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Impacts of Medication errors on 3-4-year-old Leukemia Patients

Submitted by

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

July 19, 2020

GRAND CANYON UNIVERSITY

Impacts of Medication Errors on 3-4-Year-Old Leukemia Patients

by

Bola Odusola-Stephen

Proposed

July 20, 2020

DPI PROJECT COMMITTEE:

Dr. Lisa Church, EdD, PhD, Manuscript Chair

Genevieve Onyirioha, RN, MSN, FNP, CMSRN, DNP, Committee Member

Table of Contents Chapter 2: 6 Literature Review 6 Introduction 6 Background 6 Theoretical foundations 8 Review of literature 10 Theme-1 Drug dispensation 10 Subtheme: 1 knowledge deficit 11 Subtheme 2: errors in written orders and formula conversations 11 Theme 2: Drug prescription 15 Subtheme1: errors associated with wrong prescription 16 Subtheme 2: errors associated with medical fillings 17 Theme 3: Parental administration and nurse administration 19 Subtheme1: Parental education on drug administration 19 Subtheme 2: error from ambulatory setting associated with lack of knowledge 22 Summary 28 References 29

Chapter 2: Literature Review

Introduction

Literature review will conduct views of scholarly article which will entail detail analysis of the information on medical administration errors in children between the ages of 3-4 years. The reviews will be formulated on the major areas of the PICOT question. Children aged 3-4 years have little power or control of their medication and are at great risk of encountering medial errors. The study subthemes will deal with drug prescription, parental administration and drug dispensation.

Background

Medication errors are the most common and the leading medical error in the United States. For a patient to appropriately receive the required treatment in a medical setting, there must be proper prescription of drugs, there is also the need for a pharmacist to effectively understand the doctors writing for them to be able to effectively prescribe the drugs. The nurses are also required to effectively administer the prescribed drugs (Khalek et al., 2015). Although various studies on in-patients show that the medical dispensing errors are also as common as those experienced in the in-patient setting. It is key to point out that in most of the inpatient settings, it is always the role of the patient or caregiver and rather than that of the healthcare professional. It for this reason to acknowledge the fact that potential for medication errors among the ambulatory patients is substantial. DNP- Direct Practice Improvement (DPI)

The major problem that has been identified with the medication errors for the young children that are undergoing chemotherapy and administered the leukemia drugs is of great significance (Mulatish, Dwiprahasto & Sutaryo, 2018). The leukemia drugs are by nature toxic and have low therapeutic windows and the results could be very disastrous when an error occurs during its administration. Most of the children under chemotherapy are enrolled in a specific treatment protocol (Neuss et al., 2017). This provides plenty of advantages for the health givers in that it enables them to easily identify, prescribe and avoid medical errors. With proper mechanics to effectively identify these errors, changes in the healthcare systems could help to reduce the medical errors while treatment children aged 3-4 years. It is also important to point out the fact that despite parents of children under outpatient oral chemotherapy could be properly administering the prescribed drugs, the number of required medication and complexity of dosing could be challenging for parents that have not undergone medical training.

Theoretical Foundations

A Complex Systems Theory: This addresses the hierarchical structure and the components within a system (Clancy, Effken & Pesut, 2008). The complex system’s theory will be applied to the children aged 3-4 years and suffering from leukemia and undergoing cancer treatment. The dynamic quality of patients together with the advances in science leading to changes in evidence-based practice, complex adaptive systems can best address the physiologic and psycho-social changes that could be experienced by the patient(Clancy, Effken & Pesut, 2008).Health care providers could adapt the complex systems theory or adaptive system while providing care for children with leukemia. The essential part of oncology care for children with leukemia spans from screening to provision of care. Any individual that transitions across the care continuum are identified as a risk assessment, detection, diagnosis and end- of life care (Mulatish, Dwiprahasto & Sutaryo, 2018). The process of assessing the effectiveness and shortcoming attributed to the provision of care can be challenging. The complex system helps establish effective communication between the patient care and recording of the patient data. Understanding and use of the complex systems theory can help to provide best practices in oncology care coordination and transitions while adapting science drive to improve patient outcomes (Clancy, Effken & Pesut, 2008).

Hope Theory is essential in promotion positive coping while offering treatment for children with leukemia. According to Snyder (1989) hope is a goal-directed thinking where people appraise their capability to produce workable routes to goals. Cancer survivors have shown that hope was positively associated with posttraumatic growth (Yuen, Ho, & Chan, 2014). Hope is related to adjustment, coping and social support for children with leukemia. Hope theory is a useful framework that provides clinicians with interventions for providing psychological adjustments for children with leukemia.

Review of Literature

Theme-1 Drug Dispensation

According to Mulatish, Dwiprahasto & Sutaryo (2018) the common medical errors when it comes to treatment of patients with leukemia comes in the administration phase of the medication delivery and during the drug-dispensing phase The major types of errors are attributed to the performance deficit, communication, knowledge deficit, errors in the written orders and medication delivery devices (Tumbelaka, Riono, Sastroasmoro, et al., 2014). The pediatric oncology is a high-risk area and could cause plenty of negative health effects if there is incompetence in personnel, management and lack of the supporting infrastructure. It is thus important of all patients receiving chemotherapy to be investigated.

Subtheme: 1 Knowledge Deficit

According to Phillips & Jones, (2014) there are plenty of exceptions that apply to the conversion formulas that are being used to calculate the medicinal dosage for the children. For example, standing orders for ibuprofen or acetaminophen to reduce fever. One has to determine the patient’s weight in kilograms and multiply by the suggested medication in milligrams per kilogram (Saxena et al., 2018). The unfortunate aspect is that errors could result when the clinicians or care giver calculates weights of patients that are over the 40 kg, the threshold at which to consider the adult dosage and standard pediatric dose conversion formula becomes less useful (Hallböök, Lidström & Pauksens, 2016).

Subtheme: 2 Errors in Written Orders and Formula Conversations Deficit

Errors can only be minimized if the clinicians are able to adjust the dosage according to the child’s illness and the overall medical condition which include the presence of diseases that affect the drug metabolism (Phillips, amp & Jones, (2014). For the safety of the children there is need to install systems that performs checks and balances to ensure the safety of children suffering from leukemia. This is identified as not being the case (Phillips, amp & Jones, 2014). In a survey that was conducted, by Hallböök, Lidström & Pauksens (2016), the findings were that about half of all the respondents indicated that pharmacists always recalculates the drug dose before filing an order to allow the issuance of the drugs to the children.

According to Pui et al., (2017) the technological advances which involves the use of the computerized physician order entry together with the decision support bar coding could help to minimize the medical administration errors among children age 3 to 4 years (Philips et al., 2014). The adoption of the clinical decision support software enables the clinicians to effectively reference information on medication and dosing parameters, potential drug interactions and known side effects to reduce the risk of fatalities associated with the medical errors among children. It can further help physicians while doing the order entry and help in determining of therapeutic medication dose based on the weight-based calculation and eliminate the human miscalculations. It further provides warning in instances where the dose could be larger or too small for the intended child reduce the harm that could befall the children’s (Lehmann et al., 2015). 

