1. Identify an appropriate area of interest and focus
Areas to choose from:
-Surgery on the wrong body part
-Foreign body parts left in a patient after surgery,
-Mismatched blood transfusion
-Major medication error
-Severe pressure ulcer acquired in a hospital
-Preventable post-operative deaths
-Sepsis
-Hospital Acquired Urinary Tract Infection
-Suicide during or within 72 hours of discharge from a hospital
-Unanticipated event during care of an infant
-Severe neonatal Jaundice (bilirubin >30 mg/dl)
-Prolonged fluoroscopy with very high or inappropriate dose or wrong site
-Fire during direct patient care caused by hospital equipment
-Unanticipated severe maternal morbidity resulting in permanent or severe temporary harm
-Rape
-Falls
-Delay in Treatment
-Criminal event
2. Synthesize the literature on the topic using research articles not older than ten years (1-2 single-spaced paragraphs).
3. Identify at least 1-2 research articles or a meta-synthesis, meta-analysis, or systematic review of the literature to support your information about this topic.
4. Define each of the specific aims in a sentence or two as to how it specifically relates to your topic of interest for each individual IOM Aims for Quality Improvement Safety Goals. You will find in your textbook in Chapter 23.
IOM Aims for Quality
o Safety Issue (Safety is a subset of quality)
o Effectiveness of care delivery as it relates to issue
o Efficiency of care delivery as it relates to issue (Cost/Benefit)
o Equity of care (Is there a fair distribution of resources)
o Timely (Is timing an issue with regards to intervention For example, if pressure ulcers are the issue and regular screening and monitoring of skin are strategies, are they time-sensitive. How does time impact the outcome?)
o Patient-centered How is the patient engaged. How is the patient a partner in their care? Consider fall risk, restraint use, and pain management.
o Interdisciplinary Teams: Who makes up the team in caring for the patient population (per issue addressed, i.e. pressure ulcers. Falls with harm. Pain management.
o Information/technology: What information/technology is employed? How is information communicated? How does technology aid the patient care delivery process?
o Quality Improvement: How is this issue tracked. Trended. How are outcomes measured? What happens if the quality continues to be below the benchmark. How does this impact reimbursement? Patient satisfaction.
o Evidence-based: What evidence (research) supports the care delivery as it relates to the safety/quality issue.
TEXTBOOK:
Marquis, B. & Huston, C. (2021). Leadership and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.
