvement plan.

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.

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.

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.

NURS-FPX4020 Assessment 3: Improvement Plan In-Service Presentation

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.

You are encouraged to explore the AONE Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONE Nurse Executive Competencies—especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.

Demonstration of Proficiency

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

    • Explain the need and process to improve safety outcomes related to medication administration.
    • Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative on medication administration.
  • Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
    • List clearly the purpose and goals of an in-service session focusing on safe medication administration for nurses.
    • Explain audience’s role in and importance of making the improvement plan focusing on medication administration successful.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
    • Organize content with clear purpose or goals and with relevant and evidence-based sources (published within 5 years).

Reference

Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing. Journal of Obstetric, Gynecologic & Neonatal Nursing​, 47(3), s16–s17.

Professional Context

As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group.

Preparing to run an in-service may be daunting, as the facilitator must develop his or her message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove him- or herself a valuable resource to others.

Scenario

For this assessment it is suggested you take one of two approaches:

  1. Build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to your safety improvement plan pertaining to medication administration, or
  2. Locate a safety improvement plan through an external resource and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the issues and improvement goals pertaining to medication administration safety.

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.

For tips on developing PowerPoint presentations, refer to:

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 at least 10 slides and no more than 15 slides (not including the title, conclusion, or references slides).
  • Speaker notes: Speaker notes (located under each slide) should reflect what you would actually say if you were delivering the presentation to an audience. This presentation does NOT require audio or a transcript. Another presenter would be able to use the presentation by following the speaker’s 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).

NURS-FPX4020 Assessment 4: Improvement Plan Tool Kit

For this assessment, you will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan.

Communication in the health care environment consists of an information-sharing experience whether through oral or written messages (Chard & Makary, 2015). As health care organizations and nurses strive to create a culture of safety and quality care, the importance of interprofessional collaboration, the development of tool kits, and the use of wikis become more relevant and vital. In addition to the dissemination of information and evidence-based findings and the development of tool kits, continuous support for and availability of such resources are critical.

Among the most popular methods to promote ongoing dialogue and information sharing are blogs, wikis, websites, and social media. Nurses know how to support people in time of need or crisis and how to support one another in the workplace; wikis in particular enable nurses to continue that support beyond the work environment. Here they can be free to share their unique perspectives, educate others, and promote health care wellness at local and global levels (Kaminski, 2016).

You are encouraged to complete the Determining the Relevance and Usefulness of Resources activity prior to developing the repository. This activity will help you determine which resources or research will be most relevant to address a particular need. This may be useful as you consider how to explain the purpose and relevance of the resources you are assembling for your tool kit. The activity is for your own practice and self-assessment, and demonstrates 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.
    • Analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration.
  • Competency 2: Analyze factors that lead to patient safety risks.
    • Analyze the value of resources to reduce patient safety risk or improve quality with medication administration.
  • Competency 3: Identify organizational interventions to promote patient safety.
    • Identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration.
  • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
    • Present reasons and relevant situations for resource tool kit to be used by its target audience.
    • Communicate resource tool kit in a clear, logically structured, and professional manner that applies current APA style and formatting.

References

Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329–342.

Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1–7.

Professional Context

Nurses are often asked to implement processes, concepts, or practices—sometimes with little preparatory communication or education. One way to encourage sustainability of quality and process improvements is to assemble an accessible, user-friendly tool kit for knowledge and process documentation.

Creating a resource repository or tool kit is also an excellent way to follow up an educational or in-service session, as it can help to reinforce attendees’ new knowledge as well as the understanding of its value. By practicing creating a simple online tool kit, you can develop valuable technology skills to improve your competence and efficacy. This technology is easy to use, and resources are available to guide you.

Scenario

For this assessment, consider taking one of these two approaches:

  1. Build on the work done in your first three assessments and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan pertaining to medication administration and put the plan into action.
  2. Locate a safety improvement plan (your current organization, the Institution for Healthcare Improvement, or a publicly available safety improvement initiative) pertaining to medication administration and create an online tool kit or resource repository that will help an audience understand the research behind the safety improvement plan and how to put the plan into action.