According to Weingart et al., (2018) almost all the pediatric medication requires the pediatrician to perform mathematical calculation something that could be complex. The most common calculations involve the use of fractions, percentages and decimals. While conducting the mathematical tests plenty of research have linked nurses to be poor performers in their mathematical skills (Vázquez-Cornejo et al., 2019).The inability to effectively come up with the best computational method and correct therapeutic volume drug dose could be fatal while treating children with leukemia something that has been linked as the major reason for medical errors. In most of the mathematical tests the new interns and nurses were found to possess poor mathematical skills with pharmacist’s poor computational. The research has indicated that the inability to conceptualize the correct mathematical calculation to be performed and the right mathematical process leading to the solution (Leihman et al., 2015). One of the major sources of error come in when a nurse first calculates the does and the volume to be given which is normally based on the concentration that is made available on the stock. Nurses are in many instances made to perform calculations that are needed in order to come up with the right medicine and lack of math skills needed to solve the problem could lead to fatal outcomes.

Most of the nursing staff do not understand how to apply the calculations in the clinical settings (Rivera‐Luna, 2014) Most of the nurses have not been able to use the calculations since school. While the studies involve physicians, nurses need to be able to effectively perform same calculation. In instances where they are unable to do so, they should not administer any medication. Any misplacement of a decimal point could result on dosing error which could lead to overdosing or under dosing among children with leukemia (Mueller, 2014). Some common consequences of such errors for children suffering with leukemia include transient renal failure, tachycardia, respiratory failure and cardiac arrest. Research points out that that dosage calculations for small children are hugely dependent on the use of decimal point in order to get the right results. Further research findings indicate that people that make tenfold calculation errors are more likely to cause other medication errors (Vázquez-Cornejo et al., 2019).

According to Mulatsih et al., (2015) there is a varying incidence of medical errors based on the study method and definition. Various studies have shown that most of the medical errors were found as result of wrong prescription and the incompetence among health workers. According to Mulatsih et al., (2016) nursing understanding of medical safety practice is good and continues to improve upon training and use of better reading and interpretation equipment’s. It further points out that despite having good knowledge on the patient safety, this knowledge is not quite enough when it comes to medical errors. The most common medical errors among leukemia patients between the ages of 3 and 11 years were found to result from the chemotherapy errors. Another error found was the roadmap error that was at 27 percent. Supportive care error is another, as well as timing errors, pharmacy errors and clerical errors were among the least causes of medical errors respectively. The errors that are associated with the roadmaps majorly were linked to the use of outdated, or incorrect roadmap, improper sequence of the therapy phase and the deviations of the drug administration from the one that had been scheduled.

Furthermore, the increased chances of the medical errors result from the use of multiple chemotherapy drug for a single patient. It is thus to use a tool that reflects the medical safety practice as a means to reduce medical errors associated with the treatment of the leukemia among children. The number of medical errors has been found to reduce significantly with health care providers adopting the post-intervention compared to the pre-intervention. With fever being the most common symptom among children receiving chemotherapy. The adoption of the simple medical safety program that are obtained from the findings of the local adverse drug events, people are able to reduce young patients’ harms associated with leukemia care. It is necessary to apply the medical safety practice guideline when ordering, dispensing, and transcribing, administering and the monitoring of young patients with leukemia in order to reduce the patients harm during treatment leading to a long-term outcome in patient safety. The limitation presented by the study conducted by Mulatish, Dwiprahasto & Sutaryo (2018) is that it was majorly based on a limited observation period. This necessitates for a periodical review on the implementation of the monitoring program and that other factors such as infection could contribute to bias that is related to the adverse drug events necessitating for the further investigation of the drug effects. DNP- Direct Practice Improvement (DPI)

Theme 2: Drug Prescription

Research indicates that medication error occurred majorly in nearly 10 percent of the chemotherapeutic agents prescribed that contained all the ambulatory setting. Research indicates that at least one of the errors occurs in 18.8 percent of the children. The further research findings indicated that one-sixth of the parents do not receive chemotherapeutic regimen indicated. Although a huge percentage of errors were found to relate to administration, there were lots of errors that are linked to prescription. Most of the errors in the prescription have been limited to the ones of clinical significance and are in most essence not linked to alter the probability of the survival. The research by Mulatish, Dwiprahasto & Sutaryo (2018) that children that failed to receive corticosteroid could increase the risk for recurrence and the patients with high instance of mercaptopurine despite having a history of previous neutropenia recorded an increased there was a significant increased risk of infection.

According to Khalek et al., (2015) there is little research on the multisite study errors that are associated with medication use for pediatric oncology patients. The research conducted showed that there was a variance on error rates with sites. The inconsistency depicted by the various sites indicates the actual difference in the detection of errors at home visit or medical record review. Millot, et al., (2014) point out the fact that the parent administration errors were mostly due to miscommunications that existed between the parents and clinicians or when it comes to the changing of children’s doses at home. The errors were linked to the fact that the frequent change of doses, caused the bottle labels to be outdated leading to major parental errors. Geng et al., (2015) point out that most of the errors occurred in the nonchemotherapy medication. This was linked to the fact that most of these children perform frequent visits to their oncologist and that they do not need to inquire more about the nonchemotherapy medication use.

Darlin et al., (2018) pointed out that with the error that was detected in their study, multiple support tools will be necessary to support errors that are associated with home medication use for children with cancer. The failure modes and analytical methods have for a long time been relied on to understand the medical error sources of oral chemotherapy use. Akyay et al, (2014) point out that some communication-based errors could be prevented through the adoption of the hospital around hand offs. The pharmacist case-management which involves technology could be adopted in a means to offer support to home medication use. DNP- Direct Practice Improvement (DPI)

Subtheme1: Errors Associated with Wrong Prescription

According to Geng et al., (2015). The medication errors that are associated with pediatric patients between the ages of the 3 and years presents plenty of paucity of data and thus difficult to place the results of the study in the proper contexts. The huge percentage of errors found in this scale are associated with the prescribing errors. Most common errors for children are associated with missing date, this is in addition to the huge percentage of errors that occur during the prescribing stage. The report indicates high rates, which will be much higher in pediatric patients with most of them accounting to 14 of the potential errors that were reported. Moreover, the analysis of comparing the dose versus the weight for selected medication showed that the rate of true errors among the drugs and the patients were much lower (Geng et al., 2015).

