Other Nursing Commons^™

Tailoring Interventions For Patient Safety Protocol: A Strategy To Prevent Inpatient Falls, Yashu Adhikari

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Inpatient falls were a significant safety issue at the project site, substantially affecting patient outcomes and organizational resources. The identified gap was the lack of individualized, patient-centered fall-prevention strategies despite the presence of standard fall-prevention bundles. The baseline fall rate of 6.04 was 20% higher than the national benchmark of three to five falls per 1,000 patient days, indicating a clear need for improvement.

Aim of the Project: The quality improvement (QI) project aimed to improve patient safety by reducing inpatient falls through implementation of the AHRQ Fall Tailoring Interventions for Patient Safety (TIPS) protocol on a …

Poor Adherence To Established Clinical Guidelines In Outpatient Bladder Cancer Management, Melanie Boren

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: The outpatient urology practice encountered challenges with adherence to Clinical Practice Guidelines (CPGs), primarily due to unfamiliarity and lack of operational accountability. This led to a low adherence rate of only 40% among patients with bladder cancer. Key issues included inadequate training and knowledge gaps regarding CPGs.

Aim of the Project: The project aimed to improve patient care and outcomes in bladder cancer treatment by enhancing patient retention and adherence to treatment protocols. Evidence-based interventions were implemented to optimize care delivery and support adherence to prescribed treatments.

Review of Evidence: A literature review highlights the effectiveness of nurse navigator …

Implementing The Walking Impairment Questionnaire For Peripheral Artery Disease Screening And Referral, Lisa Doyle

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Peripheral artery disease (PAD) is a leading cause of cardiovascular morbidity, mortality, and lower extremity amputation. At a Level 1 veterans medical center, the absence of a standardized screening and referral process contributed to delayed identification of symptomatic PAD and underutilization of supervised exercise therapy (SET). Between August 2024 and July 2025, only four veterans completed SET despite a large high-risk population, demonstrating a significant gap in evidence-based recommendations and clinical practice.

Aim of the Project: The aim of this project was to improve patient outcomes by standardizing screening for symptomatic PAD using the Walking Impairment Questionnaire (WIQ) to …

Utilizing A Multidisciplinary Team Approach To Opioid Stewardship In A Long-Term Acute Care Hospital, Lesley Moore

Doctor of Nursing Practice (DNP) Scholarly Project

Problem:

The opioid crisis continues to negatively affect patient safety and healthcare outcomes across the United States. Long-term acute care hospitals (LTACHs) care for medically complex patients who often require prolonged pain management and are at increased risk for opioid-related adverse events. At the project site, a 32-bed LTACH, 72% of reviewed patient charts included an opioid prescription upon admission, exceeding recommended prescribing benchmarks and identifying a gap in opioid stewardship practices. The absence of a standardized opioid stewardship program (OSP) and opioid risk screening process increased the risk of opioid misuse, dependency, and adverse patient outcomes.

Aim of the …

Improving Timely Hospice Pain Reassessments Through A Quality Improvement Initiative, Brianna Strong-Mosley

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: In a hospice care organization, a practice gap was observed in prompt pain reassessment with an onset or increase of pain, as mandated within a 48-hour timeframe by the Centers for Medicare and Medicaid Services (CMS). Baseline data showed that only 40% of eligible patients with a pain score of ≥ 6 received a documented pain reassessment within 48 hours. Overall patient satisfaction with hospice services was 45%.

Aim of the Project: The quality improvement project aimed to enhance pain management by increasing the percentage of eligible hospice patients with a documented pain score of ≥ 6 from a …

Improving Medication Reconciliation Compliance In Home Health Admissions, Paula A. Petrie-Rivas

Doctor of Nursing Practice (DNP) Scholarly Project

Background: Clinician compliance with medication reconciliation at a home health agency was below regulatory expectations, with agency performance significantly lower than state and national averages. Workflow inefficiencies, inconsistent clinician practices, and limited training contributed to noncompliance, increasing the risk of medication discrepancies, preventable rehospitalizations, and Medicare reimbursement penalties.

Aim: This quality improvement project implemented a standardized medication reconciliation workflow using the Agency for Healthcare Research and Quality’s MATCH toolkit to improve clinician compliance during admission to home health.

Evidence: Literature supports structured medication reconciliation as an effective strategy to improve safety during transitions of care. The MATCH toolkit provides a …

Fall Tailoring Interventions For Patient Safety: A Program Evaluation, Shirley Morrison

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Falls with injury rates had increased for over two years at the project hospital until nurse leaders implemented a new fall-prevention intervention. Patient falls are the most common preventable adverse event in acute care hospitals, with approximately 700,000 to 1 million occurring annually in the United States. Before implementing the Fall Tailoring Interventions for Patient Safety (TIPS) toolkit, the hospital’s program lacked an evidence-based approach and a fall communication board to alert staff, patients, and families about the individual fall risk status, leaving a significant gap in patient-centered care.

