Safety Performance Improvement Paper

NURS 490- Nursing Leadership

Purpose of Assignment
The purpose of this assignment is to identify a safety issue within a health care
organization that needs to change in order to promote better delivery of patient care; to
demonstrate an ability to collaboratively problem-solve in an interdisciplinary environment while
working towards resolution of a common problem.
Student Approach to Assignment
This assignment was a group assignment. I presented the topic of catheter associated
urinary tract infections (CAUTI) to my group. I wanted to focus on this problem because it is a
major patient safety issue. I work in the intensive care unit (ICU) at an acute care hospital.
CAUTIs are a growing problem on my unit and I was interested in researching the topic to
develop a plan to improve patient safety and outcomes. I learned evidence-based practice
guidelines for urinary catheter use and the implications on patient safety. I also gained insight on
national recommendations and hospital policy. As a nurse, it is important to understand the
reasoning behind practice and have the ability to recognize areas for improvement. This
assignment provided me with the opportunity to identify a patient safety issue and develop a plan
to improve patient outcomes.
Reason for Inclusion of this Assignment in the Portfolio
I included this assignment in my portfolio because it is an example of identifying a
patient safety issue in the workplace and developing a plan to improve patient outcomes. This
assignment represents my ability to work with others and communicate as a group to develop
and implement solutions. In nursing school, I learned about urinary catheters and how to use
them properly. As a registered nurse, I am now able to apply the knowledge I learned in school
in the workplace by recognizing areas for improvement. Continuous quality improvement is an
important aspect of nursing and key in improving patient safety.
• Research
o Applies research based knowledge from the arts, humanities, and sciences to
complement nursing practice

CAUTIs are a growing patient safety issue in acute care hospitals. In order to develop a
plan to improve the problem, research was performed to learn the evidence-based practice
guidelines and national recommendations for urinary catheter use. The American Nurses
Association’s Streamlined Evidence-Based RN Tool was a recommended resource from the
Centers for Disease Control and other peer reviewed journal articles. The tool would be
implemented in an acute care hospital by nurses to decrease the number of CAUTIs. This
intervention focuses on the science of nursing because the recommendation is based clinical data
from research studies. The knowledge gained from research was used to develop a nursing
intervention to implement in efforts to improve patient safety.

• Critical Thinking
o Performs direct and indirect therapeutic interventions that incorporate principles of
quality management and proper safety techniques based upon assessment findings
In this assignment, our group developed a bundle checklist intervention using best
practice recommendations and literature review. The implementation of best practice
recommendations with regards to Foley care is an indirect intervention to improve quality
management and proper safety techniques.

• Culture
o Considers the impact of research outcomes and, the effects of health and social policies
on persons from diverse backgrounds
The research used to develop this quality improvement assignment influences culture in a
variety of ways. First, Foley catheters are used, sometimes overused, in a wide range of patient
conditions. The outcomes of this intervention have the potential to improve outcomes for
vulnerable patient populations. Hospital health policies can be improved through the utilization
of the research outcomes of this intervention. Second, the hospital culture is developed through
employee diversity and social policy. The intervention addresses how to deal with opposition to
change and methods to gain supporters. The incorporation of the quality improvement
intervention could not be implemented due to preexisting hospital culture. The assignment
addressed how to overcome the cultural influences and positively impact patients and staff.

• Teaching
o Evaluates the efficacy of health promotion and education modalities for use in a variety
of settings with diverse populations
In this assignment, nurses are provided with education about Foley catheter best practice
recommendations and how to implement the Foley checklist during shift change. After the
teaching session, managers evaluate the effectiveness of the teaching session by nurses providing
a demonstration of how to use the checklist in a mock shift change. The Learn from Defects Tool
Worksheet is used once the checklist is used in practice. The tool is used to evaluate how a
CAUTI occurred despite the implementation of the education session and checklist.