NURS FPX 4035 Assessment 3 Improvement Plan In-Service

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NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Student name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Professor Name

Submission Date

Slide: 1

Improvement Plan In-Service Presentation

Hi, I am ________. Alarm fatigue in the high-acuity set-up occurs due to desensitization of the caregivers to the continuous false or non-urgent infection alerts, which can lead to life-threatening occurrences.

Slide: 2

The case of Mr. James Carter, whose ventricular tachycardia alarm sounded but was ignored by the doctor because of the constant background noise, demonstrates that certain measures should be taken. In addition, they have discovered that the primary source of caregiver overload to ICU alarms and consequent delay in responding to an alarm is caused by false and clinically insignificant alarms (Nguyen et al., 2025).

The assessment below will provide a detailed improvement plan for in-service that would encompass evidence-based methods, interprofessional collaboration, and smart technologies for alarms. It is supposed to devise and justify the redesign of the education curriculum and system that can control the problem of alarm fatigue, implement proper rapid triage, and prevent such sentinel events in the future.

Slide: 3

Agenda and Outcome

Agenda

It will start with a short presentation of the physiology of alarm fatigue and the hazards of this condition, and then will examine actual alarm-log data at the ICU to show why non-actionable alerts are so widespread. The journey will be to review the cases under the guidance of the participant to train various distinctions between high-urgency and low-priority alarms, with the emphasis on their effect on patient safety (Bruder et al., 2021). That will be preceded by work training on the procedure of setting such personified alarm limits and smart-alarm filter format on bedside monitors.

The teams will then have a short rest period, where rotating in stations with simulations will be performed: the utilization of rapid-response drills and rapid-response communication exercises with the application of the Situation-Background-Assessment-Recommendation (SBAR) technique. It concludes the agenda by conducting a debrief through facilitation to come up with the lessons learned and recommendations that might come to mind on how the policy should be improved to avoid the delayed response of VT in the case of Mr. James Carter.

Outcome

Upon the conclusion of the in-service, every participant will know how to classify alarms by urgency correctly and be able to set personalized threshold settings properly. The employees will succeed in simulation training with the reported improvement in the response time, showing a minimum of 40 percent reduction in the delay of critical alarms (Yang et al., 2024). The team will also work out a draft escalation plan and automatic secondary alerts on a high-priority action when it fails to be responded to.

The participants will also make an oath to follow the non-punitive reporting process and to perform regular audits of the failed health care journeys with the use of the alarm-log dashboards, which would assist in the continuous improvement process. Lastly, such results are aimed at ensuring that a VT case like that of Mr. Carter will result in a coordinated action that will save their lives rather than lose them in the peripheries.

Slide: 4

Safety Improvement Plan

Purpose

The idea of the in-service session about alarm fatigue is to change the mindset of the ICU personnel, who do not react to each sounding alarm but instead manage it as a part of the patient safety policy and prioritize it. Having identified the factors that lead to desensitization (cognitive overload, recurrent false or alarm non-urgencies), the session sheds light on how alarm fatigue takes place and why it has to be addressed as a systemic problem instead of blaming it on individual caregivers (Colquhoun et al., 2021).

The interactive features of the use of the well-founded alarm-log information and brief interaction of scenarios reinforce the relationship between alarm management steps and clinical outcome. Lastly, the proposed training is geared towards ensuring that all the team members are able to read the key cues and implement remedial action within time, and that is the absence of a delayed response that caused the hypoxic injury to Mr. James Carter.

Slide 5: Goals

The former is to improve clinical awareness and triage of alarms through educating the staff to differentiate between life-threatening and non-actionable notifications by using guided practice and case studies. The second goal is to have a standardized setting of individual alarm limits and the escalation route, whereby all the monitors of patients will be adjusted according to their clinical condition, and the unrecognized critical alarms will automatically alert the backup responders (Sangari et al., 2023).

