NURS FPX4020 Capella University Quality Care and Patient Safety Bibliography

Improvement plan tool kit You will develop a Word document or an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan, pertaining to medication administration, to understand or implement to ensure the success of the plan Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: • Competency 1: Analyze the elements of a successful quality improvement initiative. • Analyze usefulness of resources for role group responsible for implementing quality and safety improvements with medication administration. • Competency 2: Analyze factors that lead to patient safety risks. • Analyze the value of resources to reduce patient safety risk or improve quality with medication administration. • Competency 3: Identify organizational interventions to promote patient safety. • Identify necessary resources to support the implementation and sustainability of a safety improvement initiative focusing on medication administration. • Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. • Present compelling reasons and relevant situations for resource tool kit to be used by its target audience. • Communicate in a clear, logically structured, and professional manner, using current APA style and formatting. References Chard, R., Makary, M. A. (2015). Transfer-of-care communication: Nursing best practices. AORN Journal, 102(4), 329-342. Kaminski, J. (2016). Why all nurses can/should be authors. Canadian Journal of Nursing Informatics, 11(4), 1-7. Professional Context Nurses are often asked to implement processes, concepts, or practices – sometimes with little preparatory communication or education. One way to encourage sustainability of quality and process improvements is to assemble an accessible, user-friendly tool kit for knowledge and process documentation. Creating a resource repository or tool kit is also an excellent way to follow up an educational or in-service session, as it can help to reinforce attendees’ new knowledge as well as the understanding of its value. By practicing creating a simple online tool kit, you can develop valuable technology skills to improve your competence and efficacy. This technology is easy to use, and resources are available to guide you.

Scenario For this assessment, consider taking one of these two approaches: 1. Build on the work done in your first three assessments and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan pertaining to medication administration and put the plan into action. 2. Locate a safety improvement plan (your current organization, the Institution for Healthcare Improvement, or a publicly available safety improvement initiative) pertaining to medication administration and create an online tool kit or resource repository that will help an audience understand the research behind the safety improvement plan and how to put the plan into action. Preparation Google Sites is recommended for this assessment – the tools are free to use and should offer you a blend of flexibility and simplicity as you create your online tool kit. Please note that this requires a Google account; use your Gmail or GoogleDocs login, or create an account following the directions under the “Create Account” menu. Refer to the following links to help you get started with Google Sites: • G Suite Learning Center. (n.d.). Get started with Sites. Retrieved from https://gsuite.google.com/learning-center/products/sites/get-started/#!/ • Google. (n.d.). ;Google Sites. Retrieved from https://sites.google.com • Google. (n.d.). ;Sites help. Retrieved from https://support.google.com/sites/?hl=en#topic= Instructions Using Google Sites, assemble an online resource tool kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed. It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative pertaining to medication administration. For example, for an ;initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues. Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on safety with medication administration. Each resource listing should include ;the following: • An APA-formatted citation of the resource with a working link. • A description of the information, skills, or tools provided by the resource. • A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to medication administration. • A description of how nurses can use this resource and when its use may be appropriate. Remember that you must make your site public so that your faculty can access it. Check out the Google Sites resources for more information. Here is an example entry: • Merret, A., Thomas, P., Stephens, A., ;Moghabghab, R., Gruneir, M. (2011). A collaborative approach to fall prevention. Canadian Nurse, 107(8), 24-29. Retrieved from www.canadiannurse.com/articles/issues/2011/october-2011/a-collaborative-ap • This article presents the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project. It shows how a collaborative nurse lead project can be implemented and used to improve collaboration and interdisciplinary teamwork, as well as improve the delivery of health care services. This resource is likely more useful to nurses as a resource for strategies and models for assembling and participating in an interdisciplinary team than for specific fall-prevention strategies. It is suggested that this resource be reviewed prior to creating an interdisciplinary team for a collaborative project in a health care setting. Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score. • Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to medication administration. • Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on medication administration. • Analyze the value of resources to reduce patient safety risk related to medication administration. • Present compelling reasons and relevant situations for use of resource tool kit by its target audience. • Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting. Example Assessment: You may use the following example to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your tool kit will focus on promoting safety with medication administration. Note that you do not have to submit your bibliography in addition to the Google Site; the example bibliography is merely for your reference. • Assessment 4 Example [PDF]. To submit your online tool kit assessment, paste the link to your Google Site in the assessment submission box. Example Google Site: You may use the example Google Site, Resources for Safety and Improvement Measures in Geropsychiatric Care, to give you an idea of what a Proficient or higher rating on the scoring guide would look like for this assessment but keep in mind that your tool kit will focus on promoting safety with medication administration. Note: If you experience technical or other challenges in completing this assessment, please contact your faculty member. Additional Requirements • APA formatting: References and citations are formatted according to current APA style Running head: IMPROVEMENT PLAN TOOL KIT Improvement Plan Tool Kit Learner’s Name Capella University Improving Quality of Care and Patient Safety Improvement Plan Tool Kit April, 2019 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 1 IMPROVEMENT PLAN TOOL KIT 2 Improvement Plan Tool Kit This improvement plan tool kit aims to enable nurses to implement and sustain safety improvement measures in health care settings in a geropsychiatric unit. The tool kit has been organized into four categories with three annotated sources each.

