NURS-FPX4020: Evidence-Based Practice on Patient Safety Protocols

This report examines evidence-based practices and protocols aimed at enhancing patient safety within healthcare settings. It analyzes various elements of successful quality improvement initiatives, drawing upon research articles that explore topics such as the impact of clinical errors, the importance of minimizing interruptions, and the effectiveness of team-based models in improving efficiency and patient outcomes. The report also identifies organizational interventions designed to promote patient safety, including strategies for addressing priority areas like medication errors and surgical site infections. Furthermore, it highlights the significance of staff approaches, best practices for reporting safety issues, and the impact of distractions in the operating room. The report emphasizes the need for continuous improvement, transparency, and teamwork to ensure optimal patient care and safety.

Running Head: Evidence Based Practice 1
Evidence Based Practice on Patient Safety protocols in Care Settings
YOUR NAME
NURS-FPX4020
Capella University
Month, Year

Evidence Based Practice 2
Introduction
Quality improvement is an essential aspect of care practice and processes. There is a need
for improving care quality for patients in the care processes, this promotes and enhances patient
safety process. Nurses comprise of staff play an essential role in the care process. Based on best
practices and evidence-based protocols there is a need for the adoption of safety practices in the
care setting. This annotation offers evidence of practice which enhances and strengthens quality
care in the care setting.
Analyze the elements of a successful quality improvement initiative
Bognár, A., Barach, P., Johnson, J. K., Duncan, R. C., Birnbach, D., Woods, D., ... & Bacha,
E. A. (2008). Errors and the burden of errors: attitudes, perceptions, and the culture of
safety in pediatric cardiac surgical teams. The Annals of Thoracic Surgery, 85(4), 1374-
1381.
This article elaborates on the occurrence of clinical errors during preoperative care which
has an impact on negatively affecting the care process of the patient. this study assessed the
perceptions and attitudes of surgical teams towards committal of errors, its impacts and the
safety of culture. A survey was conducted at three academic hospitals with key aspects focussing
on safety culture, team process, stress recognition and the impacts it has on making clinical
errors. The results of the study showed that safety aspects were influenced by majorly on safety
concerns. Issues of concern entail staffing levels, availability of equipment, production pressures,
and hectic schedules. The study suggested that safety aspects among health care members have
an impact on performances. There is a need to address safety aspects to improve overall patient
care outcomes.

Evidence Based Practice 3
Colligan, L., Guerlain, S., Steck, S. E., & Hoke, T. R. (2012). Designing for distractions: a
human factors approach decreasing interruptions at a centralized medication station.
BMJ Qual Saf, 21(11), 939-947.
As an avenue of analyzing elements of successful quality improvement, the need for
designing distractions on the human aspect as a way of decreasing interruptions is key. the
objective of this study was to lower interruptions in the centrally located open pediatric center.
The methodology employed used various human factor approaches to assess the medication
administration process. Various processes were assessed in this study. The results demonstrated
that beneficial inexpensive barriers were established which were likely not to lead to errors.
Sightlines were employed and showed improved and preserved access on nurses, minimizing
interruptions. This study demonstrated that targeted barriers play a fundamental role in an
interruptive and chaotic hospital set up.
Lee, B. T., Tobias, A. M., Yueh, J. H., Bar-Meir, E. D., Darrah, L. M., Guglielmi, C. L., ... &
Moorman, D. W. (2008). Design and impact of an intraoperative pathway: a new
operating room model for team-based practice. Journal of the American College of
Surgeons, 207(6), 865-873.
The team-based model has been a critical tool for improving the safety and efficiency
process. Challenges have been observed during long period operating procedures. This study
assessed a novel team-based practice model for improvement in efficiency on breast
reconstruction procedures. The key outcomes measured entailed operative time, complications,