The third one is to cultivate a culture of continuous reporting and quality enhancement by encouraging non-punitive reporting of near misses, frequent evaluation of alarm indicators, and gradual adjustment of alarm settings. The following achievement would assist in eliminating the elements that did not perform well in the case of Mr. Carter, where the setting of alarms in a generic manner and the inability to escalate caused a case of ventricular tachycardia, which went undiagnosed.

Implementing Evidence-Based Strategies

The first step is to install intelligent alarm technology, which will block non-actionable alerts and leave only unusual signals corresponding to critical situations, which will reduce the total number of alarms and prevent desensitization. Every quarter, a high-fidelity simulation exercise with rapid triage and escalation, process, and smooth teamwork will be introduced to practice circumstances (Fleishman et al., 2021).

Efficient and efficient reporting of critical events is ensured in the case of handovers and alarm-notification protocols when the SBAR (Situation-Background-Assessment-Recommendation) framework is involved. The safety net Mr. Carter needed would have been the introduction of these evidence-based prevention measures in the daily practice, whereby his ventricular tachycardia alarm would have resulted in an on-the-spot concerted measure that would have prevented further hypoxic tissue damage.

Slide: 6

Explaining the Need for and Process to Improve Safety Outcomes

Alarm fatigue is a severe concern as it leads to desensitization of caregivers to life-threatening alarms and also to delayed or missed interventions. The first step to reducing this risk is to clarify that it is perceived as a cognitive load of human and system reasons, an overload of alerts that cannot be taken, malfunctioning equipment, and communication that is not linked to what is being observed (Lu et al., 2024).

The analysis of alarm logs based on data is followed by the introduction of the smart alarm systems, which select the non-urgent alerts and concentrate on the clinically significant changes to trigger the improvement process. Simultaneously, the employees will have to go through the program of training, which will include simulations, which will involve the reinforcement of the individual adjustment of alarm thresholds, timely triage, and processes of escalation, which SBAR will govern to ensure that all the team members are prepared to act and respond within several seconds, in case it is required.

The policies and workflow of the institutions should be changed to necessitate the daily assessment of individual alarm settings, and after significant clinical changes, automated secondary notifications of critically alarm settings that are yet to be identified should be instituted to provide redundancy in the safety net. The establishment of a culture of learning where the information is deployed to inform the process of enhancing technology, training, and process design through an iterative process will be facilitated by the establishment of non-punitive reporting infrastructures, quarterly audit schedules grounded on the utilization of alarm-log dashboards and frontline feedback (Sowan, 2024).

In the case involving Mr. James Carter, those measures would have possessed the features of having his Ventricular tachycardia warning go off to have risen above the background noise, automatically increasing in the occurrences of no recognition in a specific amount of time, and a rapid, concerted action to the condition eliminating the nature of hypoxic injury in a sequence of undifferentiated alarms and communications failure.

Slide: 7

Audience’s Role and Importance

All the members of our ICU team are also very instrumental in the success of our alarm management improvement plan. It needs bedside nurses to set thresholds, biomedical engineers to program smart filters, charge nurses to enforce compliance, and unit leaders to direct resource utilization to decide whether actions of individuals and teams can transform alarm management to a proactive safety practice (Bruder et al., 2021).

Communication ought to be open: data of alarm logs must be broadcast, focus on sharing small wins, be able to highlight problems and address them proactively. This entails false alarms, escalation delays and other operational issues. Since the personnel can identify the number of non-actionable alarms that have not been identified on the total report, and the response times are improved, the personnel would know the tangible worth of the scheme, which reinforces the identification.

The effort to convince an audience to be part of the change must be made in a truthful manner, showcasing the mistakes and humiliation that we have experienced, and explicitly saying what we are to accomplish. In the form of a case study, data on the ventricular tachycardia (VT) alarm that Mr. Carter omitted will be provided. This is not stated to put the blame, but to demonstrate how harmful and perilous the effects and expenses to human lives may be in case the issue of alarm fatigue is not addressed.