According to Mulatish, Dwiprahasto & Sutaryo (2018) medical safety practice is a safe procedure in the medication process. They point out that it is critical to investigate the medical safety practices among cancer children patients considering that they were found to the high risk. There are over 250,000 childhood cancer incidents annually with the highest incidences coming from developing countries. Most of the medical errors for cancer patients were found to be common among patients from developing countries and attributed to the lack of proper facilities and the nursing staff to effectively handle the patients. DNP- Direct Practice Improvement (DPI)

According to Schwappach, Pfeiffer, Taxis (2016) there has been improvement of pediatric management of cancer patients upon the improvement of technology equipment used to treat patients. Meanwhile, there has been increased mortality rates for children aged 3 to 11 years with research linked the increased rates to treatment toxicity. Other studies have also shown that the increased incidences of errors are linked to complex combinations and the chemotherapy. According to (Schwappach, Pfeiffer, Taxis (2016) that there is the need to understand the processes of the administration of chemotherapy to reduce the incidence of medical errors and risks that are attributed to the process. DNP- Direct Practice Improvement (DPI)

Subtheme 2: Errors Associated with Medical Fillings

According to (Schwappach, Pfeiffer, Taxis (2016) when it comes to chemotherapy transcribing aspects, various studies have shown that there have been a rise in the post-intervention especially in items such as height measures, body mass index, documenting of history of allergy, psychosocial status and chemotherapy planning. Research further indicates that a few aspects such as documenting of the chemotherapy regiment and planning did not meet 100 percent planning. It is key to point out that out of the 49 percent of the drugs ordering stage, 11 percent are done during transcription which is normally inclusive of the frequency, routes or times of deviation being included. There are some aspects of chemotherapy administering that have met 100 percent of the criteria for intervention for patients with leukemia. The post-intervention had the patient’s identity, drug name, drug dose, route of administration and the calculated dose. The study was in line with the previously conducted study which stated that approaching and institution by adopting a multi-discipline system helps to reduce medication errors while the conducting chemotherapy. It also was found that adherence to the drug labeled filings helped in increasing post intervention. DNP- Direct Practice Improvement (DPI)

According to Mulatish, Dwiprahasto & Sutaryo (2018) found that chemotherapy preparation by two different health workers that was independently carried out did not conform to the 100 percent standard something they attributed to the inadequate number of nurses compared to the number of patient that resulted in the lack of double checking of chemotherapy drugs. The study further found out that double checking of chemotherapy drugs that has two different independent nurses is a common thing and is believed to significantly reduce medication error among the leukemia and other cancer patients (Schwappach et al., 2016). Other research have also documented that drug verification among the nurses have over time reduced increasing the chances of medical errors among children. Most of the nurses fail to verify the drugs to check for the expiry dates and hence making the drug administration erroneous. It is key to avoid the medical error aspect considering that this medical error is common among 3 percent of medical errors for any patient regardless of age. DNP- Direct Practice Improvement (DPI)

The study by Mulatish, Dwiprahasto & Sutaryo (2018) found that chemotherapy monitoring had gotten better of post-intervention compared to pre-intervention. This is of great significance for children that are being administered with more than one drug and are less than five years of aged. These cohorts are majorly prone to chemotherapy medication error while administering. It is key to point out the fact that there is a huge difference when it comes to the documentation and assessment of patients suffering from leukemia. Further research has documented that 94 percent of medical errors that has a low harm potential and the sixty percent of the near-miss medication errors normally occur in the prescribing process. Kaush et al., 2010) points out that the most common cause of the medication errors during prescription normally occur in inappropriate abbreviations, dosing error and legality aspect. DNP- Direct Practice Improvement (DPI)

Theme 3: Parental Administration and Nurse Administration

Subtheme1: Parental Education on Drug Administration

According to Mulatish, Dwiprahasto & Sutaryo (2018) the process of the getting consent and family education is essential to increase post-intervention. In the study one aspect that was found not to escalate in post-intervention compared to the pre-intervention was family being given emergency number to be selected for chemotherapy drugs. This was majorly due to the unavailability of the emergency number on the informed consent form and form of family education related to the illness. The process of getting a consent after the provision of clear information given after provision of enough education is important in that communication is essential in the lowering of the medication errors (Schwappach, Pfeiffer & Taxis, 2016). DNP- Direct Practice Improvement (DPI)

According to Walsh et al., (2013) with the improvement of the medical care, most of the Americans are taking more of the medications at the homes than ever before. The number of the children that are taking their medication at home have increased in major drug classes. The major reasons for the rising trends in the home consumptions were attributed to the increasing use of the oral agents to treat patients with cancer, rise in the number of cancer survival rates, the rise in the number of children that are in need of ambulatory care and improvement in survival rates for children with the congenital anomalies. There is little research on the error rates that is present in the outpatient setting as a result of medications being administered by patients and their families (Walsh et al., 2013).

There is little research on the outpatient medical consumption at home. It is for this reason that there is little information or understanding on the manner in which medicines are used at home. Most of the studies have majorly relied on retrospective and large databases as a means to reduce the casualty and the risk factors. The medical records review only provide errors that were documented only on record. In studies it only relies on the errors that are reported by parents (Geng et al., 2015). Various research has pointed out this independence on parents’ error reports could at times be erroneous and thus cannot be relied upon. In other studies parents are asked to demonstrate proper dosing of home medication while being at the clinic. Some studies have pointed that the demonstrations that are being provided while at the facility are part of the entire process of home medication use and could be subjected to sampling bias. These studies point out that there is the need to investigate the spectrum errors associated with home medication use and also access the frequency, severity and target education as a means to come up with the most appropriate interventions to the problem (Khalek et al., 2015).

According to Oberoi, Trehan & Marwaha, (2014) the children that children aged between 3 and 4 years are at high risk of experiencing home medication errors. Research indicates that about 10 percent of the missed cancer doses are normally reported to have occurred from home which is a dangerous thing. Underdosing of cancer patients could lead to the fatal results. Walsh et al., (2013) conducted research to determine the types of medical errors that occur at homes for children with cancer. The study performed prospective study from which it was conducted in 3 sites which involved the reviewing of the medical records and bottle labels, and direct observed medication at home. The findings of the research showed that the medication errors for the children of the ages 3 and 4 with almost one in every two parents having been exposed to a medical error while offering treatment at home. In most of these errors the medical administration errors accounted for most of medical errors at home. The type of administration error where the parents administer the wrong dose or medication to the children. The injury rate that is associated to this error was high with the study showing that 4 parents out of the 100 experience high injuries as a result of wrong dose administration. DNP- Direct Practice Improvement (DPI)

According to Pui et al, (2018) in all the ways that the patients can be harmed during treatment, medication errors are identified as being the most common means and the most easily preventable. In instances where medication errors occur, the patients are at high risk of death than adults (Saxena et al., 2018). Evidence show that most of the medication errors do harm adult patient. There are over 100 undetected errors. The over 100 medication errors that were not detected are normally as a result of adverse drug event that normally leads to harm or death of the patient. Considering the number of inpatient medication orders that are written on daily basis, there is a high number of the pediatric medication errors that are likely to be staggering (Sheik et al., 2014).

With the current emergence of the research results, there is a great understanding of the impact of medical error on children. Several researchers have found that there are around 4 to 7 per 100 medication orders for children suffering with leukemia. Schmidt, (2019) point out that pediatric outpatients had three times the risk of developing the adverse drug reaction when compared to the adult outpatients. The risk is particularly high if in instances where the medication was used for an off-label indication something that is common among the pediatrics. Despite the study finding plenty of significant errors rates, further findings from other research indicates the frequency of pediatric medication errors from ambulatory settings are much greater. This is attributed to the fewer checks and balances that were put in place as means of preventing these errors.

