Sustaining Clabsi Prevention Through Central Line Bundle Compliance: A Focus On Iv Tubing Labeling, Visual Cues And Peer Support, See Elizabeth Vang

Master's Projects and Capstones

Abstract  

Problem: Inconsistent IV tubing labeling compliance on a telemetry unit was identified as a gap in central line maintenance practices that could affect adherence to the CLABSI prevention bundle.

Intervention: A quality improvement project reinforced existing IV tubing labeling practices through a visual job aid, staff education, and peer verification during Nursing Knowledge Exchange (NKE) bedside handoff.

Outcome Measure: The primary outcome measure was IV tubing labeling compliance, with a goal of increasing compliance from 86.5% to at least 95% on 24 bed Telemetry unit.

Results: The project did not achieve the desired improvement in compliance. Multiple concurrent quality …

Evaluation And Continuation Of Oncology Nurse Mentorship Program, Gurpreet K. Kang

Master's Projects and Capstones

Problem: Newly hired nurses on a busy inpatient leukemia and lymphoma subspeciality unit experienced challenges after transitioning into specialty oncology practice. This resulted in decreased confidence, increased risk of medication errors, and a 40% unit-based annual turnover rate. The cost of replacing one staff nurse is $61,000.  Exit interviews determined root causes of turnover rates, nurse confidence.

Context: A quality improvement program was envisioned to optimize patient and organizational outcomes on a 25-bed inpatient unit to evaluate and sustain an oncology nurse mentorship program.

Interventions: Over one year, cohort 1 (n=8) and follow up 2^nd cohort (n=7) was implemented …

Improving Physiologic Monitoring Adherence During Behavioral Emergencty Sedation In A Prehospital Ems System, Jared Aucoin

Doctor of Nursing Practice Final Project Abstract

Abstract

Purpose:

This quality improvement (QI) project evaluated whether provider education and standardized documentation improved adherence to evidence-based physiologic monitoring during behavioral emergency sedation in a prehospital EMS setting.

Background:

Behavioral emergencies are common and often require rapid chemical sedation, with risks of hypoxia, hypercapnia, and cardiovascular instability. At baseline, inconsistent adherence to recommended monitoring and documentation of end-tidal carbon dioxide (EtCO₂) and pulse oximetry (SpO₂) presented an opportunity to improve patient safety.

Methodology:

This QI project educated current adult behavioral emergency protocol in a prehospital EMS setting, re-emphasizing standardized documentation and evidence-based monitoring practices. Utilizing Plan-Do-Study-Act (PDSA) through pre- …

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

All Doctor of Nursing Practice (DNP) Scholarly Projects

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 …

The Effect Of Fall Prevention Programs With Hourly Rounding On Fall Rates Among Adults Patients In Neurological Unit, Oyinlola A. Ogundeji

Doctor of Nursing Practice Final Project Abstract

Purpose

The purpose of this QI project was to evaluate the effect of a structured hourly rounding program on patient fall rates in an adult neurological inpatient unit.

Background

Patient falls remain a major safety concern in acute care, particularly among hospitalized neurological patients with impairments in mobility, cognition, and balance. In an adult neurological unit within a Magnet-designated hospital, fall rates exceeded national benchmarks, underscoring the need for a targeted quality-improvement

Methodology

A pre–post QI design, guided by the Plan-Do-Study-Act framework, was implemented over 12 weeks in a 28-bed neurological unit. This intervention featured structured hourly rounding using the …

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 …

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. …

An Evidence-Based Practice Initiative To Promote Debriefing Within The Obstetrics Surgical Team, Rachel Lynn Runatz

Graduate Theses, Dissertations, and Problem Reports (ETD)

Introduction: Operating room debriefing is an evidence-based strategy shown to improve communication, efficiency, patient safety, and safety culture; however, debriefing is inconsistently performed in obstetric operating rooms due to workflow, cultural, and time-related barriers.

Purpose: The purpose of this Doctor of Nursing Practice (DNP) project was to increase the frequency of debriefings in the Birthing Center operating rooms at WVU Medicine Children’s Hospital through implementation of a nurse-driven, evidence-based debriefing initiative.

