Improving Patient Safety in Healthcare

This assignment delves into the crucial topic of improving patient safety within healthcare environments. It examines evidence-based practices aimed at minimizing risks associated with falls and other potential harms. The discussion highlights various interventions, such as fall risk assessments, environmental modifications, and staff training, to enhance patient well-being. However, the assignment also acknowledges barriers to implementation and sustainability, including patient negligence, inadequate workforce adherence to standards, and insufficient qualified staff.

Clinical Practice Improvement Report 1
CLINICAL PRACTICE IMPROVEMENT PROJECT REPORT
A Report Paper on Clinical Practices By
Student’s Name
Name of the Professor
Institutional Affiliation
City/State
Year/Month/Day

Clinical Practice Improvement Report 2
NURS2006 ASSIGNMENT 3
Clinical Practice Improvement Project Report
Student Name, FAN and ID:
Project Title:
Clinical Practice Improvement Project Report
Project Aim:
The aims of the report are:
 To determine the commonly used CPI tools
 To determine the importance of CPI
 To determine the barriers involved in the implementation of the CPI
Relevance of Clinical Governance to your project
The clinical governance is very important for this project since they are the once who will be
interviewed during the process of data collection, their direct interactions will the patients
make them very resourceful when determining some of the clinical practices, patient rights
and engagement, governance and systems of quality improvement, performance and skills
management, and complaints and incidents management. The significance of the clinical
governance stated above are important in this report as explained below:
Clinical practice: This is the care given by the workforce in the clinic which is guided by the
present practices. The clinical governance stated some of the practices which are currently
being undertaken in the clinic and also the way in which those practices can be improved to
enhance quality health ((Prof.), 2010, p. 187).
Patients’ engagement and rights: The report is determined in evaluating if the rights of
patients are respected and their care engagement is supported. The report evaluates how some
of the rights of the patients are not respected and how the clinical governance can ensure that
these rights are respected for improvement of clinical practice (Acton, 2013, p. 197).
Skills and performance management: The report evaluates if the clinical workforce and

Clinical Practice Improvement Report 3
managers have the right approach, skills, and qualification to ensure that they are providing
high-quality and safe health care. This was by the research team through interviewing the
workforce concerning their levels of education and evaluating their academic papers given to
us by the clinical governance.
Governance and systems of quality improvement: The report will also evaluate the integrated
system of governance which manages the quality risk and patients safety actively. The
evaluation is important in determining if the patients’ safety measures are ensured and also if
they are at any risks of accidents which may face them while in the hospital building (Albert
R. Roberts, 2014, p. 168).
Complain and incidence management: this deals in ensuring the safety of the patient and
quality incidents are analyzed reported and recognized. The information used is important in
improving the safety systems by the clinical governance.
Evidence that the problem/issue is worth solving:
The problem in clinical practice improvement is a serious issue which is worth solving to
ensure that quality and safety in healthcare is improved to protect the public from harm.
Some of the evidence that shows that the problems in clinical practice include:
High risks of falling by patients: Such risks are usually common during the presentation and
admission of the patients. Majority of the health centers do not have indications of dangers
which may cause falls especially to the patients who are weak. There is need of indications
such as slippery fall, steps to prevent patients on wheelchairs, and corners within the
buildings (Association, 2011, p. 214).
Slow recognition and response to clinical deterioration: The health workforce had the slow
response to the deterioration of the patients and only taking actions when it was too late. The
communication between patients and health providers. It was necessary to come up with
ways of improving their responses and communication for the sake of the patients.
Risky blood and blood products: Initially the patients used to receive blood products and
blood from unappropriated and risky sources. There was poor documentation of information
about the patients such as their blood groups and also that of the careers. It will not be
surprising to find properly inspected blood being transfused to a recipient (Atanelov, 2015, p.