Evidence Based Practice 4
hospital costs, complications, staff satisfaction and during administration. The results showed
that mean operating times decreased significantly, likewise mean operating costs declined. The
study demonstrated that implementing an intraoperative pathway is key in improving operative
time costs, quality aspects and staff satisfaction.
Identify organizational interventions to promote patient safety
Steelman, V. M., Graling, P. R., & Perkhounkova, Y. (2013). Priority patient safety issues
identified by perioperative nurses. AORN Journal, 97(4), 402-418.
In a hospital setting searching and developing interventions geared towards patient safety
is paramount and crucial. This study reviews the activities of nurses during preoperative care
focusing on patient safety. a survey was conducted among registered nurses on priority areas
concerning patient safety. the key priority area son patient safety entailed wrong-site procedure,
retainment of surgical sites, medication errors, instrument failure, pressure injuries, specimen
management errors, surgical fires, preoperative hypothermia, burns and difficult intubation and
airway emergencies. Focusing on these priority areas in the care process is essential in
developing educational programs and resource allocation of resources geared towards a safe per
operative patient care process.
Martinez, E. A., Thompson, D. A., Errett, N. A., Kim, G. R., Bauer, L., Lubomski, L. H., ...
& Pronovost, P. J. (2011). High stakes and high risk: a focused qualitative review of
hazards during cardiac surgery. Anesthesia & Analgesia, 112(5), 1061-1074.

Evidence Based Practice 5
Focusing on cardiac surgery review, an assessment of risks and stakes during this surgical
process is crucial. Efforts have always been developed and implemented by various stakeholders
in the health care sector. In this qualitative review, patient safety protocols were assessed during
cardiac surgery was undertaken. Fundamental key recommendations forming the basis of
intervention entails building culture safety, improving transparency, enabling and increasing
teamwork and monitoring performances. These key interventions are essential in improving care
delivery during surgical processes in care settings, especially during cardiac surgery protocols.
Healey, A. N., Sevdalis, N., & Vincent, C. A. (2006). Measuring intra-operative interference
from distraction and interruption observed in the operating theatre. Ergonomics, 49(5-
6), 589-604.
This study focused on the need for measuring the level of interferences and interruptions
during operating theatre periods. The study highlights some of the extrinsic and intrinsic
interference affecting the health care team during surgical procedures. Key sources of
interference found out linked to work entailed equipment, environment, and procedures.
Extraneous interferences entailed phone calls, external staff, and bleepers. Developing
interventions that limit the level of these interferences variables in improving health care patients
quality during surgical procedures among patients.

Evidence Based Practice 6
Staff approach
Kim, F. J., da Silva, R. D., Gustafson, D., Nogueira, L., Harlin, T., & Paul, D. L. (2015).
Current issues in patient safety in surgery: a review. Patient safety in surgery, 9(1),
26.
The study addresses the generic presence of surgical safety guidelines and checklists
which are not tailored to address specific patient issues. There is need for safety redundant
measures geared towards reduction of errors in surgery processes. In view of this, the research
advocates for medical practitioners to develop specific surgical sub specialities which address
patient safety aspects. This is aimed at keeping the safety of patients in place at all time. Sub
speciality guidelines aid the medical practitioners towards a clear process and pathway of
enhancing safety.
Li, S. Y., Magrabi, F., & Coiera, E. (2012). A systematic review of the psychological
literature on interruption and its patient safety implications. Journal of the American
Medical Informatics Association, 19(1), 6-12.
This study focused on the interruption occasioned in the care setting. These reviews
assessed on examination of interruptions in care settings during care delivery. Interruptions
aspects were focussed with the view of understanding its impacts on patients' safety and
efficiency of care delivery. the study demonstrated that interruptions result from complex
variables. The adoption of theories and variables by health care staff are essential in designing
information systems and process which are free from interruptions.

Evidence Based Practice 7
Skaugset, L. M., Farrell, S., Carney, M., Wolff, M., Santen, S. A., Perry, M., & Cico, S. J.
(2016). Can you multitask? Evidence and limitations of task switching and
multitasking in emergency medicine. Annals of emergency medicine, 68(2), 189-195.
Staff approaches have often combined aspects of multitasking activities. This study
focused on evidence and limitations linked to the switching of tasks among care staff. Multi-
tasking based on this review asserts that it is the performance of two tasks simultaneously and is
not undertaken when behaviors are automatic but rather switching done on smaller tasks. This
review shows that switching of tasks socially primary tasks can contribute positively to error
formation. Staff is highly recommended to follow a laid down framework to enhance better
understanding and practices of these behaviors and activities in the care settings.
Best Practices for Reporting and improving operating room safety issues
Fleming, M., Smith, S., Slaunwhite, J., & Sullivan, J. (2006). Investigating the interpersonal
competencies of cardiac surgery teams. Canadian Journal of Surgery, 49(1), 22.
Interpersonal competencies often are essential traits during the care process and delivery.
in cardiac surgery processes, there is a need for interaction of high skilled personnel towards
various complex situations. More often care coordination needs to be cognisant of
communication breakdown and leadership which could lead to adverse effects on care processes.
The study showed the need for open reporting and discussion of medication errors in care
settings. Further, the senior medical team has a role in encouraging other members in reporting
errors committed during the care process.