Intervention: A nurse-driven debriefing protocol was implemented using the Iowa Implementation for Sustainability Framework. Interventions included staff education, accessible laminated debriefing documents, identification of nurse champions, leadership support, and …

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 …

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 …

Optimizing Fall Prevention: A Quality Improvement Initiative To Enhance Documentation And Intervention Accuracy Using The Hester Davis Scale In Medical-Surgical Units, Kiana Conn, Brooklin Hunter-Johnson, Jashan Kahlon, Adrian Paz

Master's Projects and Capstones

Falls among hospitalized patients remain a critical safety concern, particularly in medical-surgical units caring for geriatric and oncology patients. This quality improvement project aimed to evaluate and address gaps in adherence to fall prevention protocols by utilizing the Hester Davis Scale (HDS) in two medical-surgical units at a large metropolitan hospital in Southern California. The project focused on auditing current practices to identify inconsistencies in documentation and intervention implementation, emphasizing areas such as bed alarm activation, fall risk signage placement, and armband use. Weekly audits were conducted from October 3 to October 29, 2024, to establish baseline data and inform …

Effectively Addressing Hospital-Acquired Pressure Injuries With A Multidisciplinary Approach, Nicki Roderman, Shandlie Wilcox, Andrew Beal

HCA Healthcare Journal of Medicine

Background

Hospital-acquired pressure injuries (HAPIs) result in patient harm, discomfort, and even death, with an estimated 2.5 million HAPIs occurring annually in the United States. These pressure injuries from prolonged pressure on the skin and deeper tissues cause reduced blood flow and the breakdown of skin and tissues, resulting in wounds. Additionally, these injuries contribute to longer hospital stays and increased health care costs. Hospitals have programs aimed at reducing HAPIs as well as ongoing surveillance to identify new trends early on. This ongoing monitoring revealed a trend early at our institution that HAPIs were 66% higher than the national …

Assessing The Effectiveness Of A Non-Punitive Fall Prevention Program, Nicki Roderman, Shandlie Wilcox, Cynthia Lang

HCA Healthcare Journal of Medicine

Background

Our single-center, quality improvement project evaluated the impact of a fall reduction plan while using a Just Culture Algorithm that included weekly fall reviews involving front line staff using a non-punitive structure. The project has shown successful results.

Methods

Prior to starting the program, data at this institution indicated falls were higher than the national fall rate of 3-5 per 1000 patient days. To achieve the goal of reducing the fall rate to below 3.1, an interdisciplinary fall committee was formed, consisting of nurses, nursing leaders, patient care technicians, pharmacists, and physical therapists. The committee operated in a non-punitive …

The Impact Of Electronic Health Record Unintended Consequences On Quality Of Care Within A High Complexity Healthcare Organization, Joetta Powell

ATU Theses and Dissertations 2021 - Present

“Unintended consequences are unexpected, and unwanted outcomes that can limit the value of EHR implementation and adversely affect quality of care and patient safety” (Lee & Kang, 2021, p. 898). Few organizations have redesigned the EHR to improve usability to mitigate potential patient safety concerns. This study aims to identify unintended consequences in patient care workflows and determine educational needs related to EHR usability. A mixed method approach was used to investigate unintended consequences in deidentified patient safety reports submitted Jan 1, 2020, through December 31, 2023. The data was analyzed to identify error types and educational deficits. The Acute …

Reducing Care Companion Utilization In Medical-Surgical And Telemetry Units, Mary Jane B. Sagabaen

Master's Projects and Capstones

Abstract

Problem: The facility highly utilized sitters or care companions, negatively impacting the staffing plan, budget, and productivity. An average of 56 hours of care companions were used daily. This greatly exceeded the budget of 33 hours a day. Reassigning Patient Care Technicians (PCT) as care companions resulted in inadequate nurse support for patient care and increased cost for additional staffing needs. Despite this, the fall rate remained higher than the target.