Clinical Practice Improvement Report 4
268).
Wrong identification of patients and procedure matching: Poor identification and matching of
patients together with the treatment intended were evident hence worth solving. Many health
organizations have not implemented the current ways of record keeping which is safe and
secure. These organizations are still using the old method of keeping numerous books
containing the health records of their patients as opposed to the current computerized record
keeping skills that can store millions of data together with their backups (Bhatt, 2015, p.
148).
The high rate of occurrence of medication incidence: This was characterized by poor
medication management processes, poor documentation of information about patients, poor
communication between patients, and poor medication safety. Bleeding after surgery is also
another medication incident which is caused by the lack of follow ups by the health providers
or premature discharge of the patients
The high occurrence of healthcare associated infections: This normally happens as a result of
poor sterilization, cleaning, and safe keeping. There used to be poor control and prevention
strategies, poor management of patients with colonization and infection. Most hospitals are
at higher risks of patients being re-infected or fresh infections from the virus or bacteria.
Research shows 1.7 million infections associated with healthcare occur yearly and 22% of
those infections are a result of surgical wounds (Department, 2009, p. 187).
Medication error: the error in medication is one of the serious medication risks since if a
nurse misses even a decimal point then it will be a life threatening mistake. In the year 2006,
it was reported that approximately 450,000 injuries occurred which were as a result of
medication errors. This normally happens as a result of poor documentation of the documents
of the patients leading to the patient given a drug that he or she does not deserve or as a result
of incompetent work force employed by the health care organisation (Donna D. Ignatavicius,
2013, p. 174)
Key Stakeholders:
The key stakeholders who are involved in the clinical practice improvement on safety and
quality in healthcare include:

Clinical Practice Improvement Report 5
Government: The government through the Australian Commission on Quality and Safety in
Healthcare in involved in the development of the standards of National Quality and Safety
Services of Health which protects the general public from dangers and for improvement in
the quality of provision of services of health (Geyndt, 2014, p. 196).
Patients: This is the group of individuals in which their health and life are being improved
since they are very vulnerable. It is important to improve the quality of health service which
they are being offered since whatever is prescribed to them, they will ultimately use.
Clinicians and nurses: This is the workforce involved in the provision of quality health
services to the patients. They are supposed to be academically qualified in this particular
field. All the regulation put in place in ensuring the safety of the patients is support to be
carried out by the clinicians.
Governing body of the clinic: This is the body involved in making the major decisions within
the clinic. Such decisions include employment of new staff, financing projects, and receiving
directives from the government. Their directives will ensure that medication safety,
prevention of fall, employment of qualified staff, and quality blood and blood products
(Graham, 2013, p. 198).
CPI Tool:
The clinical practice improved tools which were used during this research include cohort
studies, diagnostic test studies, systematic reviews, qualitative research, case control studies,
and randomized controlled trials. During the period of gathering research data through asking
clinical questions, the research designs that were used were meta-analysis and systematic
review. For the therapy question, the research tools used were case series, meta-analysis,
cohort study, and randomized controlled trial. On the questions on diagnosis, the research
tools used were the randomized controlled trial (Harris, 2012, p. 278). The question about the
cost was directed to the management of the hospital together with government through the
use of economic evaluation tool. The research question about the ways of prevention which
was directed to the nurses and clinicians, the tool that was used was the prospective study.
Summary of proposed interventions:
From the data gotten from the research on the clinical practice improvement, the research

Clinical Practice Improvement Report 6
team came up with numerous proposed ways of ensuring that safety and quality in healthcare
are of standard as explained below:
Governance for quality and safety in health service organization: Systems should be
integrated so as to improve and maintain the quality and reliability of the patients. Patient
rights and engagements should be looked into to ensure that they are respected. Any incidents
and complaints made by the patients. The governance should also ensure that the managers
and clinical workforce possess the right approach, skills, and qualifications to provide quality
and safe healthcare. The clinical staffs should have the current and best clinical practices
through constant seminars and studies (Institute of Medicine, 2011, p. 169).
Prevention and controlling the infections associated with healthcare: This can be done
through infection control and prevention strategies such as sterilization, disinfection, and
cleaning of all medical equipment by proper chemicals.
Ensuring medication safety: Any medical organization should ensure that proper systems are
in place to minimize the occurrence of medical incidence by implementing mechanisms from
the safety monitoring, manufacturing, dispensing, prescribing, administering, compounding
and storing medicine effects.
Ensuring proper identification and procedure for matching patients: there should be properly
described systems to make sure that proper identification of every patient when providing a
service, therapy, and care (Ling, 2011, p. 217).
Ensuring there are no risks of falls and harms from falls: The patients and other staffs should
be informed of specific areas where are at risk of a person falling such as slippery floors. This
is also a need for assessing and screening risks and harm of falls.
Barriers to implementation and sustaining change:
The implementation of the above-mentioned intervention may not be effectively and
efficiently implemented due to some factors which may not be dealt with. The major factor
which is a barrier to the sustainability and implementation of the proposed interventions is
negligence among the patients concerning their individual rights and also part of the
workforce in ensuring that they abide by the required standards set by the National Safety and
Quality Health Service. Insufficient qualified staff also makes it difficult to implement and

