CU Nurse Safety Improvement Care Plan & Processes 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. CU Nurse Safety Improvement Care Plan & Processes In Service Presentation
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Assessment 3 Instructions: 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:
- Competency 1: Analyze the elements of a successful quality improvement initiative.
- 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.
- Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.
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. CU Nurse Safety Improvement Care Plan & Processes In Service Presentation
Scenario
For this assessment it is suggested you take one of two approaches:
- 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
- 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:
- Capella University Library: PowerPoint Presentations.
- Guidelines for Effective PowerPoint Presentations [PPTX].
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.
Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course.
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Root-Cause Analysis and Safety Improvement Plan
Yailin Mur Fernandez
NURS-FPX4020
Capella University
October, 2020
Root-Cause Analysis and Safety Improvement Plan
Nurses play a central role in addressing quality improvement in healthcare and one of the approaches is through identifying root-causes of medication errors and proposing methods of addressing them. The incident of concern is a medication error whereby the nurse administered the wrong dosage to a patient leading to temporary harm. This error occurred in a large urban hospital in the medical wards. The event triggered the need for a root-cause analysis of the factors leading to wrong dosage. This paper presents a root-cause analysis of the event, discusses some evidence-based and best-practice strategies to address it, and proposes a safety improvement plan to address the root-causes with the support of the available organizational resources.
Analysis of Root-Cause
The identified event is a medication error whose root cause could be one or more factors. Medication errors are common the health care industry and they cause harm and death to numerous patients each year. Medication errors cause adverse drug events and every year, 5% of patients in the hospital experience an adverse drug event (Giardina et al., 2018). In addition to adverse drug events, medication errors generally reduce the quality of care and safety of patients hence affecting the reputation of the organization. Some events may attract litigation against the health care organization and the nurse involved and hence medication errors are costly. The incident described in the introduction led to an overdose of the prescribed drug leading to poor health outcomes and extended hospital stay. The event was detected by another nurse when the patient started exhibiting symptoms of drug overdose. A review of the patient records showed that the attending nurse had administered two times the required dose. The patient developed acute confusion, anxiety, and hyperventilation. The event can be related to human error and systems failure and hence this analysis seeks to correct these two categories of causal factors.
The incident was investigated by a team of four, including the nurse manager, charge nurse, quality manager, and attending physician. The review of patient records revealed that the indicated dosage in the prescriptions was doubled in the nurse’s entry of the administered dosage. Therefore, the nurse administered the wrong dosage and entered in the patient records. This overview presented an opportunity to discuss the issue with the involved nurse. The nurse stated that the error occurred as a genuine mistake and there must have been some confusion. The analysis then included environmental and system factors.
An overview of medication errors and the organizational environment shows that the error can be attributed to high nurse workload and burnout. A review of the medical ward showed that there was a serious shortage of staffing hence nurses handled more acuity than they should. According to Johnson et al. (2017), a leading cause of medication errors is nurse burnout and distraction. In this case, a high workload for the nurse led to confusion of the medication dosage. Distractions also occur when the nurse is interrupted when in the process of medication preparation and administration. Staff workload led to low concentration in the process of medication administration and resulted in the medication error.
Another cause of medication errors such as the identified incident is the standard processes implemented in the health unit. Systemic medication errors are those caused by the design of the system as well as equipment and technology used. The medication administration process allows nurses to prepare medication at the patient’s bedside. Bedside medication preparation presents inherent risks in nurse distraction by the patient, other patients in the ward, and other staff. In general, the stated event was caused by human error contributed by workload and distractions as well as the standard processes of medication administration in the medical ward.
Application of Evidence-Based Strategies
Medication errors have been linked to both interruptions and nurse workload. A study conducted in Australia showed that 99% of all medication events had interruptions (Johnson et al., 2017). These interruptions were mostly from other nurses and often non-care related. The frequency of interruptions was associated with procedural failures and clinical errors. Similarly, research showed that as nurse-patient-ratio increases, there is a decrease in quality of care and number of medication errors related to nursing workload (Qureshi et al., 2017). These causes of medication error show the need for interventions to reduce distractions and nurse workload. The proposed strategies will address these two root causes.
