Recent Submissions

  • Clinical Practice Guideline Development, Implementation, and Evaluation in an Oncology Practice

    Mallare, Stacy S. (2017)
    Background: Forty percent of adult cancer patients suffer from at least one clinically significant episode of anxiety and/or depression during their illness. When these mental health problems are untreated, patients will adhere less to their treatment regimens and have weakened immune systems thereby leading to more disease- related complications and higher rates of morbidity and mortality. Despite the high rate of comorbid emotional distress in cancer and its negative sequelae, most patients are not receiving appropriate care. Clinical practice guidelines can direct the detection and treatment of mental health problems that can be integrated into the cancer setting. Purpose: The purpose of this quality improvement project was to develop a best-practice guideline to screen, assess and manage patients with depression and cancer and test its feasibility in an out-patient oncology practice. Procedure: A multi-disciplinary consensus group reviewed recent literature and solicited staff opinion to develop a set of eight best practice recommendations adapted from the American Society of Clinical Oncology Guidelines for Depression and Anxiety. Based on these recommendations, a stepped-care model was developed using a multidisciplinary framework and including an algorithm with a clinical pathway to guide treatment and work flow. During a five-week period all new patients were screened at their first appointments with the Patient Health Questionionnre-9, (PHQ-9) a self-administered, nine-item scale to detect presence and severity of depression. Based on their scores, they were offered psychosocial education and, if necessary, referral to community mental health specialists. Descriptive statistics were computed to calculate PHQ-9 scores, frequency of use of tool and success of the stepped care model to direct care. Results: Between the times of data collection, 308 patients were admitted to the clinic. Of these, 240 were successfully screened for depression. One-hundred and eighty-nine of these screenings were reviewed by the patient’s provider. According to the cut-off criteria for mild (5-9), moderate (10-14), and severe (>15) depression, 84 (mild), 16 (moderate) and 9 (severe) patients were identified as positive cases. Over half of the patients (55%) were negative for depression while over a third (35%) reported minimal depression. A small portion of patients had moderate (7%) and severe (3%) depression. Of the 109 positive screens (PHQ-9 score ≥5), in 61 cases, the appropriate hand-off communication to social work occurred. Of the patients successfully triaged to social work, all were provided psychoeducation and moderate and severe cases of depression were also provided with at least one community referral. Adherence to protocol was 78% and was calculated based on: the number of patients successfully screened over the five-week period (240), the number of patient screenings reviewed by the patient provider (189) and the number of patients successfully referred to social work (61). Conclusion: Strategies to increase adherence include improving handoff interdisciplinary communication particularly between the technicians responsible for the screening and the social worker completing the advanced assessment. This could be done by streamlining work flow processes such as assigning one staff member per shift to complete all screenings which would also increase accountability. Clinical guidelines and an algorithm to guide practice should be adapted by all clinical facilities. This project increased ability of providers to identify depression in cancer patients and successfully directed patients to receiving the level of care appropriate to their need.
  • Enhancing Nursing Skills to Care for Patients with Chronic Obstructive Pulmonary Disease