The categories are as follows: general organizational safety and quality best practices, environmental safety and quality risks, staff-led preventive strategies, and best practices for reporting and improving environmental safety issues. Annotated Bibliography General Organizational Safety and Quality Best Practices Sherwood, G., & Horton-Deutsch, S. (2015). Reflective organizations: On the front lines of QSEN and reflective practice implementation. Retrieved from https://ebookcentralproquest-com.library.capella.edu/lib/capella/detail.action?docID=3440207# This e-book presents the paradigm shift required for organizations to provide QSEN (quality and safety education to nurses). It provides readers with the innovative pedagogical approaches required to change traditional content-based health care education methods to interactive methods that engage learners. These approaches include facilitative teaching, visual thinking strategies, creating a presence that is authentic, and meaningful learning through debriefing. Concrete examples in the resource demonstrate the application of reflective learning. Additionally, the reflective questions in the resource guide readers to evaluate their own practice, either independently or in groups, to implement formal education programs with a focus on self-improvement. The resource prepares nursing students for advanced competency, Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 3 which will help them adopt reflective thinking, develop a safety culture, and therefore qualitatively improve practices in critical health units such as geropsychiatry units. Fleiszer, A. R., Semenic, S. E., Ritchie, J. A., Richer, M.-C., & Denis, J.-L. (2016). A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study. International Journal of Nursing Studies, 53, 204–218. https://doi.org/10.1016/j.ijnurstu.2015.09.004 This article helps analyze the sustainability of a best practice guidelines program implemented in acute health care settings. The sustainability of the program was characterized by the following: benefits for patients as the rate of incidence of falls reduced; routinization of best practices as the team’s adherence to guidelines improved; and, in the long term, the development of the team’s adaptability to changes in circumstances that threatened the program. Seven key factors that accounted for the sustainability of the program were also identified.NURS FPX4020 Capella University Quality Care and Patient Safety Bibliography