Various strategies may be used to reduce nurse distractions and workload. First, distractions and interruptions may be reduced through design of a process to ensure that nurses are not interrupted during the medication preparation process. This process will ensure that nurses can acquire a private space where they can prepare medication away from the patient’s bedside and then go to the patient for administration. Regarding nurse workload and process for medication administration, staffing and nurse training could be implemented to reduce workload and increase the competence of nurses in offering care. The two proposed strategies can be consolidated into a safety improvement plan using the existing organizational resources to improve patient safety by limiting medication administration errors.
Safety Improvement Plan
The proposed improvement plan presents two major approaches to the medication administration challenge. The first approach is to implement the ‘sterile cockpit’ concept to the process of medication preparation to reduce nurse interruptions. This concept is borrowed from the aviation industry whereby nonessential activities are eliminated from the cockpit during critical phases of the flight (Ruby, 2016). Applied to medication administration, this strategy avails a safe space for nurses to go and prepare medications away from all nonessential activities. Previous research shows that the strategy led to 42% reduction in medication errors (Ruby, 2016). The objective of this strategy is to limit interruptions as much as possible and create an environment where the nurse can concentrate on the crucial task at hand. This strategy will be implemented by creating a medication preparation room whereby nurses will only be allowed if they are carrying out this specific activity and interactions will be kept at minimum.
The second strategy to be used for this root cause is to implement staff recruitment and training in reducing medication errors. Since staffing levels have been established as low in the organization and contribute to medication errors, increasing the number of staff in the organization can effectively reduce the number of errors. Regular staff awareness and training in patient safety have also been established as causing a significant decrease in the rates of medication errors (Di Simone et al., 2018). This strategy thus aims to increase the number of competent nurses to reduce human error emanating from knowledge deficit. Wrong dosage could emanate from the nurse’s inexperience and lack of knowledge in the medication administration processes. In this case, therefore, the intervention will reduce the risk of such errors by increasing nursing staff knowledge and competence.
Existing Organizational Resources
Implementation of the proposed strategies relies on leveraging existing resources to produce the best results. The timeline for this improvement plan includes the initial investment in the sterile cockpit and staffing needs as well as ongoing training of all nurses to enhance care quality. The safe space for medication preparation will be designated in a room adjacent to the medical ward where nurses can retreat and prepare medications without interruptions. The hospital facility has that space and furnishing and equipment are the required resources. Secondly, the organization needs financial investment in recruiting new staff and training existing ones. Financial investment in a recruitment program is required whereby the actual number of nurses and their qualifications are to be determined. An available resource is the experience of many charge nurses and nurse managers who can train the existing nurses and new recruits on patient safety and reduction of medication error risks. Overall, the organization has the financial and training capacity to implement both strategies of the improvement plan. CU Nurse Safety Improvement Care Plan & Processes In Service Presentation
Conclusion
Medication errors are common occurrences causing adverse events and near misses in the health care industry. The described medication administration error is attributed to human error and systemic challenges in the medication administration process. The proposed strategy will address staff distractions by providing a private space where nurses can concentrate on medication preparation before administration. Moreover, staffing levels will be improved to reduce the risk of errors made due to high staff workload and burnout. Leveraging the existing organizational resources, the program will effectively address the current medication administration error and prevent similar and related errors in the future. Nurse Safety Improvement Care Plan
References
Di Simone, E., Giannetta, N., Auddino, F., Cicotto, A., Grilli, D., & Di Muzio, M. (2018). Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 22(5), 346. https://doi.org/10.4103/ijccm.IJCCM_63_18
Giardina, C., Cutroneo, P. M., Mocciaro, E., Russo, G. T., Mandraffino, G., Basile, G., … & Arcoraci, V. (2018). Adverse drug reactions in hospitalized patients: results of the FORWARD (facilitation of reporting in hospital ward) study. Frontiers in Pharmacology, 9, 350. https://doi.org/10.3389/fphar.2018.00350
Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett‐Jones, T., Weidemann, G., … & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of Nursing Management, 25(7), 498-507. https://doi.org/10.1111/jonm.12486
Qureshi, S. M., Purdy, N., Mohani, A., & Neumann, W. P. (2019). Predicting the effect of nurse–patient ratio on nurse workload and care quality using discrete event simulation. Journal of Nursing Management, 27(5), 971-980. https://doi.org/10.1111/jonm.12757
Ruby, Z. C. (2016). Simple steps to reduce medication errors. Nursing, 46(8), 63-65. https://www.nursingcenter.com/journalarticle?Article_ID=3603336&Journal_ID=54016&Issue_ ID=3603170 Nurse Safety Improvement Care Plan