Preparation

Google Sites is recommended for this assessment; the tools are free to use and should offer you a blend of flexibility and simplicity as you create your online tool kit. Please note that this requires a Google account; use your Gmail or GoogleDocs login, or create an account following the directions under the “Create Account” menu.

Refer to the following links to help you get started with Google Sites:

  • G Suite Learning Center. (n.d.). Get started with Sites. https://gsuite.google.com/learning-center/products/sites/get-started/#!/
  • Google. (n.d.). Sites. https://sites.google.com
  • Google. (n.d.). Sites help. https://support.google.com/sites/?hl=en#topic=

Instructions

Using Google Sites, assemble an online resource tool kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed.

It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative pertaining to medication administration. For example, for an initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues.

Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on safety with medication administration. Each resource listing should include the following:

  • An APA-formatted citation of the resource with a working link.
  • A description of the information, skills, or tools provided by the resource.
  • A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to medication administration.
  • A description of how nurses can use this resource and when its use may be appropriate.

Remember that you must make your site ‘public’ so that your faculty can access it. Check out the Google Sites resources for more information.

Here is an example entry:

    • This article presents the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project. It shows how a collaborative nurse lead project can be implemented and used to improve collaboration and interdisciplinary teamwork, as well as improve the delivery of health care services. This resource is likely more useful to nurses as a resource for strategies and models for assembling and participating in an interdisciplinary team than for specific fall-prevention strategies. It is suggested that this resource be reviewed prior to creating an interdisciplinary team for a collaborative project in a health care setting.

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.

  • Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to medication administration.
  • Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on medication administration.
  • Analyze the value of resources to reduce patient safety risk related to medication administration.
  • Present reasons and relevant situations for use of resource tool kit by its target audience.
  • Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting.

Example Assessment: You may use the following example 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 tool kit will focus on promoting safety with medication administration. Note that you do not have to submit your bibliography in addition to the Google Site; the example bibliography is merely for your reference.

To submit your online tool kit assessment, paste the link to your Google Site in the assessment submission box.

Example Google Site: You may use the example Google Site, Resources for Improved Heparin Infusion Safety, to give you an idea of what a Proficient or higher rating on the scoring guide would look like for this assessment but keep in mind that your tool kit will focus on promoting safety with medication administration.

Note: If you experience technical or other challenges in completing this assessment, please contact your faculty member.

Additional Requirements

  • APA formatting: References and citations are formatted according to current APA style

Improvement Plan Tool Kit Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. Does not identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. Identifies resources, but the necessity or support for the safety improvement initiative focusing on medication administration is unclear. Identifies necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. Identifies necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. Organizes resources logically for ease of use.
Analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. Does not analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. Summarizes but does not analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. Analyzes usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. Analyzes usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. Provides specific examples of utility in the context of a specific health care setting.
Analyze the value of resources to reduce patient safety risk or improve quality with medication administration. Does not analyze the value of resources to reduce patient safety risk or improve quality with medication administration. Describes resources to reduce patient safety risk or improve quality with medication administration. Analyzes the value of resources to reduce patient safety risk or improve quality with medication administration. Analyzes the value of resources to reduce patient safety risk or improve quality, identifying those that may be most valuable for reducing patient safety risk or improving quality with medication administration.
Present reasons and relevant situations for resource tool kit use by its target audience. Does not present reasons and relevant situations for resource tool kit use by its target audience. Lists reasons or situations for resource tool kit use, but they are not compelling or their relevance to the target audience is unclear. Presents reasons and relevant situations for resource tool kit use by its target audience. Uses persuasive, engaging language to present compelling reasons and relevant situations for resource tool kit use by its target audience.
Communicate resource tool kit in a clear, logically structured, and professional manner that applies current APA style and formatting. Communicates a resource tool kit in an unclear, illogically structured, and unprofessional manner that does not apply current APA style and formatting and contains many errors and/or incorrect citations. Communicates online resource kit using a Word Doc or Google Sites in an unclear and disorganized structure and unprofessional manner that minimally follows APA style and formatting. Communicates resource tool kit in a Word doc in a clear, logically structured, and professional manner that applies partially follows APA style and formatting. Communicates online resource tool kit using a Google Sites in a clear and organized structure, and professional manner that applies nearly flawless, current APA style and formatting throughout.

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