| Course | NUR 659 Healthcare Safety, Just Culture, and Regulation |
|---|---|
| Module | Module 9 |
| Paper type | comprehensive organizational patient safety plan |
| Length | About 1,080 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 659 Module 9
Final Project: A Three-Year Patient Safety Plan for a Community Hospital
[Student Name]
Southern New Hampshire University
NUR 659: Healthcare Safety, Just Culture, and Regulation
Module Nine Final Project
[Instructor Name]
[Date]
Final Project: A Three-Year Patient Safety Plan for a Community Hospital
Most hospitals have patient safety policies. Fewer have a safety plan that connects culture, analysis, intervention, measurement and governance into a coherent whole. Westbrook, a composite 220-bed community hospital, learned this after a patient received insulin intended for someone else. The investigation found scanners that failed nightly, a culture in which workarounds were routine, discipline that depended on which manager a nurse had, a surgical checklist completed on paper only and a measurement system that saw a small fraction of harm. This final project presents a three-year patient safety plan for board approval. It argues that safety improves when an organization treats harm as a system product, holds people accountable fairly, investigates events to produce strong actions, adopts proven interventions with the conditions that made them work, measures harm honestly and governs the effort from the board down.
Philosophy: Systems Thinking
The plan's foundation is the system approach to error that Reason (2000) contrasted with the person approach. Humans are fallible, errors are expected and the organization's task is to build defenses that catch errors before they reach patients and to remove the latent conditions, such as unreliable equipment and chronic understaffing, that make errors likely. The board will adopt this principle formally, and it will shape every element that follows, from how events are analyzed to how staff are treated after an error.
Culture: A Just Culture Policy
Systems thinking does not mean no one is accountable. Marx (2001) laid out a just culture in which honest mistakes are met with support and system repair, risky shortcuts with coaching and only conscious recklessness with discipline. Westbrook's revised policy judges behavior rather than outcome, uses a review panel that includes a peer from the same role, applies a substitution test asking what colleagues would have done and audits consistency across units each quarter. Managers and the peer pool will be trained in the first six months. Unit reporting rates and culture survey items on fairness will show whether staff trust the policy.
Learning From Events
Serious events will be analyzed with a structured root cause analysis method by independent teams within 45 days. Actions will be ranked by strength, and every analysis must include at least one action from the stronger categories, such as a forcing function or standardization, unless the team documents why none is feasible. Every action gets a named owner, a due date and a measure of its effect, and the patient safety committee will track completion monthly. Lessons will be shared with staff through brief case summaries without names, so that reporting visibly leads to change.
Priority Interventions
Three priorities were chosen for the first two years based on local harm data. First, medication safety, beginning with reliable barcode scanning and a hard stop for manual patient identification. Second, central line infections in the ICU, addressed with the approach Pronovost et al. (2006) used in more than a hundred Michigan ICUs, where an evidence-based bundle, an insertion checklist, nurse authority to stop the procedure, a dedicated supply cart and regular feedback of infection rates were followed by a sharp and sustained fall in bloodstream infections. Third, surgical safety, with a physician-led relaunch of the surgical checklist and audits of actual performance. In each case, the plan reproduces the leadership, empowerment and feedback that accompanied success elsewhere, not only the tools.
Disclosure and Clinician Support
Harm events will be disclosed to patients and families within 24 hours by clinicians supported by a trained disclosure team, with a follow-up conversation including an explicit apology once facts are confirmed. A peer support program will contact clinicians involved in serious events within 24 hours. Both programs will be measured by timeliness and by feedback from patients and staff.
Measurement
Classen et al. (2011) found that the Global Trigger Tool detected about ten times as many adverse events as voluntary reporting or administrative indicators. Westbrook will review twenty randomly selected records a month with the trigger tool, report harm per 1,000 patient days on a run chart and use the most common categories of harm to set improvement priorities. The Safety Attitudes Questionnaire will be administered annually to measure culture by unit. Leaders have been briefed that measured harm will rise at first because more harm will be seen, and that improvement should be judged by trends over time.
Governance, Regulation and Budget
The board's quality committee will receive a quarterly safety dashboard with trigger tool harm rates, progress on priority interventions, action plan completion, disclosure timeliness and culture results. The patient safety officer will report to the chief executive, and the top nursing and medical executives will share the chair of the patient safety committee. The plan maintains compliance with the federal quality program condition, accreditation expectations for sentinel event analysis and patient safety goals and state reporting requirements, with a complete file for every serious event. The three-year budget of about $1.2 million covers replacement scanners, a half-time trigger tool reviewer, peer support and disclosure training and participation in a regional safety collaborative, offset partly by expected reductions in infections and liability costs.
Timeline and Risks
The plan is sequenced over three years. In the first six months, the board adopts the systems principle, the just culture policy is revised and trained, scanners are replaced and the trigger tool baseline begins. In the second half of year one, the ICU bundle and surgical checklist relaunch take place and disclosure and peer support programs start. Year two focuses on spreading medication safety changes to all units and acting on the first trigger tool priorities. Year three concentrates on sustaining gains and addressing the next tier of harm identified by measurement.