Subtheme 2: Error from Ambulatory Setting Associated with Lack of Knowledge

According to Sulis et al., (2018) there is need to conduct further research for patient safety in the ambulatory care setting. This has been promoted by the lack of proper policy considering the unique vulnerabilities present in ambulatory settings that exposes the children to the risk death and harm from medical errors (Taverna et al., 2017). The risks to harm were attributed to the glaring lack of knowledge and reliance on ambulatory care something that is not present in the inpatient care (Taverna et al., 2016). Medication errors come in different forms, but they all do not result in the injury or death (Taylor et al., 2016). The medication errors could be defined as being preventable, and the improper use of eh medication could occur during any stage of administering the medication which include the ordering, dispensing, and monitoring. The adverse drug events could occur at any stage of the drug administration. DNP- Direct Practice Improvement (DPI)

According to Tremolada et al., (2015) there are different phases of care where medication errors are likely to be experienced in children. In pediatrics, the most common stage where problems could occur is the prescribing or ordering phase which is normally characterized by errors that come with dosing and the administering phase (Tremolada et al., 2016). Taylor et al., (2016) point out that when respondents to patient safety survey to identify the profession that is responsible for the patient safety a huge percentage of the individuals assigned the responsibility to nurses regardless of the factors that contributed to the error. It is thus the role of the nurse that are involved in delivery of care to ensure that they are well-informed on the care or patients and the medications they order.

According to Wang et al., (2017), nurses do play a significant role in the administration of the various medication when it comes to pediatric medication errors. The research points out the fact that despite most errors occur before administration of the drug, the medical errors that are not caught or intercepted by the nurses could be fatal for children living with leukemia (Zannini et al., 2014). The fact that nurses are the one that predominantly administer medications to patients, they are always the last barrier that is present between the mediation errors and the serious harm (Yeh et al., 2014). Nurses are the ones tasked with the responsibility of ensuring that young patients have received the right medication and the most appropriate time. They also have the responsibility of monitoring patients they were assigned to observe the adverse effects of the medication early in time to prevent injury or harm (Whitlow et al., 2015). DNP- Direct Practice Improvement (DPI)

The children aged 3 and 4 years are at greater risk of being victims of the medication errors. The medical errors could be fatal considering that they do not have an immature physiology and developmental limitations that can enable them to effectively communicate or self-administer medications as it relates to adults (Schwappach, Pfeiffer, Taxis et al., 2016). Another factor for being victims of medical errors is that most of the formulations for treating Leukemia are meant for adults. It thus means that in most of the instance’s pediatric indications and the dosage guidelines are not always contained in the medication (Mulatsih, Dwiprahasto & Sutaryo, 2018). The drugs are majorly in the form of formulations that are normally weight-based. This means that in order for any drug to be used by children, there is the issuance of safe dosages which are normally fractions of adult-based drugs which must also be calculated (Zang et al., 2014). DNP- Direct Practice Improvement (DPI)

According to Mulatsih, Dwiprahasto & Sutaryo, (2018) the process of determining the pediatric dosages is complex. The complexity is mostly because one uses the child weight. The children that take these types of medications are at high risk of being involved in the medication errors compared to the children that take medication that do not required any calculations. In instances of reduced calculations, the risk is decreased significantly (Wang et al., 2017). The risk is much higher if the children are in ICUs, the ones that are in EDs and if seriously ill between the 4 am and 8 am hours or the weekends, children whose weight have not been documented and the ones that are receiving IV medication.

Summary

There are of the practical steps that nurses can undertake in order to improve pediatric medication safer for patients with leukemia (Inaba et al., 2017). While many of the things would begin in a good way to start. Understanding of the near misses is the key to managing medication errors (Cooper & Brown, 2015). Various research has indicated that the total number of the reported medical errors are few and it is difficult to determine these medical errors in its actual sense. The situation is even worse for the children aged between 3 and 4 years. Furthermore, there are various underreport that if they fear reprisal or if they are uncertain of the definition of error. It is the role of the managers to ensure that the nurses among other health providers are not punished for the mistakes, that error is encouraged with the hiding mistakes is discouraged. DNP- Direct Practice Improvement (DPI)

The lack of knowledge on the kind of medication and how to administer it has been linked by several studies as the major reason for the rise in the medical errors. To effectively manage leukemia among the children aged 3 and 4, it is key for the nurses and the caregivers to have knowledge of the medication that is being administered for the child (Hunger & Mullighan, 2015). They need to understand the medication that is being used, whether the medication is appropriate for the child, the recommended therapeutic dosage range and how these patients could respond if there were adverse reactions (American Society of Hospital Pharmacists, 2018) In any instance where one is not concerned on the dosage, it is key to ask questions as a means to gain more insights to the patient’s interests (Reinhardt et al., 2019). The lack of information or knowledge on drugs being administered has been found to contribute to fifteen percent of medication administration errors among nurses that need to take advantage of pharmacists knowledge when in to preparing, administering and monitoring drug therapy (Hinojosa‐Amaya et al., 2016). DNP- Direct Practice Improvement (DPI)

In instances of medication is prescribed for an off-label use in a child, It important to check the suggested dosage and duration of treatment with a pharmacist, in areas where there appropriate references with the current edition of physician desk reference in a computerized drug order entry system. In instances where medication is prescribed in an off-label use, it could be difficult to find the correct dose (Maaskant et al. 2015). With the improvement of knowledge of the medication and plenty of medication increases, nurses continue to improve their knowledge on means to ensure medication errors. There is need to establish higher medication errors and nurses should be cautious when administering them and double-check any orders (Tuckuviene et al. 2016). DNP- Direct Practice Improvement (DPI)

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Lehmann CU, (2015); Council on Clinical Information Technology. Pediatric aspects of inpatient health information technology systems. Pediatrics. 2015;135(3). Available at: www.pediatrics.org/cgi/content/full/135/3/e756pmid:25713282

Lehmann CU, O’Connor KG, Shorte VA, Johnson TD (2015). Use of electronic health record systems by office-based pediatricians. Pediatrics. 2015;135(1). Available at: www.pediatrics.org/cgi/content/full/135/1/e7pmid:25548325

Lipitz-Snyderman A, Classen D, Pfister DG et al. (2017). Performance of a trigger tool for identifying adverse events in oncology. J Oncol Pract. 2017; 13: 223-230

Millot, F., Guilhot, J., Baruchel, A., Petit, A., Bertrand, Y., Mazingue, F., . . . Cayuela, J. (2014). Impact of early molecular response in children with chronic myeloid leukemia treated in the French glivec phase 4 study. Blood, 124(15), 2408-2410. doi:10.1182/blood-2014-05-578567

Maaskant JM, Vermeulen H, Apampa B, et al. (2015). Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev.;(3):CD006208

Mulatsih S, Dwiprahasto I, Soetaryo (2016). Pemahaman perawat mengenai medication errors di Bangsal Perawatan Kanker Anak RSUP Dr. Sardjito. Indonesian J Cancer. 9:111–7.