Evidence Based Practice 8
Feil, M. A. (2017). Distractions in the operating room. In Distracted Doctoring (pp. 143- 160).
Springer, Cham.
Distractions in the health care setting have been demonstrated to pose a serious threat. It
is detrimental to the effective performance of care. an assessment based on analysis of events
showed that medication errors are frequent events followed by medication administration
medication. Distractions in the operating rooms have been highlighted as amplification of sterile
cockpit, reduction of distractions from technology and noise, surgical safety checklists and
briefings. There is a need for engagement of various multidisciplinary teams in addressing
distractions in the operating rooms to enhance patient safety.
An, N. I. Z. (2013). Adopting a ‘no interruption zone' for patient safety. OR manager, 29(2).
In this article piece on the operating manager, the patient safety process has been
highlighted and discussed. This summative article elaborates on the adoption of no interruption
zone for patient safety processes. No distraction strategies have been developed as an avenue for
improving the safety of patients in the operating room. There is a need for manger sin the
operating room to often take control of activities engaged towards minimizing distractions for
patient safety goals.

Evidence Based Practice 9
References
An, N. I. Z. (2013). Adopting a ‘no interruption zone’for patient safety. OR manager, 29(2).
Bognár, A., Barach, P., Johnson, J. K., Duncan, R. C., Birnbach, D., Woods, D., ... & Bacha, E.
A. (2008). Errors and the burden of errors: attitudes, perceptions, and the culture of safety
in pediatric cardiac surgical teams. The Annals of Thoracic Surgery, 85(4), 1374-1381.
Colligan, L., Guerlain, S., Steck, S. E., & Hoke, T. R. (2012). Designing for distractions: a
human factors approach to decreasing interruptions at a centralised medication station.
BMJ Qual Saf, 21(11), 939-947.
Feil, M. A. (2017). Distractions in the operating room. In Distracted Doctoring (pp. 143-160).
Springer, Cham.
Fleming, M., Smith, S., Slaunwhite, J., & Sullivan, J. (2006). Investigating interpersonal
competencies of cardiac surgery teams. Canadian Journal of Surgery, 49(1), 22.
Healey, A. N., Sevdalis, N., & Vincent, C. A. (2006). Measuring intra-operative interference
from distraction and interruption observedin the operating theatre. Ergonomics, 49(5-6),
589-604.
Kim, F. J., da Silva, R. D., Gustafson, D., Nogueira, L., Harlin, T., & Paul, D. L. (2015).
Current issues in patient safety in surgery: a review. Patient safety in surgery, 9(1),
26
Lee, B. T., Tobias, A. M., Yueh, J. H., Bar-Meir, E. D., Darrah, L. M., Guglielmi, C. L., ... &
Moorman, D. W. (2008). Design and impact of an intraoperative pathway: a new operating
room model for team-based practice. Journal of the American College of Surgeons, 207(6),
865-873.

Evidence Based Practice 10
Li, S. Y., Magrabi, F., & Coiera, E. (2012). A systematic review of the psychological literature
on interruption and its patient safety implications. Journal of the American Medical
Informatics Association, 19(1), 6-12.
Martinez, E. A., Thompson, D. A., Errett, N. A., Kim, G. R., Bauer, L., Lubomski, L. H., ... &
Pronovost, P. J. (2011). High stakes and high risk: a focused qualitative review of hazards
during cardiac surgery. Anesthesia & Analgesia, 112(5), 1061-1074.
Skaugset, L. M., Farrell, S., Carney, M., Wolff, M., Santen, S. A., Perry, M., & Cico, S. J.
(2016). Can you multitask? Evidence and limitations of task switching and multitasking in
emergency medicine. Annals of emergency medicine, 68(2), 189-195.
Steelman, V. M., Graling, P. R., & Perkhounkova, Y. (2013). Priority patient safety issues
identified by perioperative nurses. AORN journal, 97(4), 402-418.