The main risks are leadership turnover, competing financial pressures that pull resources away from safety and staff skepticism if early changes are not visible. The plan addresses them by embedding safety goals in executive evaluations, protecting the safety budget as a board commitment and publishing quarterly updates to staff describing what changed because of their reports.
Conclusion
The insulin event showed that Westbrook's safety problems were connected: unreliable systems, inconsistent accountability, weak investigation and blind measurement reinforced one another. A plan grounded in systems thinking and just culture, with strong event analysis, proven interventions implemented with their supporting conditions, honest disclosure, active measurement and board-level governance, addresses them as a whole. The board is asked to approve the plan and its budget and to hold leadership to its measures.
References
Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., Whittington, J. C., Frankel, A., Seger, A., & James, B. C. (2011). 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30(4), 581-589. https://doi.org/10.1377/hlthaff.2011.0190
Marx, D. (2001). Patient safety and the "just culture": A primer for health care executives. Columbia University.
Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., Sexton, B., Hyzy, R., Welsh, R., Roth, G., Bander, J., Kepros, J., & Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-2732. https://doi.org/10.1056/NEJMoa061115
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
What the NUR 659 Module 9 instructions ask for
The NUR 659 Final Project usually asks for a comprehensive patient safety plan for an organization, drawing together the course's work on systems thinking, just culture, event analysis, interventions, measurement and regulation. Plan on ten to twelve pages in APA 7, often with a dashboard or timeline. Begin with the problem that prompted the plan, state the guiding philosophy, show how accountability will be handled fairly, describe how events will be analyzed and acted on, choose priority interventions from local data and evidence, explain how harm and culture will be measured, address disclosure, regulation and governance and close with a budget and a clear request. Sequence the work over time and name the risks to the plan itself.
How this NUR 659 Module 9 final project example is built
This project presents a three-year safety plan for a composite community hospital after an insulin wrong-patient event. It adopts Reason's systems approach, a just culture policy built on Marx's three behaviors with a peer panel and consistency audit, structured root cause analysis requiring strong actions and three priorities, including an ICU bundle modeled on the Pronovost Michigan program. Disclosure and peer support run within 24 hours. The Classen trigger tool evidence supports active harm measurement, and a quarterly board dashboard, regulatory readiness and a budget of about $1.2 million complete the plan. A three-year sequence and risks such as leadership turnover are addressed. Staff see quarterly updates.
Where the NUR 659 Module 9 rubric puts the points
NUR 659 final plans are usually judged on how well the pieces fit together, grounding in safety science, fairness and clarity of the accountability approach, the strength of event analysis and interventions, the quality of measurement, attention to disclosure and regulation, governance and resources and APA 7 writing. Top-band projects show how each element reinforces the others rather than listing separate programs. Graders reward priorities chosen from local harm data, interventions implemented with their supporting conditions, active measurement with leaders prepared for rising numbers and board-level accountability. A realistic budget and a clear request to the board show executive readiness. A realistic sequence and attention to risks such as turnover are valued.
NUR 659 Module 9 help: the mistakes that cost points
Safety plans lose points when they list policies without connecting them, when accountability is either absent or punitive, when event analysis produces weak actions, when interventions are copied without their supporting conditions or when harm is measured by reports alone. Another gap is omitting governance and budget. Connect elements, apply just culture, require strong actions, implement proven interventions fully, measure harm actively, address disclosure and regulation and state governance and costs. If your plan is for an ambulatory network, a long-term care facility or a single unit, send the details with your NUR 659 prompt so it fits. Sequence the plan and name its risks.
Get NUR 659 Module 9 written to your instructions
Describe the organization and the NUR 659 final project prompt and attach the rubric. Your plan will connect systems thinking, just culture, strong event analysis, proven interventions and active measurement under board-level governance, within 24 to 48 hours, free the first time. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
More NUR 659 papers and related MSN samples
- NUR 659 Module 1 Discussion: What the Harm Data Show Two Decades After To Err Is Human
- NUR 659 Module 2 Systems Paper: Why Good Nurses Make Errors
- NUR 659 Module 3 Milestone One: A Root Cause Analysis That Ends in Strong Actions
- NUR 659 Module 4 Just Culture Paper: Error, At-Risk Behavior or Recklessness
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- NUR 659 Module 8 Regulation Paper: The Rules Around Patient Safety
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- NUR 636 Module 5 Case Study: A Feverish Five-Week-Old Who Looks Well
- NUR 635 Module 9 Final Project: The Complete Anticoagulant Safety Teaching Plan
NUR 659 Module 9 questions, answered
Where can I find a free NUR 659 Module 9 Final Project sample?
This page carries the full plan: a three-year hospital safety plan covering systems thinking, just culture, event analysis, proven interventions, disclosure and measured harm.
What should a hospital patient safety plan include?
A guiding philosophy, a just culture policy, event analysis, priority interventions, disclosure and support, measurement, regulatory compliance, governance and a budget.
How should priority safety interventions be chosen?
From local harm data, such as trigger tool results, combined with evidence for interventions that have reduced similar harm elsewhere.
Why must proven interventions be implemented with their supporting conditions?
Programs like Michigan's succeeded through leadership, empowerment and feedback as well as checklists, and copying only the tools often fails.
How should a board oversee patient safety?
Through a regular dashboard of harm rates, intervention progress, action completion and culture results, with leaders accountable for targets.