Improvement Plan Tool Kit

1 For this assessment, 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 to understand or implement to ensure the success of the plan. Expand All Introduction Communication in the health care environment consists of an information-sharing experience whether through oral or written messages (Chard & Makary, 2015). As health care organizations and nurses strive to create a culture of safety and quality care, the importance of interprofessional collaboration, the development of tool kits, and the use of wikis become more relevant and vital. In addition to the dissemination of information and evidence-based findings and the development of tool kits, continuous support for and availability of such resources are critical. Among the most popular methods to promote ongoing dialogue and information sharing are blogs, wikis, websites, and social media. Nurses know how to support people in time of need or crisis and how to support one another in the workplace; wikis in particular enable nurses to continue that support beyond the work environment. Here they can be free to share their unique perspectives, educate others, and promote health care wellness at local and global levels (Kaminski, 2016). You are encouraged to complete the Determining the Relevance and Usefulness of Resources activity prior to developing the repository. This activity will help you determine which resources or research will be most relevant to address a particular 2 need. This may be useful as you consider how to explain the purpose and relevance of the resources you are assembling for your tool kit. The activity is for your own practice and self-assessment, and demonstrates course engagement. 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, 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 3 understand the research behind your safety improvement plan pertaining to a specific patient safety issue and 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 resources on the following list to help you get started with Google Sites: ● Assessment 4: Google Sites reading list. 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. 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. 4 Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on a specific patient safety issue. 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 a specific patient safety issue. ● 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. ○ 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 5 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 a specific patient safety issue. ● Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on a specific patient safety issue. ● Analyze the value of resources to reduce patient safety risk related to a specific patient safety issue. ● Present 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 the quality issue you selected in Assessment 1. Note that you do not have to submit your bibliography in addition to the Google Site; the example bibliography is merely for your reference. 6 ● Assessment 4 Example [PDF] ● Download 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 found on the Assessment 4: Google Sites reading list, Resources for Improved Heparin Infusion Safety, 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 the quality issue you selected in Assessment 1. Note: If you experience technical or other challenges in completing this assessment, please contact your faculty member. Competencies Measured By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: ● Competency 1: Analyze the elements of a successful quality improvement initiative. ○ Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on a specific patient safety issue. ● Competency 2: Analyze factors that lead to patient safety risks. 7 ○ Analyze the value of resources to reduce patient safety risk related to a specific patient safety issue. ● Competency 3: Identify organizational interventions to promote patient safety. ○ Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to a specific patient safety issue. ● Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. ○ Present reasons and relevant situations for resource tool kit to be used by its target audience. ○ Communicate resource tool kit in a clear, logically structured, and professional manner that applies current APA style and formatting. Improvement Plan Tool Kit Scoring Guide NON-PERF CRITERIA PROFICIEN DISTINGUIS T HED BASIC ORMANCE 8 Identify Does not Identifies Identifies Identifies necessary identify resources, necessary necessary necessary but the resources to resources to resources to necessity or support the support the support the support for implementati implementati implementation implementati the safety on and on and and continued on and improvemen sustainability sustainability sustainability t initiative of a safety of a safety of a safety focusing on improvemen improvemen improvemen a specific t initiative t initiative t initiative patient focusing on focusing on initiative focusing on safety issue a specific a specific pertaining to a a specific is unclear. patient patient safety issue. safety issue. resources to support the sustainability of a safety improvement specific patient patient safety issue. safety issue. Organizes resources logically for ease of use. 9 Analyze the Does not Summarizes Analyzes Analyzes usefulness of analyze but does not usefulness usefulness usefulness analyze of resources of resources of resources usefulness for role for role for role of resources group group responsible for group for role responsible responsible implementing responsible group for for for responsible implementin implementin implementin for g quality and g quality and g quality and implementin safety safety safety g quality and improvemen improvemen focusing on a improvemen safety ts with a ts with a specific patient ts with a improvemen specific specific specific ts with a patient patient patient specific safety issue. safety issue. safety issue. patient Provides safety issue. specific resources to the role group quality and safety improvements safety issue. examples of utility in the context of a specific 10 health care setting. Analyze the Does not Describes Analyzes the Analyzes the value of analyze the resources to value of value of value of reduce resources to resources to resources to patient reduce reduce reduce safety risk or patient patient safety risk patient improve safety risk or safety risk or related to a safety risk or quality with improve improve improve a specific quality with quality, quality with patient a specific identifying a specific safety issue. patient those that safety issue. may be most resources to reduce patient specific patient safety issue. patient safety issue. valuable for reducing patient safety risk or improving quality with 11 a specific patient safety issue. Present Does not Lists Presents Uses reasons and present reasons or reasons and persuasive, reasons and situations for relevant engaging relevant resource situations for language to situations for tool kit use, resource present resource tool kit resource but they are tool kit use compelling use by its target tool kit use not by its target reasons and by its target compelling audience. relevant audience. or their situations for relevance to resource the target tool kit use audience is by its target unclear. audience. relevant situations for audience. 