Medicine and Health Sciences Commons^™

Safety Culture And Fall Prevention: A Collaborative Effort, Cecilia Cortina

Seton Hall University DNP Final Projects

Patient falls in the United States (US) range from 700,000 to one million annually and one third of those falls can be prevented (Du Pree, Fritz-Campiz & Musbeno, 2014). Twenty to 30% of falls are moderate to severe (Schimke & Schimke, 2014). As of 2009, The Joint Commission’s (TJC) (2015) Sentinel Event databank held 465 reports of hospital falls with injury; deaths that resulted in those injuries were reported as 63 percent. Common denominators resulting in patient falls with injury are poor assessment, lack of communication, failure to follow protocols, insufficient training and supervision, staffing levels, unsafe environments and lack …

The Effects Orthostatic Hypotension Has On Falls: A Study Done In San Francisco With The Patient Population Of The Veterans Affairs Hospital, Sherry A. Ballard Ms.

Master's Projects and Capstones

The Effects Orthostatic Hypotension has on Falls: A Study Done in San Francisco Represented

Population of the Veterans Affairs Hoapital

The global AIM of this project is to Identify patients that are at risk for Orthostatic Hypotension (OH) with in the first 24 hours of addmission. It was identified that 50% of the falls over the last 4 quarters at the VA were OH related. The patients were not identified as a fall risk and over half of them had fallen multiple times. After performing a nursing survey online, a SWOT analysis, and a Root Cause Analysis using a fishbone …

Design, Implementation, And Evaluation Of A User Training Program For Integrating Health Information Technology Into Clinical Processes, Ze He

Doctoral Dissertations

Health information technology (IT) implementation can be costly, and remains a challenging problem with mixed outcomes on patient safety and quality of care. Systems engineering and IT management experts have advocated the use of sociotechnical models to understand the impact of health IT on user and organizational factors. Sociotechnical models suggest the need for user-centered implementation approaches, such as user training and support, and focus on processes to mitigate the negative impact and facilitate optimal IT use during training. The training design and development should also follow systematic processes guided by instructional development models. It should take into account of …

The Effects Of Empowerment On Role Competency And Patient Safety Competency For Newly Graduated Nurse Practitioners, Elsie Duff

Electronic Thesis and Dissertation Repository

Introduction: Role competence and patient safety (PS) competence among healthcare professionals are rapidly developing issues due to increasing patient acuity and complexity in the healthcare system. Upon graduation, nurse practitioners (NPs) provide autonomous healthcare for populations with complex health needs, thus role and PS competence is imperative. In Canada, few studies have examined NP education and role development specific to NP role competence and PS competencies. This study addresses this gap in the research examining educational experiences of new NP graduates.

Aim: The aim of this study is to test a hypothesized model of the relationships between educational structural empowerment, …

Sentinel Event Management Model: A Performance Improvement Project, Kelly M. Johnson

Graduate Theses, Dissertations, and Capstones

The purpose of this performance improvement project was to implement a standard sentinel event management model in an acute care hospital that is part of a healthcare system based on best practices and principles of high reliability organizations. The project used define, measure, analyze, improve and control (DMAIC) methodology and Lewin’s Theory of Planned Change. High rates of medical harm and preventable deaths have been demonstrated around the world. It is estimated that one in four American families will be affected by preventable harm in healthcare involving further medical care, disability or even death. Despite international awareness and substantial efforts …

Operating Room Nurse To Post Anesthesia Care Unit Nurse Handoff: Implementation Of A Written Sbar Intervention, Erin Long

Evidence-Based Practice Project Reports

The lack of standardized handoff from the operating room (OR) nurse to the post anesthesia care unit (PACU) nurse may result in the miscommunication or omission of patient information, which increases the risk of patient safety events. The goal of this EBP project was to standardize OR to PACU nurse handoff in order to reduce risks to patient safety. A literature review revealed guidelines for handoff which included implementing a standardized protocol and using a mnemonic phrase. The Iowa Model of Evidence-Based Practice and Lewin’s Model of Change guided the EBP project. Handoff quality was evaluated by OR and PACU …

Improving Patient Safety Through Patient Safety Aide (Sitter) Competency Education, Colman Tom

Nursing Theses and Capstone Projects

Healthcare facilities today are faced with many difficult patient care and safety challenges. In addition to providing immediate complex patient medical needs, healthcare staff must ensure patients are in a safe environment. Patient safety has become a major focus of many medical and long-term care facilities. An in-house reporting system of a medium size medical healthcare facility identified a patient safety issue. Multiple patient safety sentinel events have been reported; namely patient elopements (unauthorized missing patients) and high-risk patient falls. Certified nursing assistants were contracted to sit with these high-risk patients to alleviate these patient safety issues; nevertheless, these patient …

Implementing A Good Catch Program In Nursing Homes, Leigh Raposo

Muskie School Capstones and Dissertations

Rationale and processes for reporting near misses and evidence-based tools were collected by a literature search, seminal works by Sidney Dekker and James Reason, and websites for the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement (IHI), and the Centers for Medicare and Medicaid Services (CMS). Tools, information, and strategies found in this research were evaluated for implementation in Maine nursing homes. The tools provide a communication vehicle for nursing home staff to safely report to management near misses, or mistakes that do not harm residents. To emphasize a positive approach, the project replaces the term …

Implementation Of Teamstepps In The Operating Room A Quality Improvement Project, Teresa D. Vincent

Graduate Theses, Dissertations, and Capstones

Abstract

This project aimed to determine if implementing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) at Norton Women’s Kosair Children’s Hospital (NWKCH) main operating room would decrease the occurrence of adverse events leading to patient harm. The TeamSTEPPS’ goal is to create high-reliability teams (HRT) and thus limit the potential for patient harm, including but not limited to wrong site surgery and unintentionally retained foreign objects. In the last decade, the healthcare industry has increased focus on patient safety; however, even with the implementation of evidence-based practice and new technical advances, patient safety within the operating …

The Collaborative Development Of A Pre-Operative Checklist: An E-Delphi Study, Katherine Murphy, Kim Walker, Jed Duff, Robyn Williams

Journal of Perioperative Nursing

The aim of this study was to identify which items should be included in a pre-operative checklist based on recommendations by nurse experts in order to promote patient safety and effective communication in the perioperative environment.