As the special invitation to the frontline workers to suggest how the escalation protocol can be refined and given the immediate response to the ideas, we will be able to note that this strategy is a dynamic process that is being influenced by the individuals who might be impacted by it the most (Colquhoun et al., 2021). The published dashboards, daily briefs, and non-punitive feedback are evidence that every individual knows what has changed, why it is needed, and that they can go on to make things get better. Open discussion, informed decision-making, and collective prosperity will make the improvement plan a changed mission rather than a decree, which will still achieve buy-in and will ultimately give the patients safer outcomes.

Slide: 8

Creating Resources and Activities

In order to help create applied learning in alarm management, we will design a graded ladder of simulation courses, starting with basic skills laboratories and culminating in team-based, high-fidelity crisis simulation. The skills laboratories provide nurses with the practice of customizing alarm limits in the simulation monitors and interpolating alarms and log dashboards, which trains them to choose and analyze equipment functions and data analytics.

As the simulation progresses to full-scale scenarios, the multidisciplinary teams conduct escalating alarm scenarios with the SBAR-regulated handover and automated escalation criteria and allow the participants to practice the real-time decision-making in an emergency (Lu et al., 2024). These simulations stabilize the procedural knowledge, enhance the interprofessional communication and enhance confidence in the implementation of the protocols in the real emergency.

Brief and visually attractive, fast-reference lists and pocket cards of the flows of alarm settings, escalation, and SBAR templates will be developed as an addition to the simulations. The mentioned resources are available at the nursing stations and can be easily integrated into the electronic health record in the form of pop-up notifications, a type of just-in-time learning that will reduce the cognitive load and guarantee consistency in the response (Yang et al., 2024). This makes the complex processes simple and easy to understand through easy and simplified checklists, which can help us do away with the variability in practice and can even allow the personnel to act on their own in case of an emergency.

Slide 9: To have an active learning process, an interactive e-learning tool, which is comprised of small video demonstrations, cases and quizzes, reflection and learning activities regarding human factors of alarm fatigue, is necessary. The on-demand training on mobile devices can be utilized not only by new employees but also by those who have been working in the company to refresh their knowledge even when they are not at work (Fleishman et al., 2021). Learner analytics will aid in the personalized training, and gaps in the understanding of the learners will be identified to shape the subsequent in-service training issues.

Lastly, the frontline staff, engineers and leaders are going to meet once a month in forums known as the alarm-huddle, where they will learn the current trends of the alarm-metrics, celebrate success, such as the lower false-alarm rates, as well as co-create the refinements of the process. When incorporating end users in the process of iterative enhancements, we will entrench the culture of collective ownership and constant optimization, such that practices will be responsive to the real-world challenges, and, finally, will save the lives of patients such as Mr. Carter.

Slide: 10

	Soliciting Feedback
Feedback Methodology	To get useful feedback on the improvement plan and the in-service session, I employ a multimodal methodology capable of involving the staff in the short term and long term.
Electronic Survey	In the final hour of each of the training days, we would complete a brief anonymous electronic survey, in which the orientation of the clarity of the concepts, relevancy of exercises, and confidence in the practice of new protocols would be assessed.
Post-Shift Huddle	Meanwhile, I would set up a facilitated post-shift alarm huddle and request frontline nurses, engineers, and managers to inform me of what went well and where they continue to have difficulties.
Online Suggestion Box	The version of my EHR plan is more intimate, which is the creation of an online suggestion box where team members are able to leave ideas or report how there is a nagging issue in the present, and the feedback does not cease to exist once the classroom is no longer present.
Periodic Focus Groups	Furthermore, periodic focus groups (consisting of various fields and shifts) are more likely to offer a deeper understanding of the obstacles in the system, as well as expose the areas that otherwise would not be identified during a survey.
Successive Feedback	This feedback must be included in successive versions that rely on an open feedback mechanism.
Quality Improvement Committee	Our quality improvement committee would discuss the findings of surveys and huddle topics every month; a pattern within the comments would then translate into specific action points, such as the urge to modify simulation scenarios to address specific alarm settings or the necessity to revise the content of the pocket cards in order to make sense.
Digital Portal	The digital portal would provide any suggestions that would be screened by the biomedical engineering and leadership in nursing, and priority improvement could then be launched in either quarterly software updates or policy modification.
Influence on Future In-Service	The results of the focus groups would influence the decision on the additional selection of the more developed topics for further in-service sessions, since training would also vary based on the emergent challenges.