    Watties-Daniels, A. Denyce (2017)
    Best practices in the care of patients experiencing a deteriorating condition include identifying changes in patient condition and initiating prompt and effective interventions. Nurses frequently fail to recognize deteriorating conditions and serious exacerbation of symptoms and thus are limited in providing appropriate supportive care to patients with COPD. Innovative strategies, such as the implementation of clinical simulations, are reported to be effective in reinforcing essential clinical decision-making skills to assist nurses in developing the knowledge and skills to better recognize and intervene in the care of deteriorating conditions in patients with COPD. The purpose of this Doctor of Nursing Practice quality improvement project was to develop, implement and evaluate the use of two simulation experiences to assist registered nurses to recognize and intervene in deteriorating conditions in chronically ill adult patients with COPD. Simulation scenarios included the patient with exacerbation of COPD and the patient with a spontaneous pneumothorax as a result of COPD complications. A convenience sample of seven licensed registered nurses from diverse clinical backgrounds participating in a nursing orientation program at an urban, general adult medicine and surgical hospital in Baltimore, Maryland engaged in the project. The NLN/ Jeffries Simulation Theory and the INASCL Standards of Best Practices in Simulation provided the framework for the project. Utilizing the three phases of the simulation experience, the seven registered nurses were immersed in the two simulated clinical situations. Baseline knowledge of the care of the patient with COPD and spontaneous pneumothorax was assessed by administering a 10 item, paper-pencil pre-test aligned to the simulation objectives. The simulation experiences were evaluated using the Creighton Competency Evaluation Instrument (C-CEI) and a 10 item posttest. The clinical nurse educator and the DNP project director used the C-CEI tool to separately evaluate participant performance in each simulation experience. The project director with clinical nurse educator validation, set the competency score for the C-CEI at 75%. The scores on the C-CEI were collected as an aggregate of the nurses delivering care to the simulated patient. All groups of nurses scored above 75%. A T-test (n=7, p =.000) for dependent groups was used to evaluate whether students’ performance on the COPD and pneumothorax pre-test improved on the post-test. There was a statistically significant increase in the COPD and pneumothorax mean scores from the pre-test to the post-test. The completed DNP project supports the use of clinical simulation to train and remediate practicing nurses. The participating nurses were able to immerse themselves in a realistic clinical situation and care for the simulated patients in a safe environment as though the patients were real. The participating nurses could identify significant changes in patient condition and were competent in intervening and caring for the deteriorating conditions of a COPD patient. Evidence from this DNP quality improvement project supports the need for continued clinical work and program evaluation on the development, and implementation of hospital based clinical simulation programs for nurses.
  • Patient Engagement Using a Patient Portal in a Clinical Research Hospital

    Lardner, Michelle C. (2017)
    United States spending on healthcare is astronomical. Nearly 66% of the costs are attributable to patients with multiple chronic conditions (U.S. Department of Health and Human Services, 2014) and the estimated costs of cancer may reach $158 billion by 2020 (Mariotto, Yabroff, Shao, Feuer & Brown, 2011). It is vital to address any avenue that can decrease these costs and improve outcomes. Meanwhile, growth of adult internet usage from 2000 to 2015 increased from 52% to 84% (Perrin & Duggan, 2015). According to Fox and Duggan (2013) from the Pew Research Center, 59% of adults use the internet to find health information with 53% actually talking to their providers to validate their online findings. Furthermore, 41% of adults are using the internet as a diagnostic tool to self-diagnose and getting confirmation from their provider. This is not surprising considering two-thirds of Americans have a smartphone and the less-advantaged are more likely to be dependent on their smartphone with 62% using their phones to look up health information (Smith, 2015). In 2009, the American Recovery and Reinvestment Act (ARRA) was signed and part of this act was the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act authorized the Meaningful Use (MU) program which encourages the widespread adoption EHRs by offering financial incentives and technical assistance to healthcare org that use EHR “meaningfully” (Meaningful Use [MU]) —that is, the use of certified EHR technology. The goal of MU is to improve quality, safety, efficiency, and reduce health disparities; engage patients and families; improve care coordination, population and public health; and maintain the privacy and security of patient health information (Conway, 2013, paragraph 4). One way patients can access their health information and engage with healthcare providers is through the patient portal (The Office of the National Coordinator, 2015). Patient portals have evolved from simple online tools to access clinical documentation to more robust applications where the patients and caregivers can interact using a secure communication channel (eMessaging) and send requests for medical appointments and medication refills. Many healthcare organizations are using portals as an additional means to engage their patients and deliver quality care. The Centers for Medicare & Medicaid Services (CMS, 2016) describe patient engagement as a collaborative partnership between the patient and care team that may improve outcomes. According to the Agency for Healthcare Research and Quality (AHRQ, 2013), patient satisfaction and outcomes are influenced by patient engagement. The purpose of this scholarly project was to implement and evaluate the impact of an updated patient portal on the patient experience and portal utilization in a clinical research hospital. The project took place in a medium-sized academic medical center dedicated to clinical investigation. This clinical research hospital treats a relatively high number of patients with chronic disease and cancer. There was a patient portal that was implemented in 2013, but it had very limited functionality that allowed patients to only view visit summaries, discharge instructions, and some lab results. There were 14,833 registered portal participants who used the original portal, however, only 3,881 were active users. The hospital implemented a new, more robust portal in 2017. Besides the ability to access multiple organizational portals from one portal, the new portal offers a mobile application and more importantly, secure health messaging and improved visit not usability. The potential significance with this implementation is improved engagement, communication, and patient satisfaction.
  • Implementation of a System Process to Improve Compliance with the NOTICE Act