Context: The patient population is mainly 65 years old and above, sometimes with confusion, dementia, delirium, and at high risk for falls and elopement. The culture included promptly …

Just Culture In Undergraduate Nursing Academia, Marcie Leonard

Doctor of Nursing Practice Projects

Understanding the importance of reporting errors, near misses, and good catches by nursing students is not a standard part of the curriculum at the project site. Nursing students lack pre-requisite knowledge of how just culture does not aim to place blame on individuals but focuses on system flaws. Nursing students fear being dismissed from the nursing program if they make and/or report errors. A focus on eliminating the fear of dismissal from a nursing program for error reporting and formally educating how error reporting can help shape practice for many other nursing students and nurses will result in better data …

Improving Patient Safety And Emergency Department Staff Efficiency In Barcode Medication Administration By Using The Rover™ Mobile Application, Ian Kirit

DNP Scholarly Projects

BACKGROUND: The Emergency Department (ED) is one of the busiest areas in the hospital. Patients are often acute, and it can get chaotic at times. Such a complex environment requires an effective and efficient system to increase staff efficiency and elevate patient safety. Patient and medication scanning has been a continuing issue with the current barcoding process using the in-room scanners and workstations on wheels (WOWs). In reviewing the Barcode Medication Administration (BCMA) weekly audit report, scanner broken and scanner not available are the most frequently used reasons for not scanning patients and medications. Additionally, WOWs can be hard to …

The Effects Of Nursing Bedside Shift Report On Patient Safety And Satisfaction: A Systematic Review Of The Literature, Alyssa Wong

Master's Projects

Introduction: Nursing bedside shift report is a recommended strategy to promote the effective exchange of accurate patient information during the handoff process with the goal of decreasing communication errors and adverse patient events. However, adopting this handoff method into nursing practice has been challenging in the clinical setting. This systematic review aims to understand the rationale behind nursing bedside handoff by identifying the advantages and barriers to implementation and exploring how this affects patient safety and experience.
Methods: A systematic review was conducted by searching through electronic databases and Google Scholar to identify English-language peer-reviewed journal articles published between 2012 …

Dnp Final Report: Developing Competence And Improving Patient Safety With Documentation Training In The Simulated Environment, Laura Zebreski

DNP Final Reports

With the advent of electronic health records, nursing documentation has declined in quality. Poor documentation exposes patients to safety risks. Nursing documentation is subject to legal standards set by the Texas State Board of Nursing. A DNP scholarly project was designed to create a learning and safety intervention to train student nurses to provide correct documentation before entering clinical settings. The goal of this project was to prepare nursing students to provide quality documentation that fulfills the legal standard to attempt to correct the current deficiencies seen in practice and promote patient safety. For this project, the students took a …

Purposeful Nurse Hourly Rounding: Plan To Decrease Patient Falls During A Pandemic, Robbie Masangkay

Doctor of Nursing Practice (DNP) Projects

Problem: Patient falls remain a critical and persistent safety problem in healthcare today. The prolonged impact of the COVID-19 pandemic raises leadership concerns regarding the safe care of high-risk COVID patients and mitigating the increased stress and potential risks of infection to clinical staff.

Context: This Doctor of Nursing Practice (DNP) scholarly project details implementation of an evidence-based purposeful nurse hourly rounding (PNHR) pilot project designed to decrease the incidence of patient falls on a designated COVID-19 unit.

Measure: A modified PNHR rounding tool was implemented to guide focused elements for key nurse/patient interactions.

Interventions: …

Dnp Final Report: Teamstepps For Nursing Students, Jennifer Matranga

DNP Final Reports

The purpose of this paper is to discuss the DNP project, which focused on improving communication skills for associate degree nursing students. The background and significance of this problem was identified, a systematic review of the literature was completed, and TeamSTEPPS, based on the body of evidence, was implemented in a clinical immersion setting. The project objectives were to implement communication techniques, using TeamSTEPPS, as recommended from the body of evidence. The anticipated outcomes were that nursing students would have increased confidence in asking questions in the clinical setting, reduced fear of communicating, and improved patient safety. A review of …

High Reliability Principles In Safety, Abby Henderson, Leigh Klaverkamp

Nursing Posters

• Subject matter experts compare actual performance to expected performance.
• A standard set of questions for specific subtypes of events help establish trends.
• HRO's (High Reliability Organization) equip leaders and frontline staff to spot systemic causes of human error.