Mulatsih S, Dwiprahasto I, Soetaryo Pemahaman perawat mengenai medication safety practice di Bangsal. Sari Pediatri. 2016;17:463–8

Mueller BU. (2014). Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61:966‐969.

Murphy, B. R., Roth, M., Kolb, E. A., Alonzo, T., Gerbing, R., & Wells, R. J. (2019). Development of acute lymphoblastic leukemia following treatment for acute myeloid leukemia in children with Down syndrome: A case report and retrospective review of Children's Oncology Group acute myeloid leukemia trials. Pediatric blood & cancer, e27700.

Neuss, M. N., Gilmore, T. R., Belderson, K. M., Billett, A. L., Conti-Kalchik, T., Harvey, B. E. … & Olsen, M. (2016). 2016 updated the American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology. Journal of oncology practice, 12(12), 1262-1271

Oberoi S, Trehan A, Marwaha RK. (2014).  Medication errors on oral chemotherapy in children with acute lymphblastic leukemia in a developing country. Pediatr Blood Cancer.; 61(12): 2218‐ 2222.

Padmini, C., & Bai, K. Y. (2014). Oral and dental considerations in a pediatric leukemia patient. ISRN hematology, 2014.

Pui, C., Pei, D., Raimondi, S. C., Coustan-Smith, E., Jeha, S., Cheng, C., . . . Campana, D. (2016). Clinical impact of minimal residual disease in children with different subtypes of acute lymphoblastic leukemia treated with response-adapted therapy. Leukemia, 31(2), 333-339. doi:10.1038/leu.2016.234

Phillips, F., & Jones, B. L. (2014). Understanding the lived experience of Latino adolescent and young adult survivors of childhood cancer. Journal of cancer survivorship, 8(1), 39 48.

Preacher K. J. Hayes A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891.

Reinhardt H, Otte P, Eggleton AG, et al. (2019). Avoiding chemotherapy prescribing errors: analysis and innovative strategies. Cancer. 125(9):1547‐1557.

Rivera‐Luna R, Shalkow‐Klincovstein J, Velasco‐Hidalgo L, et al. (2014). Descriptive epidemiology in Mexican children with cancer under an open national public health insurance program. BMC Cancer. 2014;14:790.

Saxena, A., Jain, G., & Gupta, R. (2018). Comment on: Effectiveness of antibacterial prophylaxis during induction chemotherapy in children with acute lymphoblastic leukemia. Pediatric blood & cancer, 65(8), e27044.Seif, A. E.,

Schmidt, C. W. P. (2019). Administration of a Pediatric Oncologic Pharmacy: From the Purchase of the Drugs to the Dispensation. In Pediatric Oncologic Pharmacy (pp. 107-116). Springer, Cham.

Schwappach, D. L. B., Pfeiffer, Y., & Taxis, K. (2016). Medication double-checking procedures in clinical practice: A cross-sectional survey of oncology nurses’ experiences. BMJ Open, 6(6), e011394. doi:10.1136/bmjopen-2016-011394

Sheikh, H. I., Joanisse, M. F., Mackrell, S. M., Kryski, K. R., Smith, H. J., Singh, S. M., & Hayden, E. P. (2014). Links between white matter microstructure and cortisol reactivity to stress in early childhood: Evidence for moderation by parenting. NeuroImage Clinical, 6(C), 77-85. doi:10.1016/j.nicl.2014.08.013

Snyder C. R. (1989). Reality negotiation: From excuses to hope and beyond. Journal of Social and Clinical Psychology, 8, 130–157.

Society of Pediatric Hematology and Oncology (NOPHO) study. J Thromb Haemost.;14(3):485‐494

Sulis, M. L., Blonquist, T. M., Stevenson, K. E., Hunt, S. K., Kay‐Green, S., Athale, U. H., …& Leclerc, J. M. (2018). Effectiveness of antibacterial prophylaxis during induction chemotherapy in children with acute lymphoblastic leukemia. Pediatric blood & cancer, 65(5), e26952.

Taverna, L., Tremolada, M., Bonichini, S., Tosetto, B., Basso, G., Messina, C., & Pillon, M. (2017). Motor skill delays in pre-school children with leukemia one year after treatment: Hematopoietic stem cell transplantation therapy as an important risk factor. PloS One, 12(10), e0186787. doi:10.1371/journal.pone.0186787

Taverna, L., Tremolada, M., Bonichini, S., Basso, G., & Pillon, M. (2016). Adaptive functioning of preschooler children with leukemia post 1 year of therapies compared with sane peers. British Journal of Education, Society & Behavioural Science, 18(4), 1-15. doi:10.9734/BJESBS/2016/30322

Taylor, J. A., Winter, L., Geyer, L. J., & Hawkins, D. S. (2006). Oral outpatient chemotherapy medication errors in children with acute lymphoblastic Leukemia. Cancer, 107(6), 1400- 1406. Retrieved from https://acsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/cncr.22131

Toft, N., Bergen, H., Abrahamsson, J., Griškevičius, L., Hallböök, H., Heyman, M., … & Quist- Paulsen, P. (2018). Results of NOPHO ALL2008 treatment for patients aged 1–45 years with acute lymphoblastic leukemia. Leukemia, 32(3), 606.

Tremolada, M., Bonichini, S., Basso, G., & Pillon, M. (2015). Coping with pain in children with leukemia. International Journal of Cancer Research and Prevention, 8(4), 451.

Tremolada, M., Bonichini, S., Basso, G., & Pillon, M. (2016). Post-traumatic stress in parents of children with leukemia: Methodological and clinical considerations. Comprehensive Guide to Post-Traumatic Stress Disorders, 579- 597.

Tuckuviene R, Ranta S, and Albertsen BK, et al. (2016). Prospective study of thromboembolism in 1038 children with acute lymphoblastic leukemia: a Nordic

Tumbelaka AR, Riono P, Sastroasmoro S, et al. (2014) Pemilihan uji hipotesis. In: Sastroasmoro S, Ismael S, editors. ‘Dasar-dasar Metodologi Penelitian Klinis’. Jakarta: Sagung Seto; 2014.

Vázquez‐Cornejo, E., Morales‐Ríos, O., Juárez‐Villegas, L. E., Islas Ortega, E. J., Vázquez‐Estupiñán, F., &Garduño‐Espinosa, J. (2019). Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico. Cancer medicine, 8(13), 5979-5987. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1002/cam4.2438

Walker, D. M., Li,Y., Huang, Y. S. V., Kavcic,M., Torp, K., … & Aplenc, R. (2015). Dexrazoxane exposure and risk of secondary acute myeloid leukemia in pediatric oncology patients. Pediatric blood & cancer, 62(4), 704-709.