    Flanary, Robin N. (2017)
    Problem: The current practice at a large urban medical center did not include a standardized process for the use of the new Medicare Outpatient Observation Notification (MOON) form; patients were not being informed about the implications of the cost of care related to being placed in observation status (OBS). Objective: The aim of this scholarly project was to implement and evaluate a standardized process for implementing the Notice of Observation Treatment and Implication for Care Eligibility Act, or NOTICE Act including a policy and procedure (P&P) and a teaching plan to deliver the MOON form. Design: This quality improvement project evaluated the implementation of a standardized process including the use of a policy and procedure to formally direct how the MOON form was delivered at a large urban academic medical center. Sample: A convenience sample of 346 Medicare beneficiaries who arrived at the medical center through the emergency department and were placed in OBS during a four week data-collection period. Methods: The DNP Project Leader (PL) developed a P&P and used one-on-one sessions to train and evaluate each of the Clinical Resource Specialists (n=12) to deliver the MOON form to these patients. The PL collected data for four weeks using chart audits on the rates of completion for the MOON. Additional reports were generated to identify when the MOON was not delivered or not delivered within 36 hours, the time mandated by Medicare. Results: There were 346 Medicare beneficiaries placed in OBS during the four weeks; 43 patients were changed to inpatient status or discharged before 24 hours, leaving 303 patients placed in OBS. Of those, 253 (83.5%) had a completed MOON form documented, 241 (95.6%) of which were delivered to the patient before 36 hours. Fifty (16.5%) patients did not receive a MOON form. Implications: Putting a standardized P&P into use could facilitate the standardization of the teaching of all providers and can help to ensure compliance with the NOTICE Act. It is anticipated that if providers are taught the standard and its implications for both the patient and the organization, providers will be better prepared to communicate this information to the patients in a consistent manner.
  • Using Simulation to Train Nurse Residents on Bedside Legal Ethical Dilemmas

    Salas, Elisa C. (2017)
    Problem: Nurse residents at a medium-size urban medical center reported a gap in knowledge on how to handle legal-ethical issues at the bedside. Objective: To develop a sustainable approach to integrate legal-ethical simulations into a nurse residency curriculum. Methods: In this quality improvement project, classroom content on ethics was replaced by a ten-minute presentation followed by two simulations depicting legal-ethical dilemmas at the bedside. The project leader designed the two legal-ethical simulations using a format consistent with the NLN/Jeffries simulation design. The topics of the simulations were cancer and pneumonia. The simulations for the first nurse resident cohort (N=9) were directed by the project leader; after training, the nursing residency coordinator directed the second cohort (N=19). Targeted training for nurse educators was also developed. Prior to and after the simulation, students completed a ten-item test to measure legal-ethical knowledge. Immediately after the simulation, students also completed the Student Satisfaction and Self-Confidence in Learning questionnaire, a 13 item Likert scale, 1= strongly disagree to 5 =strongly agree. Results: Comparison of pre and post legal-ethical knowledge scores showed a statistically significant increase in scores (Wilcoxon Signed-Rank Test p < .001, effect size medium to strong, r = .48). Scores for the Student Satisfaction and Self-Confidence in Learning showed consistency. There were no significant differences in scores between cohorts (Mann-Whitney U =256, z= 1.39, p= .1, two tailed) or between simulations (Mann-Whitney U= 371, z= 0.11, p= .9 two tailed). Implications: Providing nurse residents with a ten-minute presentation and two simulations appears sufficient to refresh knowledge of basic legal-ethical concepts. Satisfaction and self-confidence scores were high after each of the two simulations, suggesting that their implementation in the residency program could assist in filling the reported knowledge gap.
  • Decreasing Nursing Home Readmissions Using the Stop and Watch Early Warning Tool