Slide: 11

Conclusion

The successful fight against alarm fatigue needs to be multifaceted, involving a mix of technology, training, and teamwork. Justifying the application of smart alarm filters and frequent escalation processes, and the simulation of the relevant clinical response regularly, will allow us to significantly reduce the quantity of non-actionable alerts, becoming much more attentive to the actual emergencies. Such actions will ultimately result in the elimination of these tragedies, as in the case of Mr. Carter, who failed to notice the alarm of ventricular tachycardia, and the bad habit of safeguarding the health of clients all over our ICU.

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Instruction file for 4035 Assessment 3

Assessment 3

Improvement Plan In-Service Presentation

For this assessment, you will develop an 8–14 slide PowerPoint presentation with thorough speaker’s notes designed for a hypothetical in-service session related to the improvement plan you developed in Assessment 2.

Introduction

As a practicing professional, you are likely to present educational in-services or training to staff pertaining to quality improvement (QI) measures of safety improvement interventions. Such in-services and training sessions should be presented in a creative and innovative manner to hold the audience’s attention and promote knowledge acquisition and skill application that changes practice for the better. The teaching sessions may include a presentation, audience participation via simulation or other interactive strategy, audiovisual media, and participant learning evaluation.

The use of in-services and/or training sessions has positive implications for nursing practice by increasing staff confidence when providing care to specific patient populations. It also allows for a safe and nonthreatening environment where staff nurses can practice their skills prior to a real patient event. Participation in learning sessions fosters a team approach, collaboration, patient safety, and greater patient satisfaction rates in the healthcare environment (Patel & Wright, 2018).

As you prepare to complete the assessment, consider the impact of in-service training on patient outcomes as well as practice outcomes for staff nurses. Be sure to support your thoughts on the effectiveness of educating and training staff to increase the quality of care provided to patients by examining the literature and established best practices.

You are encouraged to explore the AONL (American Organization of Nursing

Leadership) Nurse Executive Competencies Review activity before you develop the Improvement Plan In-Service Presentation. This activity will help you review your understanding of the AONL Nurse Executive Competencies—especially those related to competencies relevant to developing an effective training session and presentation. This is for your own practice and self-assessment, and demonstrates your engagement in the course.

Reference

Patel, S., & Wright, M. (2018). Development of interprofessional simulation in nursing education to improve teamwork and collaboration in maternal child nursing.

Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), s16–s17.

Overview

As a baccalaureate-prepared nurse, you will often find yourself in a position to lead and educate other nurses. This colleague-to-colleague education can take many forms, from mentoring to informal explanations on best practices to formal in-service training. In-services are an effective way to train a large group. Preparing to run an in-service may be daunting, as the facilitator must develop their message around the topic while designing activities to help the target audience learn and practice. By improving understanding and competence around designing and delivering in-service training, a BSN practitioner can demonstrate leadership and prove to be a valuable resource to others.

For this assessment, build on the work that you have done in your first two assessments and create an agenda and PowerPoint of an educational in-service session that would help a specific staff audience learn, provide feedback, and understand their roles and practice new skills related to the safety improvement plan you created.

Instructions

Develop a PowerPoint presentation with detailed speaker’s notes representing the material you would deliver at a one-hour in-service session to raise awareness of your chosen safety improvement initiative and explain the need for it. Additionally, you must educate the audience as to their role and importance to the success of the initiative. This includes providing examples and practice opportunities to test out new ideas or practices related to the safety improvement initiative.

Be sure that your plan addresses the following, which corresponds to the grading criteria in the rubric. Please study the rubric carefully so that you understand what is needed for a distinguished score.

Describe the purpose and at least three goals of an in-service session for nurses.
- Include a one-line purpose statement followed by the goals.