12 Communicate Communicat Communicat Communicat Communicat resource tool kit es a es online es resource es online resource resource kit tool kit in a resource tool kit in an using a Word doc in tool kit using unclear, Word Doc or a clear, a Google structured, and illogically Google Sites logically Sites in a professional structured, in an unclear structured, clear and and and and organized unprofession disorganized professional structure, al manner structure manner that and that does and applies professional not apply unprofession partially manner that current APA al manner follows APA applies style and that style and nearly formatting minimally formatting. flawless, and contains follows APA current APA many errors style and style and and/or formatting. formatting in a clear, logically manner that applies current APA style and formatting. incorrect citations. throughout. 13 Use the resources linked below to help complete this assessment. Expand All Collaboration and Teamwork The following readings may help you in completing this assessment’s activities: ● Assessment 4: Collaboration and Teamworkreading list. Wikis, Blogs, and Google Sites The following readings may help you in completing this assessment’s activities: Wikis ● Assessment 4: Wikis reading list. Blogs ● Assessment 4: Blogs. Google Sites Refer to the resources on this list to help you build your tool kit: ● Assessment 4: Google Sites reading list. Building Professional Efficacy and Visibility The following readings may help you in completing this assessment’s activities: ● Assessment 4: Building Professional Efficacy and Visibility reading list. Evaluating Resources ● Assessment 4: Evaluating Resources. 14 ○ This reading may help you in completing this assessment’s activities: ● Think Critically About Source Quality. ○ This Capella University Library guide offers a method to help you determine which resources to include in your tool kit. Program Resources Capella Writing Center ● Writing Center. ○ Access the various resources in the Capella Writing Center to help you better understand and improve your writing. APA Style and Format ● Capella University follows the style and formatting guidelines in the Publication Manual of the American Psychological Association, known informally as the APA manual. Refer to the Writing Center’s APA Modulefor tips on proper use of APA style and format. Capella University Library ● BSN Program Library Research Guide. ○ The library research guide will be useful in guiding you through the Capella University Library, offering tips for searching the literature and other references for your assessments. 15 1 A Collaborative Approach to Fall Prevention. Authors: MERRETT, ANGELA; 1THOMAS, PATRICIA; 2STEPHENS, ANNE; 3MOGHABGHAB, ROLA; 4GRUNEIR, MARILYN5 Affiliation: 1PUBLIC HEALTH NURSE, TORONTO PUBLIC HEALTH, TORONTO, ONT. 2MANAGER OF HEALTHY LIVING, INJURY PREVENTION, TORONTO PUBLIC HEALTH , TORONTO, ONT. 3CLINICAL NURSE SPECIALIST, CLIENT SERVICES-COMMUNITY, TORONTO CENTRAL COMMUNITY CARE ACCESS CENTRE, TORONTO,ONT. 4GERIATRIC EMERGENCY MANAGEMENT NURSE PRACTITIONER, ST. MICHAEL’S HOSPITAL, TORONTO, ONT. 5CLIN ICAL SUPERVISOR,CLOSING THE GAP HEALTHCARE GROUP, TORONTO, ONT. Source: Canadian Nurse (CAN NURSE), Oct2011; 107(8): 24-29. (6p) Publication Type: Journal Article – pictorial, research, tables/charts Language: 2 English Major Subjects: Accidental Falls — Prevention and Control — In Old Age Collaboration Teamwork Risk Assessment — In Old Age Geriatric Assessment Frail Elderly Minor Subjects: Aged; Multidisciplinary Care Team; Program Implementation; Program Development; Program Evaluation; Evaluation Research; Clinical Nursing Research; Referral and Consultation; Scales; Outcomes (Health Care) — Evaluation; Prospective Studies; Attitude of Health Personnel — Evaluation; Registered Nurses; Occupational Therapists; Home Visits; Community Health Nursing; Interinstitutional Relations; Emergency Nursing; Communication; Documentation; Descriptive Statistics; Program Planning; Purposive Sample; Patient Compliance Journal Subset: Canada; Core Nursing; Nursing; Peer Reviewed Instrumentation: Berg Balance Scale (Berg et al) Timed Up and Go (Podsiadlo & Richardson) Activities-specific Balance Confidence (Myers et al) Reintegration to Normal Living Index-Postal (Daneski et al) Falls Assessment and Intervention Record (FAIR) Triage Risk Screening Tool ISSN: 0008-4581 MEDLINE Info: 3 NLM UID: 0405504 Entry Date: 20111109 Revision Date: 20111205 Accession Number: 66867307 1 Improvement Plan Tool Kit Your Name School of Nursing and Health Sciences, Capella University NURS-FPX4020: Improving Quality of Care and Patient Safety Instructor Name Month, Year Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 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. 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. 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. 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. 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. https://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. 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. 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. 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%. 