    Nesbitt-Johnson, Michaele (2017)
    Background: Nursing home (NH) residents are at high risk for hospitalization. One successful initiative to decrease avoidable hospitalizations includes the use of tools to identify changes in NH residents’ condition. The geriatric nursing assistant (GNA) is the frontline care provider for the NH resident and the GNA can identify subtle signs or behavior changes in the residents. The Stop and Watch Early Warning Tool (SWT) provides a method for the GNA to identify and communicate changes in the resident’s condition to the licensed provider to prompt early assessment and possible interventions to prevent hospital readmission. Purpose: To implement and evaluate the impact of using the SWT in a skilled care unit within a nursing home. Methods: All of the staff on a 37-bed skilled unit were educated on the use of the SWT and the SWT was implemented on the skilled unit. Results: Three hundred thirty-six SWTs were completed for a total of 15 days. Six weeks prior to implementing the SWT, the unit's readmission rate was 25%. Post-implementation, the unit's readmission rate was 18%. Conclusion: Although there was a decrease in the readmission rate post-implementation of the SWT, these data will need to be trended over several months to determine if there is a significant change in readmission rates to the hospital. The SWT tool was positively received by the staff; however, a barrier to use of the SWT included a high documentation burden for the GNAs. Future use of the SWT should target high-risk patients.
  • Clinical Practice Guideline for the Decolonization of Staphylococcus aureus in Surgical Patients

    Moledina, Ashifa (2016)
    Background: A surgical site infection (SSI) is a post-surgical complication closely linked with increased morbidity and mortality. SSIs are preventable with appropriate care and insurers no longer reimburse for their cost. Chlorhexidine Gluconate (CHG) is an antiseptic agent that is used preoperatively, often within a decolonization bundle, as a safe and cost effective means of decreasing the risk of SSIs. Objective: The purpose of this doctorate of nursing practice (DNP) project is to develop an evidence based, standardized, pre-operative CHG bathing regimen for surgical patients to be utilized in a decolonization clinical practice guideline (CPG) for elective cardiac and hip and knee arthroplasty patients at the targeted pre-op center. Design: Three DNP students developed an evidence based CPG which was evaluated for guideline quality, methodological rigor, and transparency by a group of subject matter experts (SME) (n=7) using the AGREE II tool platform. After incorporating SME feedback, the revised CPG was distributed to a group of end users (n=8) for evaluation of guideline’s quality, applicability and acceptability utilizing the Practitioner Feedback Questionnaire (PFQ). Results: All domains of the AGREE II tool were scored above the 80% benchmark with Editorial Independence scoring the highest at 94% and Applicability scoring the lowest at 82%. The PFQ Applicability scores were also low with only 35.4% favorable responses however 100% of respondents from both groups recommended this CPG for practice at their site Implications: Earlier stakeholders and end user engagement may have increased CPG applicability while decreasing staff’s reluctance to change. The finalized CPG was distributed to the Department of Infection Prevention and Hospital Epidemiology and target site staff for future implementation.
  • Implementing the Confusion Assessment Method to Improve the Care of Delirious Patients

    Akande, Irene (2016)
    Background: Delirium affects approximately fifty percent of adults aged 65 years or older. The prevalence of delirium can be as high as 74% in surgical patients and 11% to 42% in non-surgical patients. Delirium can go undetected in 72% of Intensive Care Unit (ICU) patients when routine neurological monitoring tool is not used but could be prevented in 30 to 40% of cases, if detected early. Using a valid and reliable delirium assessment tool in the ICU, is essential so early interventions can be initiated. Purpose: The purpose of this scholarly project was to implement use of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for delirium assessment at a hospital in the Mid-Atlantic region of the United States. Methods: This quality improvement project was conducted with nurses that work in the intensive care unit. Informed consent was obtained by all nurse participants whose participation in the project was strictly voluntary. Pre and post-intervention questionnaires measured perceived self-confidence and comfort levels with providing ICU delirium care and delirium knowledge. The project involved three phases: pre-intervention questionnaire administration, in-service, case scenarios, brief videos and one-on-one training and implementation of the CAM-ICU tool in the ICU setting, and the administration of post-intervention questionnaire. Laminated CAM-ICU worksheet and flowsheet were placed at each bed space to provide cues to the nurses to complete their delirium assessment. Multiple modes of interventions were used for the implementation of the CAM-ICU. A total of 34 ICU nurses consented to the project. Results: Thirty-four participants completed the pretest; 22 participants completed the posttest. The age of the participants ranged between 36 - 66 years, the average age was 53 years (SD = 7.94); years of ICU experience ranged between 3 - 40 years, average ICU experience was 20 years (SD = 9.09); 77% of participants had a Bachelor of Science degree. Comfort assessing ICU patients for delirium increased, t(21) = -2.339, p =.029, confidence providing accurate definition of delirium increased, t(21) = -3.052, p = .006, and nurses improved ability to identify interventions to prevent or decrease delirium, t(21) = -2.731, p = .013. There were statistically significant differences between the mean scores on the knowledge test from pre- to post-intervention, t(21) = -10.784, p < .001. Nurses age (p = .620), years of ICU experience (p = .352) and level of education (p = .129) did not influence the knowledge scores. Compliance in using paper CAM-ICU worksheet for documentation was 21%. Nurses scored 28% of the ICU patients screened as delirious. Conclusion: This quality improvement project suggests that a formal training program for ICU nurses coupled with the use of in-service, one-on-one sessions, and videos for the implementation of the CAM-ICU tool, can result in increased awareness and knowledge of ICU delirium. The positive results have the potential to prompt treatment and improve outcomes for ICU patients who experience delirium. Adoption of the CAM-ICU into patient electronic health record is recommended for sustainability.
  • A Clinical Practice Guideline for Staphylococcus aureus Decolonization in Select Surgical Outpatients