○ Start each goal with a verb, such as 1) Explain reasons for medication administration errors, 2) Discuss the importance of preventing medication errors, and 3) Describe strategies to prevent medication errors.

Explain the need for and process to improve safety outcomes related to a specific patient-safety issue.
Explain to the audience their role and the importance of making the improvement plan successful.
Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative.
- Create a resource slide OR do an activity with the audience to assist them in learning and applying a new skill. A resource slide could consist of in-house materials, posters, or credible websites. An activity slide may include a quiz, simulation, group work, a case study, and so forth.
Communicate with nurses in a respectful and informative way that clearly presents expectations and solicits feedback on communication strategies for future improvement.

There are various ways to structure an in-service session; below is just one example:

Part 1: Agenda and Outcomes.
- Explain to your audience what they are going to learn or do, and what they are expected to take away.
Part 2: Safety Improvement Plan.
- Give an overview of the current problem, the proposed plan, and what the improvement plan is trying to address.

○ Explain why it is important for the organization to address the current situation.

Part 3: Audience’s Role and Importance.
- Discuss how the staff audience will be expected to help implement and drive the improvement plan.

○ Explain why they are critical to the success of the improvement plan.

○ Describe how their work could benefit from embracing their role in the plan.

Part 4: New Process and Skills Practice.
- Explain new processes or skills.

○ Develop an activity that allows the staff audience to practice and ask questions about these.

○ In the notes section, brainstorm potential responses to likely questions or concerns.

Part 5: Soliciting Feedback.
- Describe how you would solicit feedback from the audience on the improvement plan and the in-service.

○ Explain how you might integrate this feedback for future improvements.

Remember to account for activity and discussion time.

Additional Requirements

Presentation length: There is no required length; use just enough slides to address all the necessary elements. Remember to use short, concise bullet points on the slides and expand on your points in the speaker’s notes. If you use 2 or 3 slides to address each of the parts in the above example, your presentation would be at least 10 slides and no more than 15 slides (not including the title, conclusion, or references slide).

○ For PowerPoint help, see Guidelines for Effective PowerPoint Presentations [PPTX] and the Capella University Library:

PowerPoint Presentations.

Speaker notes: Speaker notes (located under each slide) should reflect what you would actually say if you were delivering the presentation to an audience. This presentation does NOT require audio or a transcript. Another presenter would be able to use the presentation by following the speaker’s notes.
APA format: Use APA formatting for in-text citations. Include an APA-formatted reference slide at the end of your presentation. See APA Module.
Number of references: Cite a minimum of three sources of scholarly or professional evidence to support your assertions. Resources should be no more than five years old. Use the BSN Nursing Program Library Guide as needed to guide your research in the Capella library.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
- Explain the need for and process to improve safety outcomes related to a specific patient safety issue.

○ Create resources or activities to encourage skill development and process understanding related to a safety improvement initiative.

Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs.
- Describe the purpose and at least three goals of an in-service session on a specific patient safety issue.

○ Explain to an audience its role and importance of making an improvement plan successful.

Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. ○ Slides are easy to read and error free. Detailed speaker notes are provided. Speaker notes are clear, organized, and professionally presented.
- Organize content with clear purpose and goals and with relevant and evidence-based sources published within the last five years.

Non Performance

Does not create resources or activities to encourage skill development and process understanding related to a safety improve initiative.

Criterion 5

Slides are easy to read and error free. Detailed speaker notes are provided.

Speaker notes are clear, organized, and professionally presented.

Distinguished

Slides are easy to read and clutter free. Slide background is visually pleasing with a contrasting color for the text and may utilize graphics. Detailed speaker notes are provided.

Proficient

Slides are easy to read and error free. Detailed speaker notes are provided.

Basic

Slides are easy to read with few editing errors. Speaker notes are sufficient to support the slides.

Non Performance

Slides are difficult to read with multiple editing errors. No speaker notes provided.

Criterion 6

Organize content with clear purpose and goals and with relevant and evidence-based sources published within the last five years.