The source explains how relationships between the characteristics of sustainability (benefits, routinization, and development) and the seven key factors contributed toward the sustainability of the improvement program. This source is valuable for nursing students as it helps them understand how safety programs can be sustained to ensure the long-term reduction of the incidence of sentinel events in geropsychiatric units. Kossaify, A., Hleihel, W., & Lahoud, J.-C. (2017). Team-based efforts to improve quality of care, the fundamental role of ethics, and the responsibility of health managers: Monitoring and management strategies to enhance teamwork. Public Health, 153, 91–98. https://doi.org/10.1016/j.puhe.2017.08.007 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 4 This paper discusses the benefits of teamwork in improving the quality of health care. It presents a review of 33 papers identified after performing a search on PubMed. The paper discusses the important ingredients of efficient teamwork such as self-awareness and the individual behavior of team members, the ethical climate within the team, the work environment and institutional infrastructure, positive moderation from leadership, and communication and coordination among team members. Effective teamwork can help reduce the incidence of sentinel events that result from preventable medical errors, which are often caused by dysfunctional communication among team members. Teamwork is more reliable and efficient than individual work in high-risk environments such as a geropsychiatry unit. Although the specific contexts of readers’ practices may be different, this resource is valuable for nursing administrators and professionals as it discusses the implementation of values needed for positive teamwork as well as the monitoring and management of teamwork. Environmental Safety and Quality Risks Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339. https://doi.org/10.1177/1078390314553269 This source mentions a study conducted to analyze falls in geropsychiatric patients. The study also focused on selling falls prevention in psychiatric units. The risk factors that lead to the falls were identified by a focus group. The focus group formulated an improvement plan to reduce the number of falls, and it was found that implementing Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 5 infrastructural changes such as the use of geriatric-friendly sanitary ware such as raised toilet seats helped reduce the rate of incidence of falls. Although all the changes may not be feasible in a given setup, many of the strategies mentioned in this study could serve as a starting point for the prevention of falls. The article helps nursing students understand the challenges that occur in an adult mental health unit and the quality improvement measures taken to resolve these challenges. Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253– 262. NURS FPX4020 Capella University Quality Care and Patient Safety Bibliographyhttps://doi.org/10.1097/NCQ.0000000000000054 This source is a preliminary study conducted to determine the effectiveness of electronic sensor bed/chair alarms to reduce the occurrence of falls in patients with cognitive impairment. These alarms can be attached to the patient’s body or to the bed/chair the patient uses to alert the nursing staff every time the patients move or leave their seat. Nurses were educated about the alarms and asked to document their observations and provide feedback. Although effective at preventing falls in patients with cognitive impairment, the electronic sensors needed improvements such as the elimination of cords that may be hazardous to patients and the additional provision of alerting nurses through pagers. This source helps nursing students understand both the effectiveness and the limitations of electronic sensor alarms in reducing the occurrence of falls. Chari, S. R., Smith, S., Mudge, A., Black, A. A., Figueiro, M., Ahmed, M., . . . Haines, T. P. (2016). Feasibility of a stepped wedge cluster RCT and concurrent observational subCopyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 6 study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial. Pilot and Feasibility Studies, 2(1). https://doi.org/10.1186/s40814-015-0043-x Inadequate lighting at night in geropsychiatric wards is one of the important causes of falls in geropsychiatric units.NURS FPX4020 Capella University Quality Care and Patient Safety Bibliography

Psychotropic medications can cause cognitive impairments and blurring of vision, which can be aggravated by dim lighting in the units. The article presents a trial pilot study conducted to evaluate the effects of the use of modified night lighting in inpatient wards to prevent falls. LED lights were installed in the vicinity of the beds and the toilets, where falls were likely to occur. The study provides valuable insights that could inform design and refurbishment efforts at geropsychiatric units. An important limitation of the study is that a stepped wedge, cluster randomized controlled trial has not yet been applied to test environmental modifications in any setting. However, the modifications discussed could still be implemented as an important intervention strategy for preventing falls in older adults with cognitive impairment. Staff-Led Preventive Strategies Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016). Intentional rounding: A staff‐led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1–2), 115–124. https://doi.org/10.1111/jocn.13401 This article highlights an intervention strategy called intentional rounding to reduce the occurrence of inpatient falls. Intentional rounding is a specific strategy in which nurses conduct a routine check on patients at certain time intervals based on the needs of the Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. IMPROVEMENT PLAN TOOL KIT 7 patient. The rounding was implemented through effective communication and teamwork among the nursing staff and iterations of plan-do-check-act measures. This proactive staff-led strategy helped reduce the rate of falls by 50%.NURS FPX4020 Capella University Quality Care and Patient Safety Bibliography

This study achieved success through the combined efforts of the research team that conducted the analysis of the system to design the rounding format and the frontline nursing staff who conducted the intentional rounds. Although its sample size was small and not entirely representative, the study does establish intentional rounding as an effective falls-prevention strategy, which when implemented with adequate staff engagement and support from leadership definitively reduces the occurrence of falls. Moncada, L. V. V., & Mire, G. L. (2017). Preventing falls in older persons. Am Fam Physician, 96(4), 240–247. Retrieved from https://www.aafp.org/afp/2017/0815/p240.pdf The article posits that a history of falls in older persons is associated with an increased risk of a future fall. The American Geriatrics Society recommends that older adults aged 65 and above should undergo annual screening for balance impairment and a history of falls as a preliminary intervention for the prevention of falls. The article also highlights an algorithm developed by the Centers for Disease Control and Prevention. The algorithm suggests assessment and multifactorial interventions to prevent falls in patients who have had more than two falls and more than one fall-related injury. The multifactorial interventions include exercise routines that include balance and gait training, the use of vitamin D supplements with or without calcium based on the community in which the patients dwell, and the ma …