Aim of the Project: The aim of the project was …

Implementing Pain Reassessment Workflow To Improve Timely Pain Management In Hospice Patients: A Quality Improvement Project, Oluremi Omodara

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Timely pain reassessment is a vital component of hospice care, directly influencing the quality of life for patients. Despite the high prevalence of pain, which affects 55% of hospice patients due to disease progression or adverse drug reactions, only 51% of those reporting moderate to severe pain at admission receive a documented reassessment. The gap highlights an organizational issue in pain management stemming from the absence of a clearly defined period and workflow for reassessment.

Aim of the Project: The aim of the quality improvement (QI) project was to improve compliance with pain reassessment documentation within 48 hours …

Implementing A Sepsis Questionnaire To Reduce Readmissions…A Health Plan’S Experience, Vernita L. Kelley

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Sepsis is a life-threatening condition with high readmission risk, threatening patient recovery and survival. In the managed care organization (MCO) where this DNP project was implemented, sepsis ranks among the top five readmission diagnoses. The organization's 30-day readmission rate of 15.5% is substantially higher than the benchmark of 9.29%, highlighting a clinical quality issue, a strain on patient outcomes, and a strain on healthcare resources.

Aim of the Project: This quality improvement (QI) project aimed to reduce sepsis readmissions by embedding a sepsis questionnaire into case management workflows to identify clinical risks and social determinants of health, improve transitions, …

Fall Reduction Utilizing Fall Tailored Intervention For Patient Safety In Acute Care, Lauren Poindexter

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Hospitalized patient falls cause physical, psychological, and financial harm and persist despite prevention bundles. A Midwest Ohio acute medical unit experienced higher-than-benchmark fall rates (1.53–7.58 falls/1,000 patient days; unit rate 113% of the national median), with a rising trend in FY25. Reliance on the Schmid tool and existing interventions lacked structured patient/family engagement, as well as comprehensive medication assessment, leading to under-recognition of risk and limited nurse-driven prevention.

Aim of the Project: The aim of the project was to reduce inpatient fall rates and fall-related injuries on a medical unit by implementing the Agency for Healthcare Research and Quality …

Fall Prevention In Home Care: The Introduction Of The Steadi Initiative As Evidence-Based Tool, Margarida Barbosa - Barreiro

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Falls continue to be one of the leading causes of injury and mortality among older adults and remain a significant driver of healthcare utilization and cost. Within the home health setting, inconsistent practices in fall risk assessment and intervention have contributed to care gaps and increased patient vulnerability. The absence of a standardized, evidence-based process created the need for a structured quality improvement initiative to strengthen patient safety.

Aim of the Project: The purpose of this quality improvement project was to integrate the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit into home health visits to enhance the …

Improving Hospital Throughput Through Flash Rounds And Standardized Discharge Readiness Assessments, Erin D. Dobda

Doctor of Nursing Practice (DNP) Scholarly Project

• Problem: The target hospital faced serious throughput challenges, with emergency department overcrowding and discharge inefficiencies impacting patient outcomes and organizational performance. Discharge order to depart times exceeded the 90-minute benchmark, averaging 154 minutes, while 41.2% of patients exceeded the geometric mean length of stay (GMLOS) target of 40.17%. Gaps included inconsistent discharge planning, poor communication, and limited follow-through on barriers.
• Aim of the Project: The project aimed to improve hospital throughput by reducing GMLOS and discharge order to depart times on Unit A. This was achieved through implementation of proactive, evidence-based interventions to streamline discharges, reduce delays, and support safe …

Preventing 30-Day Rehospitalization In Congestive Heart Failure Utilizing Transitional Care Teams, Esther Baminrin

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Congestive Heart Failure (CHF) continues to be a prevalent and challenging health issue, contributing significantly to hospital readmissions within the first 30 days of patients transitioning to home health care. Rehospitalization affects the patient's quality of life and the agency's revenue, as reimbursements are paused when patients are hospitalized during the first 30 days of admission to a home health agency. The agency experienced a 22% rehospitalization rate within a year, slightly higher than the national average of 10%.

Aim of the Project: The primary objective of this project was to decrease rehospitalization of patients with CHF within the …

Reducing Emergency Department Length Of Stay, Chelsea Zigan

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Rising Emergency Department (ED) volumes and Registered Nurse (RN) shortages have led to overcrowding, delayed care, and inefficiencies. In 2023, patient visits exceeded budget projections by 14% for six months. From July to December 2024, discharged patients’ average ED length of stay (LOS) exceeded the three-hour target by over one hour, left without being seen (LWOBS) rates surpassed the 1% benchmark for five months, and diversion hours increased, restricting ambulance admissions. These issues strained nursing resources, reduced care quality, and heightened risks of complications and financial losses, emphasizing the need for a redesigned care model to optimize staff roles …

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

Doctor of Nursing Practice (DNP) Scholarly Project

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 …

Reducing 30-Day Post-Stroke Readmissions With A Discharge Checklist Tool, Monika Robinson

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: The practice site, a nationally certified stroke care hospital, faced challenges with 30-day post-stroke readmission rates of 8.7%, below the national average of 12.44%. This quality improvement initiative aimed to reduce avoidable readmissions to below 4.7% by implementing a structured education process using a post-stroke checklist for all stroke admissions.