Improving The Safety Knowledge Of Associate Degree Nursing Students, Melissa Jones

Doctor of Nursing Practice Projects

The purpose of this study was to implement the Quality and Safety Education for Nurses (QSEN) safety component using several teaching strategies during didactic experiences to improve the safety knowledge and competency of first-year students enrolled in an associate degree nursing program. As a metric assessment, aggregate scores of the QSEN safety areas on the Health Educational System, Inc © (HESI) exam were compared to the previous year’s aggregate scores on the same examination. The results indicated an improvement in scores in students who participated in the implemented intervention. Statistical analysis suggests the intervention improved the participant’s knowledge and acquisition …

A Case For Delirium Risk Prediction Models To Aid In Triaging Resources To Those Most At Risk An Integrative Literature Review, Tammy Perttula

Nursing Masters Papers

Abstract

Delirium is a complex syndrome resulting from compounding effects of acute illness, comorbidities, and the environment. It results in adverse outcomes: elevated mortality rates, length of stay, readmissions, institutionalization, long-term cognitive changes, and diminished quality of life. The rate of iatrogenic delirium is astounding, ranging from 10%-89%. There are no curative treatments; thus, primary prevention is the key. The purpose of this literature review is to identify and critique the research for the accuracy of risk stratification and feasibility in practice. Support for interventions that prevent delirium is mounting; however, interventions are resource-intensive and often not implemented. Researchers have …

The Situational Context Of Safety Culture From The Perspective Of Medical-Surgical Staff Nurses And Nurse Leaders In A Hospital, Lisa Harton

Dissertations

People enter into healthcare facilities to maintain or restore health; however, often times those seeking health are harmed during the process by avoidable medical errors. Since the Institute of Medicine report on patient harm, safety culture continues to be the largest barrier in realizing safer patient care. Staff nurses' comprise the largest component of the health care workforce in hospitals and consistently have the lowest perceptions of a safety culture. Leaders who play a key role in creating and sustaining a safety culture consistently have the most favorable perception of safety culture. The development of a safety culture and safer …

Implementing A Fall Prevention Program: A Quality Improvement Project To Promote Patient Mobility On The Medical-Surgical Unit, Alba Araiza

Master's Projects and Capstones

Implementing a fall prevention program is imperative in acute healthcare settings. Falls are one of the top reported events that occur in hospitals and it is a patient safety concern that requires the implementation of evidence-based practices to reduce falls. This quality improvement project will be developed by a master’s prepared clinical nurse leader (CNL) on a medical-surgical unit to improve patient safety.

Problem

Maintaining patient safety is the most important priority in health care. Health care organizations implement protocols, policies and procedures to ensure that care is provided in a safe manner to minimize preventable harms. However, falls are …

Implementing A Fall Prevention Program: A Quality Improvement Project To Promote Patient Mobility On The Medical-Surgical Unit, Alba Araiza

Master's Projects and Capstones

Abstract

Implementing a fall prevention program is imperative in acute healthcare settings. Falls are one of the top reported events that occur in hospitals and it is a patient safety concern that requires the implementation of evidence-based practices to reduce falls. This quality improvement project will be developed by a master’s prepared clinical nurse leader (CNL) on a medical-surgical unit to improve patient safety.

Problem

Maintaining patient safety is the most important priority in health care. Health care organizations implement protocols, policies and procedures to ensure that care is provided in a safe manner to minimize preventable harms. However, falls …

Just Culture: It's More Than Policy, Linda Ann Paradiso, Nancy Sweeney

Publications and Research

Any healthcare organization’s top priority is effective and safe care. Despite this, medical error is the third-leading cause of death in the US. Hospitals are imperfect systems where nurses have competing demands and are forced to improvise and develop workarounds. Errors rarely occur in a vacuum, rather they’re a sequence of events with multiple opportunities for correction. Clinical nurses can have a significant impact on reducing errors due to their proximity to patients. When errors are identified, the events and impact on safe care need to be shared. Just culture is a safe haven that supports reporting. In a just …

Failure-To-Rescue Simulations As A Risk Management Strategy For Registered Nurses, Trena K. Seago

Graduate Theses, Dissertations, and Capstones

In the hospital setting, prevention of failure-to-rescue (FTR) events is an important aspect of patient safety. The use of patient simulation as a strategy to educate nurses on the prevention of these events offers two modes of learning: 1) experiential learning through simulation and 2) reflection through debriefing. The act of practicing to recognize a deteriorating patient through experiential learning and reflection may help increase nurses’ self-efficacy in recognizing a similar situation in their future practice. This quasi-experimental, one-group, pretest-posttest pilot study investigated the use of patient simulation among registered nurses (RNs) in the hospital setting as an anticipatory educational …