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NURS2006 assignment 3

Clinical Practice Improvement Project Report

Project Title:

Implementing an education program to reduce medication errors by 30% amongst registered nurses in ward C, Flinders Hospital

Project Aim:

To reduce medication errors by RNs in the ward C by 30% within 6 months.

Relevance of Clinical Governance to your project

Aims to improve patient safety by minimizing medication errors, reducing risks of harm to patients. Increases quality of patient care by education of health professionals. This will also help to provide standardized care.

Evidence that the issue / problem is worth solving:

Data shows that medication errors are a significant problem. The literature says that medication errors are occurring frequently through things like human error etc, and most are preventable (5 references primary studies, literature review, tertiary study eg Bloggs and Jones 2005)

Incident reports by the hospital or wardsth at indicate there is a problem that needs to be solved.

What does the literature say about medication errors, references. Eg what we read last week.

Literature says….this is important because….

Key Stakeholders:

Patients, family, health professionals (RNs, Doctors, pharmacists etc), hospital management, govt bodies providing funding, drug companies

CPI Tool:

Plan Do Study Act (PDSA) (author –reference ) Add the steps

Plan- Plan intervention

Do-carry out the test

Study-Study the results

Act-Change practice incorporating any modifications

Summary of proposed interventions:

How might you apply the steps of PDSA in YOUR project and subsequent clinical change

Plan –organise team, get permission, gather data. Background. Stats, etdc. Particpants

Do – Doing an audit check of current med errors. Then do the education program. Check the medication errors two months later to see if the program was effective

Study – Look at the results, comparing the pre and post test data

Act – Run and education program every 6 months. Make it standard practice, put it in ward protocol

Barriers to implementation and sustaining change:

What might get in the way of doing the study and also, bringing in long term change. Eg

Cost…Time consuming, getting people involved, how many people agree to get involved and stay on board with it, failure to report, people not following protocol, not understanding, hard to follow participants, workplace culture problem, communication errors. People are reluctant to change…

Evaluation of the project:

How would you work out if the project was a success and how would you implement your change in an ongoing way in your ward.

Keep in touch with the number of incident reports.

Keep having inservices. Keep doing pre and post test audits on medication errors.

NURS2006 Assignment 3 - CPI paper Marking Rubric

PERFORMANCE STANDARD

CATEGORY &

WEIGHTING

Excellent Work

Good Work

Passing Work

Unsatisfactory work

Project Aim and Evidence the issue is worth solving

20%

Aim succinct & clearly defined. All evidence

relevant & rigorous. Shows a very high level of insight & relevance to the issue.

(17-20) o

Aim well defined.

Some irrelevant information but most evidence relevant &

rigorous. Shows a very good level of insight & relevance to the issue.

(13-16.5) o

Aim stated with some ambiguity. Some evidence relevant and rigorous,

Acceptable level of insight. Quite a lot of irrelevant information is present.

May be overlong/ too brief

(10-12.5) o

Aim not clearly stated Most evidence is not relevant or rigorous.

Poor level of insight & relevance to the issue.

Significant amount of irrelevant/ missing information.

(0–9.5) o

Relevance of

Clinical

Governance to your project

10%

Succinct and highly relevant discussion of the relevant pillar of clinical

governance related to the chosen clinical issue.

(9-10) o

Succinct and mostly relevant discussion of the relevant pillar of clinical

governance related to the chosen clinical issue.

(7-8.5) o

Adequate discussion of the relevant pillar of clinical

governance related to the chosen clinical issue.

Some parts not relevant

Overlong / too brief, may be missing relevant information.

(5-6.5) o

Inadequate discussion of the relevant pillar of

clinical governance related to the chosen clinical

issue. Overlong / too brief, may be missing a

significant amount of relevant information

(0-4.5) o

Key

Stakeholders 5%

Identifies most relevant key stakeholders.

Discusses clearly how they could be involved in the project.

Succinctly and expertly written. Very high level of insight into the role of stakeholders.

(4.5 - 5) o

Identifies some relevant key stakeholders and

adequately discusses how they could be involved in the project.

Very well written. Good level of insight into the role of stakeholders.

(3.5-4.25) o

Identifies a few relevant key stakeholders.

Mentions briefly how they

could be involved. Quite

well written but contains some irrelevant

information, or minor

information is missing.

Adequate level of insight into the stakeholder role. (2.5 – 3.25- ) o

Contains irrelevant information, or major

information is missing.

Inappropriate or no key stakeholders are identified

Poor insight into the stakeholder role.

(0-2) o

Clinical Practice

Improvement

Tool

20%

Describes a relevant CPI tool Very clearly discusses

how it could be used to

address the aim and implement the

interventions. Succinctly

and expertly written with no omissions of relevant information.

(17-20) o

Describes a relevant CPI tool Discusses quite clearly how the tool could be used

to address the aim and implement the

interventions. Well written but may contain some

irrelevant information, or some minor information is missing

(13-16.5)o

Describes a relevant CPI tool and adequately

discusses how the tool

could be used to address the aim and implement the interventions.

Not succinct, contains

irrelevant information,

significant information is missing

(10-12.5) o

A relevant CPI tool is not identified. There is no

adequate discussion of how the tool could be

used to meet the aim or implement the

interventions.

Contains irrelevant information or some major information is missing.

(0–9.5) o

Summary of proposed

interventions

20%

All relevant interventions are discussed very well.

Project outline is very clear and the relevance to

clinical practice is very high.

(17-20) o

Most relevant interventions discussed quite well.

Project outline is clear & relevance to clinical

practice is good. Contains some irrelevant

information, minor

information may be missing.

(13-16.5)o

Acceptable level of relevant interventions discussed.

Project outline mostly clear, although it may be

unclear how the project would actually be

implemented in clinical practice due to irrelevant/missing info

(10-12.5)o

Some elements missing or incomplete. May contain large amounts of

irrelevant information.

Project poorly described and it is unclear what the project actually entails or its relevance to clinical practice.

(0–9.5)o

Barriers to

Implementation 15%

Identifies most potential barriers to implementation & clinical change. Discusses in depth how these barriers could be overcome or minimised.

(13-15) o

Identifies some potential barriers to implementation & clinical change.

Discusses how these barriers could be overcome or minimised.

(10-12.5) o

Identifies a few potential barriers to implementation & clinical change.

Discusses how barriers could be overcome or minimised. Minor

omissions and/or some

irrelevant information present

(7.5-9.5) o

Relevant barriers not identified. Poor or no

discussion about how they

could be overcome or minimised. Major

omissions, much of the

information provided is

irrelevant / unrelated to the CPI goal.

(0-7) o

Evaluation of the project

10%

Succinct discussion of an excellent and achievable plan for how the

intervention/s could be evaluated.

(9-10)o

Succinct discussion of a very good and mostly

achievable plan for how

the intervention/s could be evaluated.

(7-8.5)o

Discussion of an adequate plan for how the

intervention/s could be

evaluated. Some parts not relevant or achievable

Overlong / too brief, may be missing relevant information.

(5-6.5)o

Plan absent or not well described. Most or all of

the plan is not relevant or achievable

Overlong / too brief, may be missing a significant amount of relevant information

(0-4.5) o

Name of Marker

Grade

Overall Comments

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