Date of Graduation

Fall 12-12-2014

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions



First Advisor

KT Waxman

Second Advisor

Juli Maxworthy

Third Advisor

Janeen Whitmore


The purpose of this evidence-based change in practice project was to provide nurses with an experiential learning opportunity, using simulation, to identify and report near miss events during the medication administration process related to patient-controlled analgesia (PCA) usage. Despite extensive in-service training on a Medical/Surgical (Med/Surg) floor in an acute care hospital, inconsistent, inaccurate and incomplete documentation with use of the new PCA pumps continued to be problematic. A conceptual framework of just culture was used with the quality improvement method of the Plan-Do-Study-Act (PDSA) cycle for testing change. Medication safety education was a valid andragogical strategy to decrease rates of medication errors and improve patient outcomes by identifying complex system issues that interfered with safe practices. The education program consisted of a series of self-learning modules, definitions of near miss events and medication errors; in addition a simulation learning experience was included. A needs assessment was conducted to help determine gaps in practice. Results of the survey demonstrated inconsistencies in the current practice of documenting vital signs on patients with a PCA in contrast to the existing policy and procedure; these results were shared with the staff nurses at a staff meeting and via email. Although no changes in care delivery were directly observed, the doctorate of nursing practice (DNP) student was able to reinforce the documentation requirements per the hospital’s policy.

Included in

Other Nursing Commons