Distinguished

Organizes content with clear purpose and goals. PowerPoint slides support main points, assertions, arguments, conclusions, or recommendations with relevant and evidence-based sources that were published within the last five years.

Proficient

Organizes content with clear purpose and goals and with relevant and evidence-based sources published within the last five years.

Basic

Organizes content with clear purpose or goals. PowerPoint slides do not consistently support main points, assertions, arguments, conclusions, or recommendations with relevant and evidence-based sources that were published within the last five years.

Non Performance

Does not organize content with clear purpose and goals and with relevant and evidence-based sources published within the last five years. Use the resources linked below to help complete this assessment.

Reading

Facilitating Learning

This reading list provides more background about facilitating learning to improve quality and safety.

Assessment 3: Facilitating Learning.

Leadership Competencies

The AONL (American Organization of Nursing Leadership – formerly AONE) nurse executive competencies may be a helpful resource as you design your presentation, especially with regard to communication and collaboration. Take a look in this reading list.

Assessment 3: Leadership Competencies.

Program Resources

Capella Writing Center

Access the various resources in the Capella Writing Center to help you better understand and improve your writing.

APA Style and Format

Capella University follows the style and formatting guidelines in the Publication Manual of the American Psychological Association, known informally as the APA manual. Refer to the Writing Center’s APA Module for tips on proper use of APA style and format.

Capella University Library

The BSN Nursing Program Library Guide will be useful in guiding you through the Capella University Library, offering tips for searching the literature and other references for your assessments.

PowerPoint

Refer to these helpful Campus resources for PowerPoint tips:

References For NURS FPX 4035 Assessment 3

Bruder, A. L., Rothwell, C. D., Fuhr, L. I., Shotwell, M. S., Edworthy, J. R., & Schlesinger, J. J. (2021). The influence of audible alarm loudness and type on clinical multitasking. Journal of Medical Systems, 46(1). https://doi.org/10.1007/s10916-021-01794-9

Colquhoun, D. A., Davis, R. P., Tremper, T. T., Mace, J. J., Gombert, J. M., Sheldon, W. D., Connolly, J. J., Adams, J. F., & Tremper, K. K. (2021). Design of a novel multifunction decision support/alerting system for inpatient acute care, ICU and floor. Biomed Central, 21(1). https://doi.org/10.1186/s12871-021-01411-9

Fleishman, S., Hess, A., Sloan, L., Schlesinger, J. J., & Shive, J. (2021). Detecting abnormalities on displays of patient information. Lecture Notes in Networks and Systems, 287–300. https://doi.org/10.1007/978-3-030-74611-7_40

Lu, S.-F., Kuo, Y.-W., Hung, S.-H., Wu, C.-H., Wang, C.-Y., Chou, S.-S., & Huang, S.-H. (2024). Coping strategies of intensive care unit nurses in alarm management: A qualitative research study. Biomed Central, 23(1). https://doi.org/10.1186/s12912-024-02374-1

Nguyen, V., MacDonald, B., Cignarella, A., & Miller, C. (2025). A descriptive investigation of alarm activation in a critical care setting. Nursing in Critical Care, 30(2). https://doi.org/10.1111/nicc.13302

Sangari, A., Bingham, M. A., Cummins, M., Sood, A., Tong, A., Purcell, P., & Schlesinger, J. J. (2023). A spatiotemporal and multisensory approach to designing wearable clinical ICU alarms. Journal of Medical Systems, 47(1), 105. https://doi.org/10.1007/s10916-023-01997-2

Sowan, A. (2024). Effective dealing with alarm fatigue in the intensive care unit. Intensive and Critical Care Nursing, 80, 13. https://doi.org/10.1016/j.iccn.2023.103559

Yang, J. K., Su, F., Graber-Naidich, A., Hedlin, H., Madsen, N., DeSousa, C., Feehan, S., Graves, A., Palmquist, A., Cable, R., & Kipps, A.K. (2024). Mitigating alarm fatigue and improving the bedside experience by reducing non-actionable alarms. The Journal of Pediatrics, 12. https://doi.org/10.1016/j.jpeds.2024.114278

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