    Celotto, Abigale A. (2017)
    Surgical site infections (SSI) are among the most prevalent types of hospital-acquired infections, causing substantial negative consequences for patients and health care systems, including increased morbidity and mortality rates, and higher costs to hospitals and insurers. Preoperative nasal colonization with Staphylococcus aureus (S. aureus) is an independent risk factor for the development of an SSI. Decolonization bundles that include combined use of nasal S. aureus colonization screening, targeted nasal decolonization, and preoperative Chlorhexidine gluconate (CHG) bathing are an effective means of SSI prevention. The purpose of this DNP scholarly project was to develop and evaluate an institutional clinical practice guideline (CPG) for the decolonization of S. aureus in adult, non-emergent cardiac surgery and total hip and/or knee arthroplasties. This manuscript focuses on the CHG recommendations within the larger decolonization bundle. The setting for this project was an ambulatory, Patient Readiness and Evaluation Center within a tertiary, mid-Atlantic medical center. It was anticipated that the guideline would be evaluated and graded as high quality and be considered reasonable and practical for implementation. Guided by Steven’s Stevens Star Model of Knowledge Transformation, the CPG was developed and evaluated in three phases. Prior to Phase One, a thorough evidence review and first draft of the CPG were completed. Phase One involved introductory meetings with stakeholders while Phases Two and Three were evaluation and revision phases. Two samples& Evaluation (AGREE II) Tool. The second sample consisted of eight end-users who assessed the CPG for applicability and sustainability utilizing the Practitioner Feedback Questionnaire. All six domains within the AGREE II tool scored greater than the targeted 80% agreement. The highest scoring domain was Editorial Independence with 94% agreement, while the lowest scoring domain was Applicability scoring 82% agreement. The final item, Overall Assessment of the Guideline, scored 90% agreement all SMEs stating they would recommend use of the guideline. Components that scored close to 80% were revised before Phase Three commenced. Of the four factors within the Practitioner Feedback Questionnaire, quality scored the highest with 93.75% favorable responses, while applicability of recommendations scored the lowest with 35.5% positive responses. Overall the CPG was found to be of high quality and practical for implementation with all SMEs and end-users stating they would use the CPG if it were implemented at their facility. The overarching goals of the CPG to standardize practice and minimize patient morbidity aligned with the institutional missions to deliver superior health care and discover ways to improve health outcomes. If the CPG were implemented as standard institutional practice, it is anticipated that the number of SSIs, specifically S. aureus infections, would decrease, reducing the targeted medical center’s healthcare costs and improving patient outcomes.
  • Pilot Implementation Project of the FOUR Score in a Neurocritical Care Unit