Walsh, K. E., Dodd, K. S., Seetharaman, K., Roblin, D. W., Herrinton, L. J., Von Worley, A., … &Gurwitz, J. H. (2009). Medication errors among adults and children with cancer in the outpatient setting. Journal of Clinical Oncology, 27(6), 891-896. Retrieved from https://www.academia.edu/download/39833209/891.pdf

Walsh, K. E., Roblin, D. W., Weingart, S. N., Houlahan, K. E., Degar, B., Billett, A… & Mazor, K. M. (2013). Medication errors in the home: a multisite study of children with cancer. Pediatrics, 131(5), e1405-e1414. Retrieved from https://pediatrics.aappublications.org/content/131/5/e1405.short

Walsh, K., Ryan, J., Daraiseh, N., & Pai, A. (2016). Errors and nonadherence in pediatric oral chemotherapy use. Oncology, 91(4), 231-236. Retrieved from https://www.karger.com/Article/Abstract/447700

Wang, Y., Liu, Q., Yu, J., Wang, H., Gao, L., Dai, Y., . . . Yu, J. (2017). Perceptions of parents and paediatricians on pain induced by bone marrow aspiration and lumbar puncture among children with acute leukaemia: A qualitative study in china. BMJ Open, 7(9), e015727. doi:10.1136/bmjopen-2016-015727

Weingart, S. N., Zhang, L., Sweeney, M., & Hassett, M. (2018). Chemotherapy medication errors. The Lancet Oncology, 19(4), e191-e199. doi:10.1016/s1470-2045(18)30094-9

Whitlow, P. G., Saboda, K., Roe, D. J., Bazzell, S., & Wilson, C. (2015). Topical analgesia treats pain and decreases propofol use during lumbar punctures in a randomized pediatric leukemia trial. Pediatric blood & cancer, 62(1), 85-90.

Yeh, T. C., Liu, H. C., Hou, J. Y., Chen, K. H., Huang, T. H., Chang, C. Y., & Liang, D. C. (2014). Severe infections in children with acute leukemia undergoing intensive chemotherapy can successfully be prevented by ciprofloxacin, voriconazole, or micafungin prophylaxis. Cancer, 120(8), 1255- 1262.

Yuen A. N. Ho S. M. Chan C. K. (2014). The mediating roles of cancer-related rumination in the relationship between dispositional hope and psychological outcomes among childhood cancer survivors. Psychooncology, 23, 412–419. doi: 10.1002/pon.3433

Zannini, L., Cattaneo, C., Jankovic, M., & Masera, G. (2014). Surviving childhood Leukemia in a Latin culture: An explorative study based on young adults’ written narratives. Journal of psychosocial oncology, 32(5), 576-601.

Zhang, F. F., Rodday, A. M., Kelly, M. J., Must, A., MacPherson, C., Roberts, S. B., … K. (2014). Predictors of being overweight or obese in survivors of pediatric acute lymphoblastic leukemia (ALL). Pediatric blood & cancer, 61(7), 1263-1269.

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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. DNP- Direct Practice Improvement

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

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NU560 Unit 7 Presentation

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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. NU560-8D-Unit 6 Assignment EBP

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• Multiple answer questions

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

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Discussion: Developing a Culture of Evidence-Based Practice

As your EBP skills grow, you may be called upon to share your expertise with others. While EBP practice is often conducted with unique outcomes in mind, EBP practitioners who share their results can both add to the general body of knowledge and serve as an advocate for the application of EBP.

In this Discussion, you will explore strategies for disseminating EBP within your organization, community, or industry.

To Prepare:

· Review the Resources and reflect on the various strategies presented throughout the course that may be helpful in disseminating effective and widely cited EBP.

·. Explain which dissemination strategies you would be least inclined to use and explain why. Identify at least two barriers you might encounter when using the dissemination strategies you are most inclined to use. Be specific and provide examples. Explain how you might overcome the barriers you identified. Module 06 Wk11 Discussion: Developing a Culture of EBP

Rubric Detail

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Name: NURS_6052_Module06_Week10_Discussion_Rubric

Name: NURS_6052_Module06_Week10_Discussion_Rubric

Assignment: Evidence-Based Capstone Project, Part 6: Disseminating Results

The dissemination of EBP results serves multiple important roles. Sharing results makes the case for your decisions. It also adds to the body of knowledge, which creates opportunities for future practitioners. By presenting results, you also become an advocate for EBP, creating a culture within your organization or beyond that informs, educates, and promotes the effective use of EBP. Module 06 Wk11 Discussion: Developing a Culture of EBP

To Prepare:

·.

To Complete:

Create a 5-minute, 5- to 6-slide narrated PowerPoint presentation of your Evidence-Based Project.

·.

By Day 5 of Week 11

Submit Part 6, your revised PowerPoint presentation of your Evidence-Based Project.

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6052_Module06_Week11_Assignment_Rubric

Name: NURS_6052_Module06_Week11_Assignment_Rubric

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – Week 11 Discussion: Developing a Culture of EBP

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. Week 11 Discussion: Developing a Culture of EBP

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. Week 11 Discussion: Developing a Culture of EBP

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Week 11 Discussion: Developing a Culture of EBP

• Guarantee

• Zero Plagiarism
• On-time delivery
• A-Grade Papers
• Free Revision
• 24/7 Support
• 100% Confidentiality
• Professional Writers

• Services Offered

• Custom paper writing
• Question and answers
• Essay paper writing
• Editing and proofreading
• Plagiarism removal services
• Multiple answer questions

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. Week 11 Discussion: Developing a Culture of EBP

Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper

Template Explanation on the Direct Practice Improvement (DPI) Project

Proposal and the DPI Final Manuscript Template (all-in-one)

This template is used for both the DPI Project Proposal as well as the Final Manuscript.

You are required to refer to yourself as the Primary Investigator throughout the proposal and final manuscript. It is preferred that you write your manuscript in the third person, but when necessary, you must refer to yourself as the Primary Investigator.

In your proposal, you will write in the future tense (present tense, i.e., the purpose of this quantitative quasi-experimental project is to…). In contrast, in the final manuscript , you will write in the past tense (the purpose of this quantitative quasi-experimental project was to… as now you have implemented your project)

In DNP 955, you will be writing chapters 1-3 which also includes your 10-Strategic Points as an appendix. The learner is required to submit to AQR-1 by the due date week 8 (or you will not pass the course) with your manuscript in the present (future tense). In addition, in DNP 955, the appendices are as follows:

· Appendix A is your 10 Strategic Points – REQUIRED

· Appendix B is your instrument/tools -REQUIRED (if your project includes the use of an instrument/Tool)

· Appendix C is your permission to use your instrument/tools -REQUIRED (if your project includes the use of an instrument)

· Appendix D is a detailed process you as the learner will use to prepare staff/health care providers to implement the practice improvement intervention. This should include specific information obtained from the literature and from developers of the evidence-based practice guideline, protocol, toolkit, or screening tool, etc. An agenda may be included as well as an outline of materials to be used, delivery method, handouts, ppts., when, & where. Remember when you submit to AQR-1, you will include your completed cover page, abstract, TOC, chapters 1-3, and your appendices in the current APA edition.

