Date of Conferral

5-5-2025

Date of Award

May 2025

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Corinne Romano

Abstract

Summary This staff education project was an initiative designed to address the practice problem of medication errors in the psychiatric intensive care unit (PICU). The project’s purpose was to improve the nursing staff’s knowledge regarding medication administration and documentation through a structured educational intervention. The practice-focused question was: Will staff education on medication administration and documentation in the electronic medical record (EMR) result in an increase in staff knowledge with an aim to promote a reduction in medication errors in the PICU? The education was delivered through in-person sessions during regularly scheduled staff meetings to ensure full participation without disrupting workflow. I used a PowerPoint presentation to guide the training. The pre-and post-training surveys were used to assess the effectiveness of the educational presentation by measuring the change in participants’ knowledge from pre- to post-education surveys. Survey results were analyzed using descriptive statistics to measure knowledge gains. The post-education survey scores demonstrated an increase in participant knowledge after the educational presentation. The mean score of the pre-education surveys was 47%, and this increased to 72% in the post-education survey. The project’s implications for nursing practice were aimed at improving nursing staff knowledge and patient safety. The project contributes to positive social change by safeguarding mental health patients. Based on the results, I recommend integrating this educational module into routine onboarding and annual competencies. Background The impetus for this project emerged from a pattern of medication errors noted in incident reports and quality audits within the psychiatric inpatient care setting. These errors presented significant safety concerns for psychiatric patients, who are particularly vulnerable due to cognitive and behavioral health challenges. I conducted this project to address a clear gap in staff knowledge regarding medication documentation and administration. The practice problem question was: Will staff education on medication administration and documentation in the EMR result in an increase in staff knowledge with an aim to promote a reduction in medication errors in the PICU? Evidence from national data indicated that medication errors are a leading cause of preventable harm in health care (Rodziewicz et al., 2023). I conducted a review of 10 peer-reviewed articles to support this project. The literature included three Level I systematic reviews, four Level II randomized controlled trials, and three Level III quasi-experimental studies. The articles were rated using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) evidence level and quality guide, which categorizes studies based on their design and rigor to support the strength of evidence used in clinical decision-making. These sources consistently supported the effectiveness of targeted education for healthcare providers in reducing documentation-related risks and improving practice outcomes (Mieiro et al., 2023; Rajeh et al., 2021). The strength of evidence is moderate to high, highlighting the reliability and applicability of staff training interventions in clinical settings. Staff Education Project Development The project included 6 registered nurses and 2 licensed vocational nurses assigned to the PICU project site. I delivered educational materials through in-person sessions over the course of 1 week. These sessions incorporated PowerPoint presentations, printed handouts, and live demonstrations to enhance engagement and retention. I created pre- and post-education surveys based on the content of the PowerPoint presentation to assess the effectiveness of the educational presentation by measuring the change in participant knowledge from before to after the presentation. Survey results were analyzed using descriptive statistics to measure participant knowledge gains. Results The participants’ post-education survey scores demonstrated an increase in knowledge after the educational presentatio The participants’ scores on the posteducation survey increased by an average of 25% compared to their preeducation survey scores. The mean score of the preeducation survey was 47%, which increased to 72% in the posteducation survey. These results reflect the importance of addressing medication safety through targeted education, particularly in high-risk environments like psychiatric inpatient care (see Agency for Healthcare Research and Quality, 2023). Table 1 and Figure 1 reflect the detailed results of the project. Table 1 Staff Knowledge Pre- and Post-education Survey Results Knowledge area Pre-education survey correct (%) Post-education survey correct (%) Medication administration procedures 47 72 EMR documentation protocols 62 89 Confidence in practice (self-reported) 66 95 Figure 1 Bar Graph Showing Improvement in Staff Knowledge Pre- and Post-education Impact on the Organization The project had a positive short-term impact on the organization by enhancing staff awareness and promoting safer medication administration practices within the unit. However, due to the limited duration of the intervention and the small, unit-specific sample, the broader organizational impact remains modest. While the initiative helped foster a culture of learning and accountability, long-term behavioral changes and system-wide improvements require further evaluation and scaling. Additionally, reliance on self-reported surveys and knowledge-based rather than direct observation or actual medication error data limits the ability to directly correlate knowledge improvements with reductions in medication errors. To enhance the validity and generalizability of the findings, future studies should incorporate a longer follow-up period, including larger and more diverse sample sizes, and utilize objective clinical outcome measures. These enhancements will provide a more comprehensive assessment of long-term knowledge retention, sustained changes in clinical practice over the impact, and the overall impact of educational interventions on patient safety. This project reinforces the value of ongoing staff education in reducing medication errors and improving patient safety. The participants’ observed knowledge gains highlight the need for integrating medication safety training into new staff orientation and offering regular refresher courses. The initiative supports positive social change by fostering a culture of safety, accountability, and continuous learning. The project can be easily replicated for utilization and value beyond the local site. Conclusions This staff education initiative had a meaningful impact on clinical knowledge of medication safety in the psychiatric inpatient care setting. Recommendations for sustaining improvement include regular refresher training, inclusion of EMR competency in new staff onboarding, and ongoing monitoring of medication error trends. The implications for nursing practice involve promoting continuous professional development and fostering a proactive approach to quality and safety. The project contributes to positive social change by safeguarding mental health patients and supporting equitable care to all patients.   References Agency for Healthcare Research and Quality. (2023). Patient safety primer: Medication errors. https://psnet.ahrq.gov/primer/medication-errors Mieiro, D., Fernandes, L., Ferreira, C., & Ribeiro, O. (2023). Effectiveness of staff Education programs on medication safety: A systematic review. Journal of Nursing Management, 31(2), 234–245. https://doi.org/10.xxxxxx Rajeh, M., Alshaikh, M., AlRabiah, Z., & Al-Omar, M. (2021). Impact of educational interventions on medication administration errors: A systematic review. Saudi Pharmaceutical Journal, 29(9), 992–1000 https://doi.org/10.1016/j.jsps.2021.07.001 Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2023). Medical error reduction and prevention. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/

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