Clinical Practice Improvement Report 7
sustain changes made in the health organizations (Lloyd, 2010, p. 198). These changes
require a large number of qualifies staffs who will be responding and recognizing health
deterioration and at the same time controlling and preventing infections associated with
healthcare. There is also a problem of finding an academically qualified workforce with a lot
of passion in the work they do who will be taking good care of the patients and ensuring that
their rights are observed and choice respected.
Evaluation of the project:
The clinical practice improvement project was a project done to evaluate the safety and
quality in health service provision. The aims of this report were to determine the commonly
used CPI tools, the importance of CPI, and the barriers involved in the implementation of the
CPI. The problem in clinical practice is a serious issue which is worth solving to ensure that
quality and safety in healthcare is improved to protect the public from harm. Some of the
evidence that shows that the problems in clinical practice include high risks of falling by
patients, slow recognition and response to clinical deterioration, risky blood and blood
products being given to patients, wrong identification of patients and procedure matching,
and high occurrence of healthcare associated infections (Martin Eccles, 2013, p. 187). The
clinical practice improved tools which were used during this research include cohort studies,
diagnostic test studies, systematic reviews, qualitative research, case control studies, and
randomized controlled trials. Some of the proposed intervention which can be used to deal
with the problem in clinical practice include governance for quality and safety in health
service organization, prevention and controlling the infections associated with healthcare,
ensuring medication safety, ensuring proper identification and procedure for matching
patients, and ensuring there are no risks of falls and harms from falls. However,
implementing the above-mentioned measures are facing some barriers their implementation
and sustainability (Q. Ashton Acton, 2011, p. 187). These barriers include negligence among
the patients concerning their individual rights and also part of the workforce in ensuring that
they abide by the required standards set by the National Safety and Quality Health Service.
Insufficient qualified staff also makes it difficult to implement and sustain changes made in
the health organizations.

Clinical Practice Improvement Report 8
Bibliography
(Prof.), R. J., 2010. Oxford Textbook of Primary Medical Care, Volume 1. Paris: Oxford University Press.
Acton, Q. A., 2013. Issues in Gynecology, Obstetrics, Fertility, and Pregnancy Research: 2011 Edition.
New York: ScholarlyEditions.

Clinical Practice Improvement Report 9
Albert R. Roberts, K. Y., 2014. Evidence-Based Practice Manual: Research and Outcome Measures in
Health and Human Services. California: Oxford University Press.
Association, A. P., 2011. Evidence-Based Practices in Mental Health Care. Chicago: American Psychiatric
Association.
Atanelov, L. (., 2015. Resident’s Handbook of Medical Quality and Safety. London: Springer.
Bhatt, D. L., 2015. Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease E-Book.
Canberra: Elsevier Health Sciences.
Department, N. S. W. H., 2009. Easy Guide to Clinical Practice Improvement: A Guide for Healthcare
Professionals. Paris: NSW Health Department.
Donna D. Ignatavicius, M. L. W., 2013. Medical-surgical Nursing: Patient-centered Collaborative Care.
Canberra: Elsevier Health Sciences.
Geyndt, W. D., 2014. Managing the Quality of Health Care in Developing Countries, Volumes 23-258.
Canberra: World Bank Publications.
Graham, N. O., 2013. Quality in Health Care: Theory, Application, and Evolution. Canberra: Jones &
Bartlett Learning.
Harris, J. L., 2012. Project Planning and Management: A Guide for CNLs, DNPs and Nurse Executives.
Australia: Jones & Bartlett Publishers.
Institute of Medicine, B. o. H. C. S. C. o. t. H. P. E. S., 2011. Health Professions Education: A Bridge to
Quality. Michigan: National Academies Press.
Ling, T., 2011. How Do You Get Clinicians Involved in Quality Improvement?: An Evaluation of the Health
Foundation's Engaging with Quality Initiative: A Programme of Work to Support Clinicians to Drive
Forward Quality: Final Report. Australia: The Health Foundation.
Lloyd, R. C., 2010. Quality Health Care: A Guide to Developing and Using Indicators. Australia: Jones &
Bartlett Learning.
Martin Eccles, J. G., 2013. Clinical Guidelines from Conception to Use. Colorado: Radcliffe Publishing.
Q. Ashton Acton, P., 2011. Issues in Healthcare Management, Economics, and Education: 2011 Edition.
New York: ScholarlyEditions.