DO NOT DELETE CHAPTERS 4 AND 5 FROM THE PAPER OR YOU WILL LOSE THE FORMATTING. THE REVIEWERS ARE AWARE THEY WILL BE INCLUDED BUT ARE NOT GOING TO BE REVIEWED DURING AQR-1.

In DNP 960, you are required to make all recommended changes listed within your AQR-1 review for chapters 1-3. This is not optional; failure to do so may result in a failing grade for DNP-960. Address all comments in the 10-Strategic Points. All edits from your AQR-1 revisions are to remain in the present (future tense) until you have received the written GCU DNP IRB Outcome Letter (typically between weeks 3-7). After you have begun implementation, you may start to write in the past tense for all 5 chapters. While waiting for the outcome letter, it is expected that all learners will write chapters 4 (including tables and figures) and 5 as a draft in preparation for the data they will be collecting in implementation. DNP-DPI Project- Quality Improvement

In DNP 965, all writing in the manuscript is written in the past tense (as long as you have received the GCU DNP IRB Outcome Letter. Submission to AQR-2 occurs at the end of week 5 in DNP 965 (required to progress to final manuscript review, no AQR- 2= continuation course).

In this AQR-2 submission, you will submit all five chapters with the actual data (not the made update from DNP-960) along with your cover page, copywrite page, title page, abstract (paragraph form), TOC (updateable), the body of the manuscript, and all applicable appendices:

· Appendix A GCU IRB Outcome Letter

· Appendix B is your instrument/tools -REQUIRED (if your project includes the use of an instrument/Tool)

· Appendix C is your permission to use your instrument/tools -REQUIRED (if your project includes the use of an instrument)

· Appendix D is a detailed process you as the learner will use to prepare staff/health care providers to implement the practice improvement intervention. This should include specific information obtained from the literature and from developers of the evidence-based practice guideline, protocol, toolkit, or screening tool, etc. An agenda may be included as well as an outline of materials to be used, delivery method, handouts, ppts., when, & where.

· No other appendices are needed unless you have multiple tools (which is not recommended).

*Please make certain that you have used programs such as Grammarly (check into investing in Grammarly Premium), ThinkingStorm (GCU), an editor, a formatter, statistician, and any additional resources you feel like you need to be successful before you submit to AQR-2 and most importantly, before final manuscript review.

Feel free to contact the AQR Manager for any questions or concerns related specifically to AQR-1 or AQR-2. Meet regularly with your Chair, mentor, and/or content expert to ensure that your manuscript meets all requirements, deadlines, and revisions. Your DNP faculty, Chairs, and Program Lead want you to be successful and are here to support you each step of the way! Please use your University Policy Handbook on your chain of command and any appeal you feel you might need.

Blessed are those who have learned to acclaim you, who walk in the light of your presence, O Lord. – Psalm 89:15

Submitted by

Insert Your Full Legal Name (No Titles, Degrees, or Academic Credentials) Comment by Author: For example: Jane Elizabeth Smith

Equal Spacing Comment by Author: Delete yellow highlighted “Helps” as project develops.

~2.0” –

(7 lines)

A Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Nursing Practice

Equal Spacing

~2.0” –

(7 lines)

Grand Canyon University

Phoenix, Arizona

[Insert Current Date]

© by Your Full Legal Name (No Titles, Degrees, or Academic Credentials), 2020 Comment by Author: NOTE: The copyright page is included in the final practice improvement project. Comment by Author: For example: © by Jane Elizabeth Smith, 2012 This page is centered. This page is counted, not numbered and should not appear in the Table of Contents.

All rights reserved.

GRAND CANYON UNIVERSITY

The Direct Practice Improvement Project Title Appears in Title Case and is Centered Comment by Author: If the title is longer than one line, double-space it. The title should be typed in upper and lowercase letters.

by

Insert Your Full Legal Name (No Titles, Degrees, or Academic Credentials) Comment by Author: For example: Jane Elizabeth Smith

has been approved

September 22, 2020 Comment by Author: Date of Dean’s signature. Until then, use the current date to fill this space. Upon final submission, this date should match the date on the title page.

APPROVED:

Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Chairperson

Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Mentor

Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Content Expert

ACCEPTED AND SIGNED:

________________________________________

Lisa Smith, PhD, RN, CNE

Dean and Professor, College of Nursing and Health Care Professions

_________________________________________

Date

Abstract Comment by Author: On the first line of the page, center the word “Abstract” (boldface font, italics, underlining, or quotation marks). Beginning with the next line, write the abstract. Abstract text is one paragraph with no indentation and is double-spaced. This page is counted, not numbered, and does not appear in the Table of Contents. Abstracts do not include references or citations. The abstract should be one page Comment by Author: Comment by Author: You will notice a difference between the proposal template and final manuscript template. The final template allows the option to remove headers if you need more room.

The first sentence or two outlines the problem; why is this being addressed? Do not make statements that require a citation as there are no citations in an abstract! The second statement is the supporting what is happening at the site. The purpose of this quantitative quasi-experimental project was to determine if or to what degree the implementation of _________________ (intervention) would impact ______________(what) when compared to current practice among ___________(population) in a ________ (setting i.e.: primary care clinic, ER, OR) in ________ (state) over four-weeks. State the nursing model/theory and other frameworks used in ONE SENTENCE! Data analysis and the sample size is next Now you want to state how the results were statistically and clinically significant. How did these results impact patient outcomes impact the practice at the site and recommendations for what should be done in the future based on the project findings Comment by Author: See the DC Network, Templated Abstract in writing resources Comment by Author: Whose intervenstion? Example: Sutter’s Oral Hygeine Tool or the Institute of Medicinxes XYZ tool.

Comment by Author: this is your measurable PATIENT outcome. Comment by Author: Make sure you take this statement and replace it throughout the manuscript to ensure it matches everywhere you discuss the purpose 🙂 From this statement you will need to make certain that the problem statement and clinical questions match (align) with this statement as well. Comment by Author: – DO NOT SAY p> 0.05 or p<0.05 Must say p= VALUE (EXAMPLE: Data on the motivation to quit was measured by TTM and nicotine dependence was measured by the Fagerstrom Test for Nicotine Dependence (FTND) questionnaire in diabetic adult smokers aged 18 years and older, (n=16) were compared at baseline, two weeks, and four weeks post-implementation of the Five A’s model.

A paired t-test showed that there was a statistically significant improvement in patient’s motivation to quit smoking (M=-2.86; SD=1.29; p=0.003), a substantial decrease in nicotine dependence (M= -1.86; SD=1.41; p=0.001), and 100% of the healthcare providers (n=6) were compliant in assessing tobacco use p=0.000). Comment by Author: (Based on the results, the Five A’s model may result in increased patient motivation to quit smoking as well as a decrease in nicotine dependence. Recommendations include the continuation of the program and possible repetition of the project at another clinical site over an extended monitoring period as well as with larger sample sizes.) or maybe if there was no significance (Even though statistical significance was not found STATS, the INTERVENTION provided needed areas for reinforcement measurement and enhanced nursing staff awareness. Therefore, the findings suggest that continuous utilization of INTERVENTION may DO WHAT to IMPROVE WHAT. Replication of the project is needed in larger settings and over a longer period of time.)

