The document summarizes the results of an evidence-based patient safety intervention conducted over 3 months at St. Anthony Medical Center. Data shows improvements in key safety indicators in 2020 compared to 2018 and 2019. Staff response has also been positive, with nurses utilizing a new incident reporting system and leadership holding education sessions. Next steps discussed include sustaining these gains over time, obtaining continued stakeholder buy-in, and addressing differing viewpoints as the organization works to create a culture of evidence-based practices.

1. Vila Health: Creating a Culture of Evidence
You continue your work with the EBP intervention Team at St.
Anthony Medical Center. Over the last three months, the
organization has conducted an evidence-based intervention to
address the hospital’s poor patient safety scores. Now, it’s time
to review data about the results of the intervention. It’s also
time to make recommendations for how the hospital can move
forward to creating a culture of evidence.
You have an email from Andrea Branch, the EBP Intervention
Team Lead.
EMAIL INBOX
Inbox – (1)
PDSA Cycle Outcomes – First Quarter 2018
From: Andrea Branch, EBP Intervention Team Lead
To: Kayla Stephens
Thank you so much for all of your work on the patient safety
intervention. Here is a report on how the intervention went over
the past 12 weeks. I pulled data from our tracking system for
the first quarter of 2020 for the same indicators with poor
performance in 2018 and 2019.
According to the data, it seems like we might be making a
difference so far, but you will be the best judge of that. Here
are the 2018 and 2019 yearly rates again, and at the bottom you
will see the first quarter of 2020 rates:
2018
1. Patient Falls - Expected: 0 Observed: 3
2. Medical Errors causing patient allergic reaction - Expected: 0
Observed: 2
3. Staff member in Emergency Department (ED) needed urgent
treatment for concussion = 1
2019
1. Medical Errors causing patient allergic reaction - Expected: 0
Observed: 4
2. Staff member in Emergency Department needed urgent
treatment for lacerations = 1

2. 3. Nurse on critical care unit slipped and broke her arm = 1
2020
1. Patient Falls – Expected: 0 Observed: 0
2. Medical Errors causing allergic reaction – Expected: 0
Observed: 1
I also wanted to mention that the EBP Intervention Team seems
to think that staff members like the new Incident Reporting (IR)
system.
Also, they heard about a couple of incidents where water was
spilled in the ICU, and one of the nurses reported each of these
incidents immediately. She said it was about time we had an IR
system where we could see possible immediate results and make
positive changes to the safety of our environment.
I also heard that the Lead Nurse in ICU had two huddles with
all staff in the unit, including Environmental Services staff, on
the importance of preventing slips and falls for both staff and
patients and ensuring the floors in rooms and stations are clean
and any spills are taken care of immediately. The Environmental
Services staff members mentioned it to their supervisors and I
guess their department will be adding one more round during
the evening hours to help ensure floors are clean and not
slippery for anyone. The Lead Nurse was even thinking about
creating an educational poster on preventing falls to put up on
the wall in the break room as a reminder.
Anyway, that is just what I heard. Maybe if there is another
formal town hall or something like that we can all talk about
everyone’s experiences and get some input on how it’s going for
everyone with the implementation of the intervention using
PDSA cycles.
I suggest you speak with Emilio Ramirez, the PDSA Team
Director, to ask questions and gain insight on how you might
write your final report and create a culture of evidence at St.
Anthony Medical Center.
Again, thanks for all of your hard work.
Sincerely,
AndreaSt. Anthony Medical Center

3. You meet with Emilio Ramirez, the PDSA Team Director, to
discuss your next steps, including how to move forward with
building a culture of evidence at the hospital.
What questions do I need to be asking myself as I complete my
final report?
Emilio: That’s an excellent question. One important question
you should yourself is, “When do I want another report?” What
kind of time frame is needed to ensure that you have the data
you need. Another important question is, “How are we going to
sustain this?” Going forward, do you have a plan to obtain
continued buy-in by stakeholders, as well as the resources you
need to continue with the intervention?
EMAIL INBOX
Inbox – (1)
Final report
From: Jackie Sandoval, CNO
To: Kayla Stephens
I am aware of the success of the evidence-based intervention
with the PDSA cycle team and with the nursing staff. This is
great news! Now we need to spread this optimism about EBP
throughout the organization.
As you write your final report and make recommendations to
foster engagement by various stakeholders in the organization
to create and sustain a culture of evidence. Please address the
following:
· Differing opinions that existed within the medical staff.
· Organizational culture.
· Leadership strategies.
· Communication planning to share the results with stakeholders
across the organization.
Thank you for all your hard work!
– Jackie