Aim of the Project: The primary goal was to ensure that all stroke patients received consistent discharge education. This was achieved by introducing the American Heart/Stroke Association Post-Stroke Discharge Checklist, aligning with best practices to standardize patient education.

Review of Evidence: Evidence shows inconsistencies in the discharge process, particularly …

Reducing Patient Falls In A Behavioral Health Unit: Improvement Through Audit Implementation, Kristin Gardner

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: Fall-related events are a significant source of harm, with more than 700,000 patients falling every year in U.S. hospitals. The project was implemented in a 41-bed acute inpatient adult behavioral health unit (BHU). Over the last eight quarters, the BHU experienced an average of 3.16 falls per 1,000 days, exceeding the benchmark's median of 2.53 total falls.

Aim of the Project: The primary aim of this project was to decrease overall falls in an acute inpatient behavioral health unit.

Review of the Evidence: A comprehensive literature review identified intervention prevention bundles, compliance auditing, and staff education as effective ways …

A School-Based Asthma Initiative To Improve Student Self-Management Behaviors, Jenni R. Newland

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: In a Midwest public school system, students received robust academic education. Health education programs, specifically asthma management, were not offered. Over 400 elementary students with asthma lacked the knowledge and skills to effectively recognize and manage their asthma symptoms resulting in increased school clinic visits and absences, highlighting the urgent need for targeted intervention.

Aim of the Project: The aim of this project was to improve students’ asthma self-management skills by providing education based on the Open Airways for Schools (OAS) curriculum. Improving asthma self-management skills reduces student absences and time away from the classroom.

Review of Evidence: A …

Fall Prevention In Behavioral Health, Kanesha Moss

Doctor of Nursing Practice (DNP) Scholarly Project

Problem:

Falls in hospital settings pose significant safety and financial risks, particularly in Behavioral Health Units (BHU), where fall rates often exceed national averages. Despite traditional fall prevention practices, such as risk assessments and post-fall huddles, the target BH unit continued to experience high fall rates, failing to meet the National Database of Nursing Quality Indicators (NDNQI) standards. The lack of alignment between fall prevention strategies and the unique needs of behavioral health patients contributed to these unmet targets.

Aim of the Project:

This project aimed to reduce the number of falls in a 41-bed BH unit by 20% over …

Enhancing A Pressure Injury Prevention Bundle In A Skilled Nursing Facility, Lorillie Soleta

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: The purpose of the project was to address the increase in pressure injuries in a skilled nursing facility, which had risen from 6% to 10% despite the implementation of a prevention bundle. The project aimed to evaluate and enhance the effectiveness of existing interventions.

Aim of the Project: The aim was to add evidence-based interventions to the existing pressure injury prevention bundle. The desired outcome was to decrease the number of acquired pressure injuries.

Review of the Evidence: Research indicated that pressure injury prevention bundles were more successful when incorporating offloading interventions. These offloading measures, including frequent turning and …

Prescribing Protocol For Postoperative Opioids In An Orthopedic Spine Practice, Kelly M. Manda

Doctor of Nursing Practice (DNP) Scholarly Project

Problem: The opioid epidemic is magnified by excessive post-surgery prescriptions. Over six months at an orthopedic spine practice, 50% of patients received two or more opioid refills beyond their first. This highlighted the absence of a clear prescribing policy and emphasized the need for a structured protocol and to promote patient safety.

Aim of the Project: The primary aim was to implement a prescribing protocol to lower opioid refills provided to post-surgical patients in this surgical practice. The desired result was to reduce the number of opioid refills provided to patients after surgery.

Review of the Evidence: Evidence highlighted …

Inspiring Excellence In Doctoral Nursing Education Through Partnership: Incorporating An Innovative Change Model To Improve Dnp Project Outcomes, Melanie Brewer, Debbie Conner, Transition Management Partners, Llc

All Faculty and Staff Scholarship

Background/Introduction

Franklin University, a leader in educating working adults, formed an academic practice partnership with OhioHealth. Integrating the OhioHealth Change Management Model (CM) into the Doctor of Nursing Practice (DNP) program marks a deviation from a theory-based project to a more theory-to-practice model for managing organizational change. The CM provides leadership-driven DNP students with access to an innovative, real-world approach to prepare to transform organizations, systems, and healthcare through evidence-based interventions.

Purpose

The CM is a novel, goals-focused, data-driven approach used to manage people while implementing evidence-based practice, policy, or business change in an organization. The model includes Identifying executive …