Keywords: Abstract, theory, theorists, tools, instruments, assist future investigators, vital information Comment by Author: Make sure to add the keywords at the bottom of the abstract to assist future investigators.

Comment by Author: Make sure to add the keywords at the bottom of the abstract to assist future investigators. Librarians and investigators use the keywords to catalogue and locate vital research material.

Dedication Comment by Author: Title in bold font

An optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. It is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the ¶Show/Hide button (go to the Home tab and then to the Paragraph toolbar). DNP-DPI Project- Quality Improvement

26

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Comment by Author: Bola, please use the updated DPI template that I shared with you previously. There are specific things within the template that are required. Your cover pages for example needs to follow the template.

Submitted by

Bola Odusola-Stephen

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

January 30, 2021

GRAND CANYON UNIVERSITY

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings

by

Bola Odusola-Stephen

Proposed

January 30, 2021

DPI PROJECT COMMITTEE:

Mary Guhwe, DNP, Manuscript Chair

Bamidele Jokodola, DNP, Committee Member

Abstract

Home healthcare programs have been effective in the current environment as they provide a technique for improving health outcomes for diabetes patients. At the project site, although staff consistently assesses for patient medication adherence, there is no standardized process for addressing medication adherence when it is identified. Medication adherence project (MAP) resources have been utilized to improve medication adherence in chronic disease management. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of Medication Adherence Project resources that include the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Padimpact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64, at a home healthcare organization located in urban Texas. The theoretical frameworks guiding the project include ………….This paper shall assess the program in line with various articles that promote adoption of the technique. The peer reviewed journal articles would ensure the paper has factual information that ensure implementation of the home healthcare program would occur seamlessly. The inclusion of home healthcare providers promotes the validity of the program. Medication adherence rates will be abstracted from the EHR based on documentation from home health personnel and compared with baseline medication adherence rates.The project would use the proposed initiatives to enhance home healthcare provision based on the need to improve health departments. The project shall assess the validity of the proposed home healthcare initiative based on the availability of trained personnel to monitor patient outcomes. The methodology that shall get applied is using quantitate approach by studying various research articles about diabetes and home-based care. The quantitative approach shall get applied to determine how the proposed MAP resources would promote patient outcomes. The population size for the project shall be persons living with Diabetes in Texas. It shall be possible to enhance the project’s outcome based on the metrics mentioned. DNP-DPI Project- Quality Improvement

Keywords: home-based care, MAP resources, quantitative approach, medication adherence, diabetes mellitus type II.

Chapter 1: Introduction to the Project

According to the CDC (2020) diabetes impacts one in 10 Americans. Furthermore, the prevalence of diabetes continues to rise and is projected to increase by 0.3 % per year until 2030 (Lin et al., 2018). There are two types of diabetes that plague a large proportion of Americans. Type I diabetes is dependent on insulin whereby the pancreas produces little amounts of insulin (Bellou, 2018). Type II diabetes is impairment related to the body’s ability to regulated glucose (Bellou, 2018). There are ways to curtail the onset of Type II diabetes; however, once individuals are diagnosed with diabetes, there is no cure (Kvarnström, 2017). DNP-DPI Project- Quality Improvement

Among individuals with Type II diabetes, proper and effective medication adherence is critical (Kvarnström, 2017). According to the World Health Organization (2003), “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvements in specific medication treatment.” Furthermore, Kvarnström (2017) stated that more than half of the population does not adhere to the prescribed medication regiment, thereby resulting in various health-related challenges. Health-related challenges associated with poor medication adherence include limited knowledge of patients, lack of proper technique of providing dosage, lac of patient self-management, and lifestyle constraints (Kvarnström, 2017). For individuals with Type II diabetes, lacking medication adherence can mean the difference between life and death (Rathish, 2019). DNP-DPI Project- Quality Improvement

Various researchers have denoted the critical role that home healthcare providers play in promoting enhanced medication adherence (Bussell et al., 2017). Furthermore, the World Health Organization (WHO), as cited by Brown and Bussell (2011), explained that there are five factors that impact medication adherence, which include: (1) patient-related factors, (2) socioeconomic factors, (3) therapy-related factors, (4) condition-related factors, and (5) the health system/health care team-related factors. For the purpose of this project, the project investigator (PI) will explore focus on the role that health care team members play in addressing patient related factors that affect medication adherence enhancing medication adherence among home health care diabetic patients.

Background of the Project

Home-based healthcare has existed since 1909 (Choi et al., 2019). Since its inception, home-based healthcare has been perceived as a more costly method of patient care as compared to expenses associated with hospitalization (Singletary, 2019). In the early 20th century, home-based healthcare was mainly practiced due to financial disparities, specifically since many individuals were unable to afford hospitalized care. Furthermore, home-based healthcare was also practiced due to medical inaccessibility, which often existed in African-American communities to due to limited access to resources (Choi et al., 2019).

Present day, home-based healthcare is often selected due to an individual’s personal preferences. There are some situations in which individuals prefer the comforts of their own home as compared to that of a hospital or group home. As older generations continue to age, they often prefer to remain in their home for as long as possible. Given the needs of older generations and the impact of advances in healthcare and technology, home-based healthcare has grown exponentially (Wong et al., 2020). While home-based healthcare is not appropriate for all patients, Szanton et al. (2016) noted that this care option is best when an individual’s condition can be managed without admission to a hospital. Patients who have diabetes and/or hypertension are often recipients of home-based healthcare (Wong et al., 2020). DNP-DPI Project- Quality Improvement

Home healthcare providers often visit patients three and engage in assessment of the patient’s blood pressure, cognitive functioning, and adherence to treatment proposals. During patient visits, home healthcare providers are responsible for biological assessment of patients (Wong et al., 2020). One of the paramount functions of home healthcare providers is to ensure that patients are adhering to their medication regiment (Wong et al., 2020). According to Wong et al. (2020), medication adherence is predicated on medication understanding and education, which should be conveyed by home healthcare providers (Wong et al., 2020).

Adhering to diabetes medication regiment requirements can be complex. In fact, in a study by Rauofi et al., (2018), researchers noted that 0.1 % of diabetic patients did not properly monitor their glucose levels nor did they adhere to medication requirements. Dr. Goldbach, who is the Chief Medical Officer for Health Dialogue, stated, “Especially for people with chronic illness that are facing challenges like depression, or transportation, or complexity of medication regimens – that these interpersonal, trusted interactions with a nurse tend to be very effective” (Heath, 2019). Patients with diabetes often express difficulties in adhering to medication regimens, thereby reinforcing the critical role of receiving education from home healthcare providers (Wong et al., 2020).

In a study by Wong et al. (2020), home healthcare patients expressed that they did not have sufficient knowledge about the requirements associated with diabetes treatment. Often times, diabetic home healthcare patients fail to practice medication adherence, thereby resulting in health complications, which is due to unmanaged health conditions. DNP-DPI Project- Quality Improvement.

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• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. DNP-DPI Project- Quality Improvement

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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