PEER RESPONSES FOR Patient Outcomes and Sustainable Change

PEER RESPONSES FOR Patient Outcomes and Sustainable Change

Assessment Description

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DQ 1

Reflecting on the “IHI Module: PS 202 Achieving Total Systems of Safety,” describe the eight recommendations proposed in the IHI report that DNP leaders can apply to accelerate patient safety and the prevention of harm. What three key recommendations will you use as a DNP leader to promote safety among the workforce in your organization to improve health outcomes?


Bonnie Flores


This week’s module by the Institute for Healthcare Improvement (IHI) PS 202 provided many examples of how patient safety can be implemented and how doctoral leaders can help transform the culture so that the focus is on safety within the organization and the entire system.

The eight IHI recommendations are:

·     Ensure leaders establish and sustain a culture of safety

·     Create centralized and coordinated oversight of patient safety

·     Create a common set of safety metrics that reflect meaningful outcomes

·     Increase funding for research in patient safety

·     Address safety across the entire care curriculum

·     Support the healthcare workforce

·     Partner with patients and families for the safest care

·     Ensure that technology is safe and optimized to improve patient safety (IHI, 2020).

Among the examples provided, the three key recommendations where I would start to promote safety are supporting the healthcare workforce, partnering with patients and families for safe care, and ensuring that technology is safe and optimized to improve patient safety. Supporting healthcare workers is essential to consistency across all units and departments. This can be done via mandated annual training in a remote environment that is reinforced during in-person annual training. Additionally, safety among healthcare workers can be reinforced each day with visual reminders (e.g., posters and signs) and during a 1-minute daily safety huddle on the current metrics (Gray, 2020). The working conditions can be improved by ensuring adequate staffing to reduce overtime, resulting in fatigue and errors in judgment. Providing the necessary safety measures like adequate personal protective equipment, ample cleaning supplies, and sharps containers that are replaced before they are full (Haegdorens et al., 2022).

Partnering with the patient and families is the next measure I would ensure. Patients who lack access to their medical records may not know about their disease condition or how to take their medication; thus, resulting in increased hospitalizations and higher mortality rates. Therefore, it is vital that patients partner with the healthcare team so they can take an active role in restoring their health. With pressing time constraints, practitioners often do not take the necessary time to ensure meaningful conversations and learning. With improved staffing, practitioners will have more time to spend more time building rapport with patients to ensure that they understand instructions and have time to ask questions. (Bird et al., 2020). Through patient engagement and rapport building, patient trust increases, and outcomes improve (Bird et al., 2020). Additionally, with the growing diversity, ensuring that patients have a translator if they need it is another key step to providing safe and meaningful care.

Finally. Technology is growing exorbitantly, and it is in nearly every patient interaction. As care providers, we must ensure that we are not relying on technology to do our jobs but that it is a tool we use to help us provide safer care. For example, wearable technology with integration into the electronic health record is helping transform healthcare and improve patient outcomes (Asan et al., 2020). Patients can virtually see practitioners from their homes, and they can get help managing their conditions (Asan et al., 2020). Within the hospital setting, technology helps us trend data and deliver medications safely, technology helps in care delivery, but it does not replace the human factor. For example, we frequently use patient monitoring systems to assess cardiac rhythms, but before we determine that the rhythm is accurate, we must assess the patient first. Sometimes there is a technological failure, and it would be negligent care to start compressions on a patient because the monitor read as asystole. Hence, looking at the patient and trying to arouse them, and assessing for a pulse is the first step. There are many safety avenues that the doctoral nurse can use to improve patient care. I look forward to being able to implement a few of these key recommendations in my practice.


Asan, O., Bayrak, A. E., & Choudhury, A. (2020). Artificial intelligence and human trust in healthcare: focus on clinicians.  Journal of medical Internet research,  22(6), e15154.

Bird, M., Ouellette, C., Whitmore, C., Li, L., Nair, K., McGillion, M. H., … & Carroll, S. L. (2020). Preparing for patient partnership: a scoping review of patient partner engagement and evaluation in research.  Health Expectations,  23(3), 523-539.

Gray, T. (2020). Safety huddle in a community nursing setting. British Journal of Community Nursing, 25(9), 446-450.

Haegdorens, F., Franck, E., Smith, P., Bruyneel, A., Monsieurs, K. G., & Van Bogaert, P. (2022). Sufficient personal protective equipment training can reduce COVID-19 related symptoms in healthcare workers: a prospective cohort study.  International journal of nursing studies,  126.

Institute for Healthcare Improvement (IHI). (2020). PS 202: Achieving total systems safety. IHI. Retrieved from


Veronica Montemayor


This week the “IHI Module: PS 202 Achieving Total Systems of Safety” discussed the eight recommendations along with action steps for hospital leadership and healthcare professionals to move to a systems approach to safety. In reviewing the eight recommendations, they all align with ensuring safety systems are in place for healthcare organizations. Out of the eight, I will focus on the following three within my organization; ensuring that leadership establishes and sustain the safety of culture in our hospital, support the healthcare workforce, and ensure that our technology is safe and optimized to improve patient safety. In an article by Leininger et al. (2021), they noted that all hospitals need to establish a culture of safety by designing processes or protocols that make it easier for people to be successful in order to reduce the chance of error that can lead to safer care. The authors also noted that the literature supports designing a comprehensive multidisciplinary committee that meets regularly to discuss system issues in the hospital that may have led to a patient’s death or an unanticipated event.

Hospital leaders and administrators play a considerable role in the safety of culture in the organization; they must set expectations, lead by example, and have the resources to support such culture. Supporting the healthcare workers is vital to them, the patients, and the organization to ensure the patients are receiving the proper care and meeting the hospital’s quality metric goals. Compassionate leaders engage with all caregivers as collaborators and co-designers of the healthcare processes and policies they live and work with every day (Lown, 2021). Lown (2021) group launched an open-access resource page on their website and a complimentary series of webinars to help all frontline caregivers and their leaders face the pandemic’s socioemotional and mental health effects. Keeping patients’ medical records safe and private is essential so they do not become victims of identity theft; having the proper software is vital. Mohammad et al. (2022) noted that software applications and systems hold critical importance in the healthcare domain due to severe consequences associated with their malfunction; thus, healthcare applications are based on design rules and best practices for high-quality applications. The three recommendations selected will help improve healthcare outcomes throughout our facilities.


Leininger, S., Laux, L., McGonigal, M., & Shiner, D. (2021). Utilization of Institute for Health Care improvement tools to develop a mortality review process.  Critical Care Nursing Quarterly,  44(3), 301–308.

Lown, B. A. (2021). Translational, transformative compassion to support the healthcare workforce.  Journal of Healthcare Management,  66(4), 254–257.

Mohammad, U. G., Imtiaz, S., Shakya, M., Almadhor, A., & Anwar, F. (2022). An optimized feature selection method using ensemble classifiers in software defect prediction for healthcare systems.  Wireless Communications & Mobile Computing, 1–14.

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