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 management of psychotropic medication. These interventions have been known to cause a significant decrease in the rate of falls Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 8 and can be implemented across all geropsychiatric wards to prevent sentinel events. The source is authentic and hence can be referred to by nursing students to understand multifactorial interventions in the prevention of falls. Isaac, L. M., Buggy, E., Sharma, A., Karberis, A., Maddock, K. M., & Weston, K. M. (2018). Enhancing hospital care of patients with cognitive impairment. International Journal of Health Care Quality Assurance, 31(2), 173–186. https://doi.org/10.1108/IJHCQA-112016-0173 This paper evaluates the TOP5 intervention strategy of improving patient care. The strategy involves engaging with carers of geriatric patients (individuals who are family members or friends of the patients) to collect characteristic non-clinical information about patients to personalize care and reduce falls. The carers of patients narrated to the nursing staff five important and distinct characteristic details such as the patients’ needs and past emotional experiences. The nursing staff then prepared a customized plan of care for each patient based on this information. This study reported a significant reduction in falls and qualitatively improved care. The study enables nursing students to meaningfully involve the carers of cognitively impaired patients and reduce the incidence of falls. Best Practices for Reporting and Improving Environmental Safety Issues Tan, A. K. (2015). Emphasizing caring components in nurse-patient-nurse bedside reporting. International Journal of Caring Sciences, 8(1), 188–193. Retrieved from https://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocvie w%2F1648623547%3Faccountid=27965 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 9 This source provides a review of strategies that improve bedside reporting and transfer of duties after a change of shift among nursing staff. The source also emphasizes team engagement that can help reduce the incidence of sentinel events, especially in health care units such as geropsychiatry units. Bedside reporting is a vital concern in geropsychiatric units as patients are prone to behavioral changes and unpredictable behavior may affect other patients in the unit. During a shift change, the nursing staff can alert the incoming staff about the condition of such patients to proactively prepare the staff to address any forthcoming issue. Barriers to bedside reporting were also analyzed, and barriers perceived by patients and those perceived by nurses were identified. These barriers can be eliminated through open communication and by educating the nursing staff. The article provides a valuable discussion of factors that influence bedside reporting such as patient-centered care philosophy, guidelines of the Joint Commission Institute, demand for patient participation in making health care decisions, and the shortcomings of traditional handover practices. Stergiopoulos, S., Brown, C. A., Felix, T., Grampp, G., & Getz, K. A. (2016). A survey of adverse event reporting practices among US healthcare professionals. Drug Safety, 39(11), 1117–1127. https://doi.org/10.1007/s40264-016-0455-4 This article highlights the severity of underreporting of adverse drug events. An adverse drug event is defined by the World Health Organization as “a response to a medicine which is noxious and unintended, and which occurs at doses normally used in man.” Adverse drug events are estimated to cause 7,000 deaths across health care settings in the United States each year. It is also said that half of these adverse drug events result from Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 10 preventable medication errors. The article also identifies factors that lead to the underreporting of the adverse drug events such as lack of training among health care professionals and standardized reporting processes. Underreporting of adverse drug events can be a critical problem, especially in health care units such as geropsychiatry units. Individual patients may react differently to psychotropic drugs; reactions may include overdoses or allergic reactions. These reactions need to be monitored closely and reported efficiently to avoid complications including falls. Nursing students can understand the importance of reporting adverse drug events through this source. Lozito, M., Whiteman, K., Swanson-Biearman, B., Barkhymer, M., & Stephens, K. (2018). Good catch campaign: Improving the perioperative culture of safety. AORN Journal, 107(6), 705–714. https://doi.org/10.1002/aorn.12148 This article provides evidence-based results to show that the culture of safety in a perioperative unit was improved after implementing the good catch campaign. Good catch is the ability of nursing staff to point out mistakes and report them to avoid sentinel events. The campaign described in the article involves implementing a standardized electronic reporting system and debriefing process. The nursing staff discusses the plan of care for each patient at the end of the day during debriefing. This helps the nursing staff note characteristic risks involved with each patient and provide better care. Training nursing staff to implement the good catch campaign in health care units such as geropsychiatry units should enable the effective reporting of factors that could cause falls with a view to avoid them. This source enables nursing students to implement electronic reporting systems to report good catches and thereby reduce falls. Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 11 References 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 substudy 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 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 Isaac, L. M., Buggy, E., Sharma, A., Karberis, A., Maddock, K. M., & Weston, K. M. (2018). Enhancing hospital care of patients with cognitive impairment. International Journal of Health Care Quality Assurance, 31(2), 173–186. https://doi.org/10.1108/IJHCQA-112016-0173 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 Lozito, M., Whiteman, K., Swanson-Biearman, B., Barkhymer, M., & Stephens, K. (2018). Good catch campaign: Improving the perioperative culture of safety. AORN Journal, 107(6), 705–714. https://doi.org/10.1002/aorn.12148 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 12 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 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 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 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# Stergiopoulos, S., Brown, C. A., Felix, T., Grampp, G., & Getz, K. A. (2016). A survey of adverse event reporting practices among US healthcare professionals. Drug Safety, 39(11), 1117–1127. https://doi.org/10.1007/s40264-016-0455-4 Tan, A. K. (2015). Emphasizing caring components in nurse-patient-nurse bedside reporting. International Journal of Caring Sciences, 8(1), 188–193. Retrieved from https://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocvie w%2F1648623547%3Faccountid=27965 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 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited. 13 cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253– 262. https://doi.org/10.1097/NCQ.0000000000000054 Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

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