NR 451 Week 6 Assignment: EBP Change Process form
Student Name
Chamberlain University
NR-451: RN Capstone Course
Prof. Name
Date
Week 6 Assignment: EBP Change Process Form
ACE Star Model of Knowledge Transformation
Star Point 1: Discovery (Identify topic and practice issue)
Identify the topic and the nursing practice issue related to this topic.
The selected topic focuses on reducing nursing errors within healthcare institutions through the establishment of a robust safety culture. In hospital environments, clinical errors occur frequently, placing patients at significant risk of harm, disability, or even death. These errors can involve medication administration, patient monitoring, infection prevention, and procedural accuracy. Promoting a safety-oriented culture in nursing practice is a crucial strategy for minimizing these incidents and improving patient outcomes.
Briefly describe your rationale for your topic selection. Include the scope of the issue/problem.
Hospital errors represent a global health challenge. According to the World Health Organization, millions of patients are adversely affected annually by preventable errors. The causes are multifaceted—ranging from fatigue and distraction to insufficient communication and lack of adherence to protocols. Nurses, as the largest group of healthcare providers with direct patient contact, are uniquely positioned to design and implement strategies that reduce such risks. Creating and sustaining a safety culture can significantly reduce preventable harm and improve the overall quality of healthcare delivery.
Star Point 2: Summary (Evidence to support need for a change)
Describe the practice problem in your own words and formulate your PICOT question.
The core practice issue is the persistent occurrence of clinical errors in healthcare facilities. These may include omissions in patient care, delayed interventions, infection control lapses, patient falls, and medication misadministration. Despite the known dangers, the implementation of systematic safety culture initiatives remains insufficient. Strengthening this culture is vital for enhancing patient safety and preventing adverse outcomes.
PICOT Question:
In acute care hospital settings (P), how does the implementation of a structured patient safety culture program (I) compared to standard practice without such a program (C) influence the frequency of nursing errors (O) over a period of six months (T)?
List the systematic review chosen from the Cochrane Database of Systematic Reviews from the Chamberlain library.
APA Reference:
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. https://doi.org/10.1111/inr.12159
List and briefly describe other sources used for data and information.
- 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. https://doi.org/10.4037/ccn2016498
- Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1), 29–35. https://doi.org/10.7748/cnp.14.1.29.s20
- 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. https://doi.org/10.1097/NNE.0000000000000142
Briefly summarize the main findings (in your own words) from the systematic review and the strength of the evidence.
The systematic review emphasizes that patient safety is a cornerstone of quality healthcare delivery. Nurses play a pivotal role in promoting a culture of safety due to their continuous involvement in direct patient care. Key predictors of a strong safety culture include open communication about errors, consistent feedback loops, managerial commitment, clear expectations, and interprofessional teamwork. The evidence presented in the review is robust, supported by both qualitative and quantitative studies across diverse healthcare settings.
Outline one or two evidence-based solutions you will consider for the trial project.
Two key interventions will be prioritized:
- Leadership-driven safety programs – Hospital leadership should establish systems that foster ongoing communication, encourage organizational learning, and maintain a blame-free environment.
- Team-based safety training – Regular interprofessional workshops to improve error reporting, collaboration, and safety checklist adherence.
Star Point 3: Translation (Action Plan)
Identify care standards, practice guidelines, or protocols that may be in place to support your intervention planning.
Existing best-practice guidelines, such as the World Health Organization’s Patient Safety Curriculum Guide and The Joint Commission’s National Patient Safety Goals, recommend structured safety training, error-reporting mechanisms, and continuous skills enhancement. These protocols provide a solid foundation for intervention planning.
NR 451 Week 6 Assignment: EBP Change Process form
List your stakeholders (by title and not names) and describe their roles and responsibilities in the change process.
| Stakeholder Title | Role and Responsibility |
|---|---|
| Staff Nurses | Implement safety measures, report incidents, complete safety checklists. |
| Nursing Leadership | Oversee implementation, allocate resources, monitor progress. |
| Hospital Management | Approve policies, provide funding, ensure organizational alignment. |
| Pharmacists | Reduce medication errors through verification and dispensing protocols. |
| Patients | Engage in care process, report safety concerns, provide feedback. |
What specifically is the nursing role in the change process?
Nurses are central to executing the change process. Their responsibilities include promptly reporting errors or near misses, using shared governance channels to address unsafe conditions, and rigorously applying standardized checklists to ensure comprehensive care delivery.
List your stakeholders by position titles. Why are the members chosen important to your project?
- Nurse Leaders (5): Provide supervision, mentorship, and advocacy for safety measures.
- Pharmacists (3): Address and prevent medication-related errors through expert oversight.
What type of cost analysis will be needed prior to a trial? Who needs to be involved with this?
A cost–benefit analysis will be conducted, focusing on training expenses, materials production (checklists, posters, flashcards), and digital resources (training videos). Involvement will include hospital administrators, finance officers, and nurse leaders to ensure budget feasibility.
Star Point 4: Implementation
Describe the process for gaining permission to plan and begin a trial.
Permission will be formally requested by nurse leaders through a written proposal to hospital management. The proposal will outline the identified problem, its patient safety implications, and the evidence-based interventions proposed, along with anticipated benefits.
Describe the plan for educating the staff about the change process trial.
Staff will undergo structured training sessions highlighting the importance of safety culture and practical strategies to prevent errors. Interactive workshops, case studies, and role-playing scenarios will be incorporated to ensure deep understanding and engagement.
Outline the implementation timeline for the change process.
| Date | Activity |
|---|---|
| 01.02.2018 – 14.02.2018 | Staff training on safety culture and error prevention. |
| 15.02.2018 – 28.02.2018 | Preparation of educational and promotional materials. |
| 01.03.2018 – 30.03.2018 | Safety awareness campaign launch. |
| 01.04.2018 – 31.04.2018 | Evaluation of skill application and knowledge retention. |
List the measurable outcomes based on the PICOT. How will these be measured?
| PICOT Element | Measurement Indicator |
|---|---|
| P – Number of Medication Errors | Incident reports before and after intervention |
| I – Promotion of Patient Safety | Safety audit compliance rates |
| C – Use of Checklists | Percentage of checklist completion per shift |
| O – Mortality Rate | Monthly mortality statistics |
| T – 6 Months | Comparative analysis at baseline and at 6 months |
What forms, if any, might be used for recording purposes during the pilot change process?
Incident report forms, electronic medication error logs, and checklist compliance sheets will be used to track progress and outcomes.
What resources are available to staff during the change pilot?
- Printed safety checklists
- Educational posters
- Flashcards summarizing safety protocols
Will there be meetings of certain stakeholders throughout the trial? If so, who and when will they meet?
Weekly review meetings will be held with nurse leaders, pharmacists, and management representatives to assess progress and adjust strategies as necessary.
Star Point 5: Evaluation
How will you report the outcomes of the trial?
Results will be compiled into frequency tables and comparative graphs to illustrate changes in error rates before and after the intervention.
What would be the next steps for the use of the change process information?
If the intervention demonstrates a significant reduction in errors, the program will be expanded hospital-wide and adapted for other clinical units. Lessons learned will be documented to refine future safety initiatives.
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. https://doi.org/10.1111/inr.12159
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. https://doi.org/10.1097/NNE.0000000000000142
NR 451 Week 6 Assignment: EBP Change Process form
Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1), 29–35. https://doi.org/10.7748/cnp.14.1.29.s20
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. https://doi.org/10.4037/ccn2016498