NR 451 Week 6 Assignment: EBP Change Process form Week 6 Assignment: EBP Change Process Form using the ACE Star Model of Knowledge Transformation Star Point 1: Discovery (Identify Topic and Practice Issue)

The topic identified for this assignment is the reduction of errors made by nurses in healthcare institutions, with a focus on promoting a culture of safety. Errors are prevalent in hospital settings, often resulting in severe consequences that jeopardize patient health and, in some cases, lead to fatalities. These errors can stem from various factors, including recklessness, fatigue, and inattentiveness. Given their critical role in patient care, nurses are uniquely positioned to implement strategies that can significantly reduce or eliminate these errors.

The rationale for selecting this topic stems from the alarming frequency of errors reported in hospitals, which have contributed to the deaths of millions globally. The scope of the issue is broad, affecting not only individual patients but also overall healthcare quality and institutional credibility.

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

The primary practice problem revolves around the increasing incidence of errors in healthcare settings, which encompasses missed care, patient hand-offs, infections, falls, and medication errors. Despite the serious implications of these errors, efforts to foster a safety culture within healthcare environments remain insufficient. Consequently, there is a pressing need for research and interventions aimed at improving patient outcomes.

To formulate a guiding question, the PICOT framework is utilized. The relevant systematic review selected from the Cochrane Database of Systematic Reviews is:

• 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.

Other scholarly sources consulted include:

1. 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.
2. Cloete, L. (2015). Reducing medication errors in nursing practice. Cancer Nursing Practice, 14(1).
3. 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.

The systematic review highlights that patient safety is crucial in enhancing healthcare quality. Key predictors of patient safety include effective communication about errors, continuous feedback, hospital management support, clear management expectations, and teamwork in addressing potential errors.

To address the identified issues, evidence-based solutions will be proposed. Hospital management should prioritize developing systems and practices that nurture a culture of patient safety while enhancing leadership capabilities to facilitate open communication, foster continuous organizational learning, and create a blame-free environment.

Star Point 3: Translation (Action Plan)

To support intervention planning, it is essential to identify existing care standards, practice guidelines, or protocols. A comprehensive, learner-centered training module can significantly enhance nurses’ skills, attitudes, and knowledge, while also raising awareness about various error-reduction strategies.

Key stakeholders involved in the change process include:

Nurses play a vital role in the change process by reporting errors or near misses to the appropriate authorities, allowing for analysis and subsequent preventive measures. They must also report unsafe conditions, such as faulty equipment, and utilize activity checklists to ensure comprehensive care.

Star Point 4: Implementation

To initiate the trial, the nurse leaders will formally seek permission from hospital management by submitting a detailed letter that outlines the problem, its implications, and the proposed intervention measur