Method: Thirty-five nurses participated in this e-Delphi study, which was conducted online via SurveyMonkey.. Each survey presented participants with a list of potential items for inclusion in a pre-operative checklist. Participants were asked to identify items they felt should be included in the checklist with the option to include comments. Comments were de-identified and shared with other participants to allow confidential interaction. The surveys …

Educational Strategies For Reducing Medication Errors Committed By Student Nurses: A Literature Review, Kristi Miller, Lisa Haddad, Kenneth D. Phillips

International Journal of Health Sciences Education

Medication errors cause harm, yet most of them are preventable (Institute of Medicine, 2006). Nurses spend 40% of their time administering medications; therefore they play a key role in the reduction of medication errors. Little empirical evidence has been collected about the effectiveness of nursing education in reducing medication errors committed by nursing students. Traditional educational interventions focus on the five rights of medication administration; however, the literature shows that interventions focused on instilling a culture of safety have a greater impact on reducing medication errors. The purpose of this article is to review educational strategies that have been implemented …

Simulation As Staff Development For Competency In Nursing Care Of Patients With Chest Tubes, Jennifer Dent

Doctor of Nursing Practice Projects

There is an estimated 98,000 to 400,000 hospital errors that result in patient harm or death annually (David, Gunnarsson, Waters, Horblyuk and Kaplan, 2013; James 2013). As a member of the health care team nurses coordinate and provide continual care to the hospitalized patient (American Association of Colleges of Nursing, 2011; Parker, 2014). Patient safety is promoted when nurses are competent in their knowledge, skills, attitude, and performance related to evidence-based practice, protocols, and standards of care (; American Nurses Association, n.d; Schroeter, 2009). The purpose of this evidence-based project was to promote patent safety by developing and maintaining competency …

Orientation Of Nurses Transitioning Into Hospital Specialty Units, Mary Laly Chacko

Walden Dissertations and Doctoral Studies

Competency-based nurse orientation programs focus on the new nursing graduate and experienced nurse employees' ability to perform skills necessary in a new work setting. The purpose of this project was to develop a learner-focused and competency-based orientation program for new nursing employees at a large urban hospital to enhance patient safety and nurse retention. The Johns Hopkins nursing evidence-based practice model and guideline were used in the selection of articles with higher levels of evidence and research quality for the critical appraisal of literature in support of the program development. The best practices for nursing orientation content and delivery for …

A Nurse's Perception Of Hand-Off Communication Before And After Utilization Of The I-5 Verification Of Information Tool, Maryann Bowersox

Walden Dissertations and Doctoral Studies

Abstract

Miscommunication or omission of critical patient information contributes to preventable

medical errors that result in 98,000 patient deaths each year. The hand-off

communication process creates a critical time for the patient as necessary information for

the continuity of care must be communicated. The purpose of this practice project was to

evaluate the nurses' perception of the current hand-off communication process before and

after an educational intervention and implementation of the I-5 Verification of

Information Tool. Registered nurses were asked to complete a pre survey of their

perception of the current hand-off communication process, followed by an educational

power point …

Education Program For Nurses Working In An Immigration Detention Facility, Dr. Tiney Elizabeth Ray

Walden Dissertations and Doctoral Studies

Nursing response to medical emergencies has been an ongoing issue in immigration detention centers. Lack of teamwork and poor communication with medical and security staff have resulted in detainees sustaining injuries during medical emergencies. This project was developed to persuade Immigration and Customs Enforcement Health Service Corps (IHSC) leaders to consider piloting the TeamSTEPPS emergency response curriculum for nurses working in the immigration detention center. Tuckman and Jensen's model of group development will provide guidance to IHSC leaders in understanding the transformational stages of forming a successful team. TeamSTEPPS will address gaps in emergency health care competency by improving collaboration, …

Post Foley Removal Guideline Process And Outcome Evaluation, Sarah E. Gabbard

DNP Projects

When patients are admitted to a hospital patient safety should be a priority in all aspects of the care they receive. Preventing patients from acquiring hospital infections (HAIs) is one example of patient safety. All hospital employees have the responsibility to ensure that standard workflow and processes are in place to ensure this safety. The purposes of this Practice Inquiry Project (PIP) were to examine and develop interventions to decrease the risk of catheter associated urinary tract infections (CAUTIs), incorporate an effective process and standard workflow to implement evidence practice practices (EBP), and to evaluate the effectiveness of implementing the …

Nurse Staffing And Patient Outcomes: A Longitudinal Study On Trend And Seasonality., Jianghua He, Vincent S. Staggs, Sandra Bergquist-Beringer, Nancy Dunton

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Time trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated.

METHODS: Quarterly unit-level nursing data in 2004-2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided …