Advancing Safe Medication Administration During Pediatric Emergency Care Through Nurse Education: A Quality Improvement Project, Ciera Hunter

Master's Theses and Capstones

Background: Due to the increased complexities of pediatric medication administration, preventable errors occur at a higher rate than in general adult populations. Rural emergency departments (EDs) often see fewer pediatric patients and have less specialized support available on-site. Nurse continuing education is an evidence-based intervention to reduce medication administration errors making it vital to supporting patient safety and maintaining pediatric readiness.

Local Problem: The microsystem is a rural, critical access hospital in northern New England. In 2021, the microsystem scored 66/81 on the National Pediatric Readiness Project’s (NPRP’s) ED Assessment. In 2026, the score dropped 11 points to 55/81. Contributing …

Incorporating Structured Safety Huddles To Improve Nursing Communication And Reduce Medical-Surgical Inpatient Fall Rates: A Quality Improvement Project, Alexia K. Leonard

Master's Theses and Capstones

BACKGROUND: Patient falls are a significant concern for patient safety in the acute care setting and are typically connected to inadequate communication during shift transitions. Bedside shift report is considered the standard of care, however, barriers are still present when shifting patient care responsibilities among nursing staff. A literature review identified standardized safety huddles as an evidence-based practice to improve areas of communication, teamwork, situational awareness, and patient safety. This quality improvement (QI) project concentrated on the implementation of a standardized evening safety huddle in order to improve nursing communication and reduce patient falls on an inpatient medical-surgical/telemetry unit. METHODS: …

Improving Nurse Well-Being And Patient Safety Through A Structured Break Buddy System: A Quality Improvement Project, Elizabeth Harrington

Master's Theses and Capstones

Abstract

Background: Nursing burnout has become an increasing concern due to heavy workloads, staffing shortages, and the inability of nurses to consistently take uninterrupted rest breaks during their shifts. Missed breaks contribute to fatigue, emotional exhaustion, decreased job satisfaction, and an increased risk of patient safety events. Evidence suggests that structured break interventions may improve opportunities for recovery during the workday.

Methods: A quality improvement (QI) project was conducted on a respiratory care unit at a midsized hospital in central New Hampshire using the Plan-Do-Study-Act (PDSA) framework. A microsystem assessment identified inconsistent break-taking as a significant gap. A five-question anonymous …

Building Confidence And Team Communication: Implementation Of A Rapid Response In Situ Simulation Program In The Neonatal Intensive Care Unit, Janell F. Hacker

DNP Projects

Background: Neonatal code events are high-risk, low-frequency occurrences in the neonatal intensive care unit (NICU). Simulation-based training is used to support skill development, maintain competencies, and enhance team performance.

Purpose: The purpose was to determine if a multidisciplinary, high-fidelity, rapid response in situ simulation program would impact confidence and communication among frontline healthcare providers during neonatal code events.

Methods: A quasi-experimental, pretest-posttest study was conducted in a 90-bed Level IV NICU. A multidisciplinary, high-fidelity in situ rapid response simulation program was implemented over a 3-month period for frontline NICU healthcare providers. Pre- and post-surveys assessed perceptions of role clarity, …

Improving Compliance With Preoperative Antibiotic Protocols For Cardiac Implanted Electronic Devices: A Quality Improvement Project, James Kaup

DNP Projects

Abstract

Background

Cardiac implantable electronic device infections remain a serious complication of permanent pacemaker implantation despite evidence-based infection prevention guidelines.

Local Problem

An academic electrophysiology laboratory identified inconsistent guideline-concordant antibiotic selection despite consistently high compliance with recommended antibiotic timing.

Methods

A nurse-led, quasi-experimental pre-post quality improvement project evaluated implementation of a standardized preoperative antibiotic prophylaxis protocol. Data from 36 permanent pacemaker implantations (16 pre-intervention, 20 postintervention) were analyzed.

Interventions

The intervention included a standardized antibiotic protocol, multidisciplinary staff education, and performance feedback.

Results

Guideline-concordant antibiotic selection improved from 37.5% to 95.0% (χ² = 11.27, P = .001). Antibiotic timing remained …

Improving Handoff Communication Among Uaps In A Group Home By Implementing Standardized Sbar Tool And Evaluating Its Impact On Communication Quality And Resident Safety, Ola Iweala

Doctor of Nursing Practice Final Project Abstract

Purpose

Improving handoff communication among unlicensed assistive personnel (UAPs) in a group home through Situation, Background, Assessment, Recommendation (SBAR) tool implementation.

Background

Communication failures during shift handoffs among unlicensed assistive personnel (UAPs) in a group home contributed to missed information, inconsistent care, and resident safety events. Baseline observations showed that only 37.5% of handoffs met criteria for high-quality communication, and approximately 75% of safety incidents were related to communication breakdowns.

Methodology

This project was conducted in a group home serving adults with intellectual and developmental disabilities and included 19 UAPs. The Plan-Do-Study-Act (PDSA) model and Adult Learning Theory guided implementation. …

Charting The Course: Improving Psychotropic Medication Documentation Through Staff Education To Promote Patient Safety And Cms Compliance, Anne J. Bertram Rn

Master's Projects and Capstones

The University of San Francisco master’s level nursing program culminates with a clinical nurse leader (CNL) quality improvement project. The objective of this project is to reinforce the program’s didactic CNL classes by allowing students the opportunity to design, implement, and analyze a quality improvement project in a microsystem. SETTING: Skilled nursing facilities often prescribe psychotropic medications to help manage residents’ behavioral and psychological symptoms. Due to the possibility of side effects and increased sedation, there are concerns for patient safety and quality of life. Inadequate management of these patients and symptoms compromises patient safety and breaches state and federal …

Reducing Falls In The Acute Care Setting: A Quality Improvement Project, Elorm M. Adzokpa

Doctor of Nursing Practice Final Project Abstract

Falls remain one of the most common adverse events in acute care settings and are associated with increased morbidity, extended hospital stays, and higher healthcare costs. Orthopedic and trauma patients are particularly vulnerable due to mobility limitations, postoperative recovery, and complex medical conditions. The purpose of this quality improvement project was to reduce inpatient falls on an adult orthopedic and trauma unit by implementing a visual aid to reinforce the 5P fall-prevention framework. A pre–post quality improvement design was used during an eight-week implementation period. The intervention included a standardized fall prevention bundle that reinforced existing Fall TIPS board use …

Bridging The Language Gap: The Impact Of In-Person Versus Remote Interpreter Services On Medication Adherence And Patient Safety In Adult Spanish-Speaking Patients, Ashley E. Alarcon Martinez, Jocelyn N. Lopez Maradiaga

Nursing | Student Research Posters

Background: Significant health inequities are caused by language barriers between patients and health care staff, resulting in miscommunication among adult Hispanic patients with low English proficiency, reducing medication adherence, impairing patient safety, and raising the possibility of medical errors. To address this issue, interpreter services, both in-person and remote translation, have been introduced in healthcare settings to enhance communication. Objective: The purpose of this study is to investigate the differences in patient safety and medication adherence between in-person and remote translation services for adult Hispanic individuals with limited English proficiency in healthcare settings. Methods: The proposed research involves five local …

Reduction In Patient Falls: A Quality Improvement Project, Jotis J. Lee

Doctor of Nursing Practice Projects

Patient falls remain one of the most frequent adverse events in hospital settings, leading to injury, prolonged hospital stays, and increased healthcare costs. The identified problem was high fall rates at a specialty hospital. The purpose of this Doctor of Nursing Practice (DNP) quality improvement (QI) project was to evaluate the effectiveness of an evidence-based (EB) educational intervention, using the Fall TIPS (Tailoring Interventions for Patient Safety) toolkit, in improving direct care nursing staff’s knowledge, confidence, and perceived ability to implement fall prevention strategies for high-risk patients. The aim was to improve the nursing staff’s knowledge, confidence, and perceived ability …

Experiences Of A Simulated Medical Malpractice Lawsuit On Nursing Students' Documentation Practices: A Transcendental Phenomenological Approach, Heide Thorne

Doctoral Dissertations and Projects

The purpose of this qualitative, transcendental phenomenological study is to understand the perspectives of first semester nursing students participating in a simulated medical malpractice lawsuit and documentation practices. The theory guiding this study is Kolb’s experiential learning theory (ELT), as it explains the relationship of learning and knowledge transfer through a simulation-based learning activity (SBL). Data collection approaches included observations, anonymous reflective journals, and individual interviews or questionnaire capturing students’ personal experiences and emerging themes. Bracketing enhanced reflexivity, reduced bias, and strengthened the study’s credibility and dependability. Results of the study support the efficacy of a specific, powerful SBL activity …

Enhancing Nursing Documentation Accuracy For Female External Urinary Collection Devices Through Structured Documentation Huddles, Tiffany Ealy

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: Accurate documentation of female external urinary collection devices (EUCDs), such as the PureWick, is crucial for maintaining continuity of care and ensuring efficient resource utilization. However, inconsistent nursing documentation practices have led to gaps in regulatory compliance and communication among healthcare teams. Baseline data revealed frequent omissions and inaccuracies in female EUCD charting, indicating a significant practice gap that requires targeted improvement.

Aim of the Project: The purpose of the evidence-based practice (EBP) project was to improve nursing documentation accuracy for female EUCDs by implementing structured documentation huddles, thereby enhancing organizational compliance.

Review of the Evidence: A …

Glucometer Cleanliness On A Neuro-Medical Intensive Care Unit, Abbey Camire

Operations Transformation

Glucometers on the Neuro-Medical ICU are being docked with visible reddish/brown residue, indicating they are not properly cleaned beforehand. This poses a risk of transmitting pathogens, endangering patient and staff safety, and violates hospital policy and regulatory standards. Proper disinfection of mobile medical equipment is essential for infection control and hospital accreditation.

The Strategies And Interventions For Interprofessional Collaboration To Improving Patient Safety In Hospitals: A Systematic Review, Keumalasari Keumalasari, Krisna Yetti, Enie Novieastari, Evi Martha

Jurnal Keperawatan Indonesia

Interprofessional collaboration strategies and interventions are carried out to improve patient safety in hospitals. This study aimed to analyze the strategies and interventions used in interprofessional collaboration to improve patient safety. Interprofessional collaboration strategies and interventions were searched using five English-language databases, eligible studies were extracted, and the risk of bias was independently evaluated by two authors. The literature search yielded a total of 10,729 registered papers. We conducted an analysis on 3,793 health professionals. The following articles were included: 1) articles that described an intervention interprofessional collaboration to improve patient safety; 2) those focused on interprofessional collaboration in hospitals; …

Optimizing Transfer Classification: Enhancing Accuracy And Reducing Readmission Rate Penalties For Cardiovascular Care In Short-Term Rehab, Aeshia Hicks

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: In a short-term rehabilitation (STR) setting, misclassification of planned hospital transfers as unplanned readmissions among elderly cardiovascular patients inflated CMS-reported readmission rates, distorted performance metrics, and led to financial penalties under the Hospital Readmissions Reduction Program (HRRP). A gap analysis revealed a 14% misclassification rate, significantly higher than the CMS benchmark of 8.65%, which was attributed to inconsistent documentation and a lack of standardized classification criteria.

Aim of the Project: To reduce transfer misclassification by 20% through the implementation of a standardized electronic health record (EHR) template and targeted staff education, thereby improving CMS compliance and documentation integrity in …

Optimizing Pressure Injury Prevention: Implementation Of The Sskin Bundle In Acute Care, Joycelyn Mccall

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: Hospital-acquired pressure injuries (HAPIs) contribute to increased morbidity, extended hospitals stay, and significant healthcare costs. At the project site in northwest, Indiana, HAPI rates averaged 6.29%, which significantly higher than the national benchmark of 2.24%. Inconsistencies in documentation, a lack of standardized preventive practices, and variable staff engagement contributed to these increased rates. Despite the use of the Braden Scale, staff inconsistently implemented preventive interventions.

Aim of the Project: The aim of the project is to reduce HAPI incidence by 30% over 10 weeks by implementing the surface, skin inspection, keep moving, incontinence/moisture management, and nutrition (SSKIN) bundle and …

Optimizing Warfarin Management In Cardiovascular Care, Tessa A. Martinez

Doctor of Nursing Practice Final Manuscripts

Background: Maintaining a therapeutic International Normalized Ratio (INR) is essential to reduce bleeding and thromboembolic risks in patients on warfarin therapy. In a rural outpatient cardiac clinic serving a predominantly underserved population, many patients face financial and access barriers that preclude the use of newer non-vitamin K antagonist oral anticoagulants (NOACs). Patients with atrial fibrillation (AF) or mechanical valve replacements who rely on warfarin require consistent monitoring and management, which can be challenging in settings with limited resources and staffing.

Purpose: The purpose of this evidence-based pilot project was to improve therapeutic INR outcomes through the implementation of a standardized …

The Effects Of Healthcare Professionals Wearing Nail Enhancements, Sydney Johnson

Honors Capstones

Healthcare-associated infections (HAIs) continue to be a major concern in hospital settings, with one in thirty-one patients affected daily in the United States (CDC, 2020). While hand hygiene is widely promoted, the impact of nail enhancements worn by healthcare workers is often overlooked. Acrylics, gels, and other artificial nails can harbor bacteria even after handwashing and glove use, increasing the risk of infection transmission.

The purpose of this study was to explore whether hospitals with stricter nail enhancement policies have better staff hygiene practices and potentially lower rates of HAIs. This research used an original survey distributed to registered nurses …

Staff Education To Early Detection And Response To Patient Decline, Kein Gareth Rufino Pantaleon

Walden Dissertations and Doctoral Studies

This doctoral project implemented a staff education program to enhance early recognition and escalation of patient deterioration. Conducted at a 343-bed acute care hospital, the initiative addressed the ongoing problem of delayed detection and response to clinical decline, which often results in rapid response team activations and code blue events. Delays in intervention increase patient morbidity and mortality, despite many of these events being preventable through timely action. The project evaluated whether an interactive targeted education program could improve nursing staff’s knowledge, confidence, and willingness to activate escalation protocols, including Condition H and Code Help. Pre- and post-education surveys were …

Enhancing Nurse Competency: Proper Application Of Chlorhexidine Gluconate Dressings To Prevent Central Line Associated Bloodstream Infections, Joseph Earich

Doctor of Nursing Practice Scholarly Projects

Central line-associated bloodstream infections (CLABSIs) pose a significant risk to patient safety and healthcare outcomes. The proposed Doctor of Nursing Practice (DNP) project addresses the knowledge gap among nurses regarding the correct procedures for changing chlorhexidine gluconate (CHG) dressings on central lines. The goal is to enhance nurse education and adherence to best practices, thereby reducing the incidence of CLABSIs. The project employs a quasi-experimental design with a pre-test and post-test methodology. Nurses will complete a pre-test to assess their baseline knowledge of CHG dressing changes. The nurse will participate in a hands-on educational session to improve their understanding and …

Preventing Errors With Two-Component Pediatric Vaccines, Angela C. Clarke

MSN Student Capstones

No abstract provided.

Effective Multidisciplinary Communication For Critical Access Hospitals During Obstetric Emergencies, Beverly D. Carpenter

MSN Student Capstones

No abstract provided.

Improving Management Of Suicidality Within An Outpatient Eating Disorder Treatment Program Through Standardization Of A Suicide Rating Scale Among Clinical Staff Members: An Evidenced-Based Practice Project, Nicole Neale

Doctoral Dissertations and Projects

Standardization of suicide assessment protocols is essential for maintaining standards of care and optimizing patient safety. However, many healthcare organizations lack a universal protocol for suicide assessment, likely due to the absence of a gold-standard method or tool. This evidence- based practice project aims to enhance the accuracy and consistency of suicide assessments for individuals diagnosed with eating disorders as well as other mental health disorders, ultimately improving patient safety measures and outcomes within an eating disorder treatment center. This project includes a thorough literature review of suicide risk factors, assessment methods, and available tools, followed by the education and …

The Benefits Of Implementing Medication Administration Simulation In The Undergraduate Nursing Pharmacology Course, Ogulbagt Narova

SACAD: Scholarly Activities

Medication administration is one of the most critical tasks for nurses. Yet, it can also be a source of anxiety and errors, especially for nursing students who are still building their skills. Many new nursing students struggle to feel confident and competent when administering medications in real clinical settings. Simulation-based learning offers a powerful way to address this challenge. Using realistic, hands-on scenarios, students can practice medication administration in a safe environment without harming patients. This approach helps students build critical skills, gain confidence, and reduce the likelihood of medication errors. Incorporating medication administration simulations into nursing pharmacology courses will …

Acknowledging: A Classic Grounded Theory Explaining How Nurses' Employ Clinical Judgement When Complying With Early Warning System Protocols, Justine Connor, Tracy Flenady, Trudy Dwyer, Deb Massey

Research outputs 2022 to 2026

Background: Recognition and response to clinical deterioration of hospitalised patients is a worldwide health priority area. In response to this concern, international bodies have implemented early warning systems to help clinicians keep people safe and prevent patient deterioration. Registered nurses hold a significant role in managing care provision and utilise early warning system tools to support their clinical judgement when making decisions about patient care. Objective: To generate a theory explaining how registered nurses employ their clinical judgement when complying with an early warning system protocol. Design: Classic grounded theory. Participants: Participants included twenty registered nurses working with early warning …

Patients' Perception Of Missed Nursing Care In A Tertiary Hospital: A Cross-Sectional Study, Afia Achiaa Sarpong, Amanda Towell-Barnard, Lucy Gent, Ebenezer Afrifa-Yamoah, Diana Arabiat

Research outputs 2022 to 2026

AIMS: To identify types of patient-reported missed nursing care and adverse events and identify the factor associated with missed care in a Western Australian tertiary hospital. BACKGROUND: Research in the domain of missed nursing care has established the association between missed nursing care and unsafe patient outcomes. However, there is a paucity of evidence on patient perception of missed nursing care and associated factors. DESIGN: Cross-sectional study. METHOD: A study of inpatients in a tertiary teaching hospital in Western Australia was carried out. Ninety-eight patients admitted in 16 medical and surgical wards were sampled. The patient MISSCARE survey was used …

The Safe Steps Project: Fall Prevention Amongst Older Adults In A Skilled Nursing Facility, Maiana Cabrera, Nicole Le, Yen Tran, Madeline Turcotte

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

BACKGROUND: The Safe Steps Project aimed to reduce falls at Pine Creek Care Center, a skilled nursing facility located in Roseville, CA. Before this intervention, the fall rate at Pine Creek Care Center had been rising above their 15% goal in the first few months of 2025. Through an in-service education, this project has helped educate and increase nursing staff knowledge on fall prevention, such as intentional rounding with the 4 Ps (pain, position, potty, and possessions).

AIM: The Safe Steps Project addresses a major cause of injury in older adults, falls. The aim of this project was to improve …

Perioperative Surgical Site Infection Reduction Bundle In Colorectal Patients, Flatasha A. Roland

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Surgical site infections (SSIs) are a common and preventable complication after colorectal procedures, significantly impacting patient morbidity and increasing healthcare costs. This quality improvement (QI) project aimed to lower SSIs in adult colorectal surgery patients by implementing a perioperative SSI reduction bundle at a large acute care facility in North Texas. The intervention targeted three modifiable risk factors: perioperative hypothermia, hyperglycemia, and incorrect antibiotic timing. Despite established protocols, institutional data revealed subpar compliance with active warming (46%), blood glucose control (52%), and antibiotic stewardship (75%), all of which fell below national benchmarks. A gap analysis and literature review guided the …

Emotional Safety In Maternity Care: An Evolutionary Concept Analysis, Elliesha O'Reilly, Kate Buchanan, Sara Bayes

Research outputs 2022 to 2026

Background: Safety in maternity care is a priority, and a broadened view of safety (e.g., emotional, psychological, cultural) is evident in scientific literature and in lay discourse. ‘Emotional safety’ is being referred to with increasing frequency in this context; however, there is a lack of clarity in its use and meaning. Aim: The aim of this concept analysis was to examine the concept of emotional safety in maternity care. Methods: The evolutionary approach was used for this concept analysis. Data sources: This concept analysis was literature-based, with a systematic search conducted of CINAHL, MIDIRS, and MEDLINE databases. Ten articles published …

Implementing A Gerontological Nursing Competencies Programme In Aged Care: Participant Experiences, Victoria Traynor, Nicole Britten, Diane Gibson, Stephanie Munk, Lynn Chenoweth, Jolan Stokes, Tracey Moroney, Karen Strickland, Toni Donaghy, Kasia Bail

Research outputs 2022 to 2026

Aims: To explore the experience of registered nurses and their mentors in the implementation of the Gerontological Nursing Competencies in long-term aged care and the perceived effectiveness and suitability of the programme to support nurse development. Background: The global population is ageing and needs a reliable aged-care nursing workforce. Introduction: Opportunities for education and mentorship for newly qualified and experienced aged-care nurses warrant investigation. Methods: Qualitative evaluation using semi-structured focus groups was conducted following the implementation of the programme into five not-for-profit long-term aged-care organisations and analysed by a reflexive qualitative thematic approach and reported according to COREQ criteria. Results: …