NR 451 Week 6 Assignment: EBP Change Process form

Student Name

Chamberlain University

NR-451: RN Capstone Course

Prof. Name

Date

Week 6 Assignment: EBP Change Process Form Using the ACE Star Model of Knowledge Transformation

Star Point 1: Discovery (Identify Topic and Practice Issue)

What is the identified topic?
The topic chosen for this assignment is the prevention and reduction of nursing-related errors within healthcare organizations, with an emphasis on strengthening a culture of patient safety.

What is the issue being addressed?
Nursing errors, such as medication mistakes, omissions in care, or lapses in communication, frequently occur in hospitals and can place patients at risk of harm or death. Contributing factors often include staff fatigue, inadequate supervision, and lack of attentiveness. Nurses, being central to patient care, are strategically positioned to drive initiatives that minimize these errors.

Why is this topic significant?
The rationale for this topic is based on the alarming global statistics that attribute millions of preventable deaths annually to healthcare errors. These errors not only endanger patients but also diminish the credibility of healthcare institutions and impact overall care quality. Thus, fostering a patient safety culture is a critical public health priority.

Star Point 2: Summary (Evidence to Support Need for Change)

What evidence supports the need for change?
The core practice concern centers around the high occurrence of clinical errors, including patient falls, infections, hand-off communication failures, and medication mistakes. Despite the established risks, many organizations fall short in developing robust safety cultures. This gap necessitates stronger evidence-based interventions to enhance patient outcomes.

What evidence from the literature was reviewed?
To frame the issue, the PICOT model was used to structure the guiding research question. The following scholarly resources support the urgency for change:

Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al Kindi, S. N. (2015). Patient safety culture among nurses. International Nursing Review, 62(1), 102–110.
Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical Care Nurse, 36(4), 19–35.
Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1).
Bush, P. A., Hueckel, R. M., Robinson, D., Seelinger, T. A., & Molloy, M. A. (2015). Cultivating a culture of medication safety in prelicensure nursing students. Nurse Educator, 40(4), 169–173.

What did the evidence reveal?
The systematic review emphasizes that patient safety is a cornerstone of high-quality care. Factors linked to safer practices include effective communication regarding errors, leadership engagement, ongoing feedback systems, clear expectations from management, and collaborative teamwork.

What change is recommended?
Hospitals should establish policies and systems that reinforce a patient safety culture. Leadership must ensure open communication, continuous organizational learning, and a non-punitive reporting environment. Training programs, safety checklists, and leadership modeling are essential for sustaining long-term improvement.

Star Point 3: Translation (Action Plan)

What is the action plan?
The action plan is to integrate structured education and supportive leadership practices to reduce errors. A learner-centered training program will be developed, focusing on awareness of safety protocols, error reporting, and the use of structured communication tools.

Who are the stakeholders and what are their roles?

Stakeholder	Role and Responsibilities
Nurses	Deliver direct patient care, apply safety checklists, and report errors or unsafe conditions.
Management	Design and implement safety policies, organize training, and foster a supportive environment.
Patients	Actively engage in care, communicate concerns, and report errors to staff.
Nurse Leaders	Mentor and supervise staff, encourage reporting, and ensure compliance with policies.
Pharmacists	Monitor prescriptions, identify and address medication errors, and collaborate with nurses.

How do nurses contribute to the change?
Nurses play a central role by documenting errors and near misses, which allows for pattern analysis and corrective action. They are also responsible for reporting unsafe conditions, such as malfunctioning equipment, and using checklists to standardize care delivery.

Star Point 4: Implementation

How will the plan be implemented?
The implementation will begin with nurse leaders seeking approval from hospital administration. A formal proposal will outline the safety issue, intervention plan, and anticipated outcomes. Staff education will be prioritized, ensuring nurses understand the change process and its relevance to patient safety.

What is the proposed timeline?

Timeline	Activities
Feb 1 – Feb 14	Conduct staff training on error reduction strategies.
Feb 15 – Feb 28	Prepare educational and promotional materials (e.g., posters, flyers).
Mar 1 – Mar 30	Launch awareness campaigns on safety policies and practices.
Apr 1 – Apr 31	Assess the application of newly learned skills and knowledge.

How will outcomes be measured?
Outcomes will be tracked using the PICOT format:

P (Population): Incidence of medication errors.
I (Intervention): Implementation of patient safety promotion strategies.
C (Comparison): Error rates before and after using structured checklists.
O (Outcome): Reduction in mortality and adverse events.
T (Time): Six months.

Weekly stakeholder meetings will be conducted to evaluate progress, troubleshoot barriers, and refine interventions.

Star Point 5: Evaluation

How will the effectiveness of the plan be evaluated?
Effectiveness will be measured by comparing error frequency before and after intervention, presented in frequency tables for clarity. Reductions in error rates will demonstrate success, while areas with limited improvement will guide further modifications. Long-term evaluation will determine the sustainability of safety practices and inform broader institutional adoption.

References

Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al Kindi, S. N. (2015). Patient safety culture among nurses. International Nursing Review, 62(1), 102–110. https://doi.org/10.1111/inr.12159

Bush, P. A., Hueckel, R. M., Robinson, D., Seelinger, T. A., & Molloy, M. A. (2015). Cultivating a culture of medication safety in prelicensure nursing students. Nurse Educator, 40(4), 169–173. https://doi.org/10.1097/nne.0000000000000143

NR 451 Week 6 Assignment: EBP Change Process form

Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1), 29–34. https://doi.org/10.7748/cnp.14.1.29.e1259

Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016). Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical Care Nurse, 36(4), 19–35. https://doi.org/10.4037/ccn2016319