    Aparicio, Johanna (2017)
    Introduction: The neurological exam is performed and monitored closely by clinicians to trend, intervene, and improve patient outcomes. The Full Outline of UnResponsiveness Score (FS) is a novel, reliable, and validated tool that can be used to trend neurological exams in critical care settings. The FS assesses brainstem function, can be used among intubated comatose patients, and can detect subtle neurologic changes. Background: The Neurocritical Care Unit (NCCU) in a large urban academic medical center currently uses the Glasgow Coma Scale (GCS) for neurological exam monitoring. However, the medical providers were interested trialing the FS. The purpose of this project was to determine the feasibility for the adoption of the FS into routine practice. A pilot implementation project was conducted with the Advanced Practice Providers (APPs) [i.e. Nurse Practitioners (NP) and Physician Assistants (PA)] to determine if the APPs would use the FS and discuss the FS during rounds. The adoption of the FS should improve neurological exam trending and may also improve provider confidence in making treatment decisions and prognostication. Methods: APPs performed the FS once per shift for four weeks on each patient in the 10-bed East NCCU. Daily FS compliance and discussions during rounds were measure. The APPs experience with the FS was measured at the end of the project with the User Experience Questionnaire (UEQ). Results: Eleven APPs completed the project. Overall, weekly compliance decreased (76% to 25%) along with daily discussion during rounds (95%-55%). APP experience with the FS tool was excellent for perspicuity (ease of learning to use the product; M=2.32; SD=0.60; 95% CI=1.96-2.68) and efficiency (ease and speed of use; M=2.16, SD=0.71, 95% CI=1.74-2.58) and average on all other UEQ scales. Conclusions: Although compliance rates were low, the FS was well received by the APPs. The APPs rated their experience with the FS tool as excellent, practical, easy to learn and easy to use. The FS adoption into practice is feasible however a longer implementation period is needed to further explore compliance factors affecting adoption and sustainability. Lessons learned from this project will assist in a revised implementation plan for adoption of the FS under development at the practice site with the goal to transition away from the GCS and to the FS during the next 1-2 years.
  • Implementation and Evaluation of Electronic Prescribing for Preoperative Patients

    Lewis, Cameron N. (2017)
    Background: The adoption of health information technology (HIT) in the United States (US) is increasing due to government efforts to reform the healthcare system. Electronic prescribing (e-prescribing) is a type of HIT that enables prescribers to electronically transmit prescriptions directly and securely to pharmacies via certified and accredited software. Although the use of e-prescribing is rising, the Institute of Medicine’s 2006 recommendation that all prescriptions be received electronically by 2010 has not been met. Problem: The Procedure Readiness Evaluation and Preparation (PREP) center at the targeted site is staffed almost exclusively with advanced practice registered nurses (APRNs). Patients are provided preoperative evaluation and treatment. Mupirocin is the most commonly prescribed medication and is provided preoperatively to surgical cardiac, joint, and spine patients. Although an electronic health record (EHR) system with e-prescribing capabilities was implemented at the site in 2015, providers continued to use paper prescriptions. Thus, the purpose of this DNP scholarly project was to implement and evaluate e-prescribing within an ambulatory surgical preparation center at a large academic medical facility. Methods: This 10 week quality improvement project included all APRNs (N= 7) at the PREP center. Prior to implementation, the project coordinator (PC) met with key organizational stakeholders to obtain support. Frontline staff was engaged. The PC attended several staff meetings during the months leading up to implementation and scheduled informal visits to build rapport and obtain end-user feedback. A site champion from the PREP center was selected to facilitate enhanced provider engagement. Through collaboration with the clinical informatics team, the cardiac, joint, and spine preoperative order sets were modified to contain the appropriate mupirocin regimen, allowing the APRNs to electronically prescribe from directly within each of the order sets. The APRNs were then thoroughly educated and e-prescribing was implemented at the site. During the final month of implementation, a retrospective chart review was completed to determine the number of preoperative cardiac, joint, and spine patients who received their mupirocin prescription electronically. At the conclusion of the project, all APRNs were invited to complete the System Usability Scale (SUS) survey to determine their perceptions of the usability of the e-prescribing system. Results: All PREP center APRNs (N= 7, 100%) received education prior to initiating e-prescribing. During the final month, the APRNs were compliant with e-prescribing, electronically prescribing more than half of all mupirocin prescriptions (n= 33/53, 62%). All of the PREP center APRNs (N= 7, 100%) completed the post-implementation SUS survey and the mean score was 80. Discussion: Sixty-two percent of prescriptions were transmitted electronically during the final month of implementation, which exceeded the goal of 50%. SUS survey results indicated that the providers felt that the e-prescribing system had a high degree of usability. Organizational support, selection of a project champion, and the positive attitudes among the APRNs, along with the EHR modification were crucial to the success of this project. This project is significant given that the utilization of HIT, including e-prescribing, has become a key feature in the US government’s efforts to reform the healthcare system.

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