include at least 3 reference in apa 7th format
Unit 1 Discussion 2 PICOT question — 800 words due 3/8/22
Read the article “Asking the clinical question: A key step in evidence-based practice (Links to an external site.).” The article is attached.
After reading the article, create your own PICOT question around the topic you selected that will be used for your Unit 2 Introduction to an Evidence-Based Practice Problem. In your discussion post, complete the following 2 questions :——-(I have already selected the PICOT question it is located below).
1. Share and discuss your created PICOT question. (I have already selected the PICOT question it is located below).
2. Describe your selected topic and its significance (500 words).
Topic selected: The effects of proning therapy in COVID 19 patients.
For COVID-19 positive patients, has the use of proning therapy been effective in reducing mortality and intubation rates?
P: Covid- 19 positive patients with the ICU.
I: Proning therapy
C: supine position
O: Reduced intubation & mortality of COVID-19 patients
T: during hospital admittance.
What is PICOT?
To formulate questions in Evidence Based Practice, use the PICOT format.
PICOT stands for:
· Population/ Patient Problem: Who is your patient? (Disease or Health status, age, race, sex)
· Intervention: What do you plan to do for the patient? (Specific tests, therapies, medications)
· Comparison: What is the alternative to your plan? (ie. No treatment, different type of treatment, etc.)
· Outcome: What outcome do you seek? (Less symptoms, no symptoms, full health, etc.)
· Time: What is the time frame? (This element is not always included.)
Your PICOT question will fall under one of these types:
· Therapy/Prevention
· Diagnosis
· Etiology
· Prognosis
The documents in the box on the left to find which level of research is appropriate for your type of PICOT question.
T
o fully implement evidence-
based practice (EBP),
nurses need to have both
a spirit of inquiry and a culture
that supports it. Inour first article
in this series (“Igniting a Spirit of
Inquiry:AnEssential Foundation
for Evidence-Based Practice,”
November 2009),we defined a
spirit of inquiry as “an ongoing
curiosity about the best evidence
toguide clinical decisionmaking.”
A spirit of inquiry is the founda-
tionof EBP, andonce nurses pos-
sess it, it’s easier to take the next
step—toask the clinical question.1
Formulating a clinical question
in a systematicwaymakes it pos-
sible to find an answermore
quickly and efficiently, leading to
improved processes and patient
outcomes.
In the last installment,wegave
an overviewof themultistepEBP
process (“The Seven Steps of
Evidence-Based Practice,” Janu-
ary). Thismonthwe’ll discuss
step one, asking the clinical
question. As a context for this
discussionwe’ll use the same
scenariowe used in the previous
articles (see Case Scenario for
EBP: Rapid Response Teams).
In this scenario, a staff nurse,
let’s call herRebeccaR., noted
that patients on hermedical–
surgical unit had a high acuity
level thatmay have led to an in-
crease in cardiac arrests and in the
number of patients transferred
to the ICU.Of thepatientswho
had a cardiac arrest, four died.
Rebecca sharedwith her nurse
manager a recently published
study onhow the use of a rapid
response teamresulted in reduced
in-hospital cardiac arrests andun-
planned admissions to the critical
Asking the Clinical Question: A Key Step in
Evidence-Based Practice
A successful search strategy starts with a well-formulated question.
This is the third article in a series from the Arizona State University College of Nursing and Health Innovation’s Center
for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the
delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and
patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the
highest quality of care and best patient outcomes can be achieved.
The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one
step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward
implementing EBP at your institution. Also, we’ve scheduled “Ask the Authors” call-ins every few months to provide a
direct line to the experts to help you resolve questions. Details about how to participate in the next call will be pub-
lished with May’s Evidence-Based Practice, Step by Step.
Case Scenario for EBP: Rapid Response Teams
You’re a staff nurse on a busy medical–surgical unit. Overthe past three months, you’ve noticed that the patients on
your unit seem to have a higher acuity level than usual, with
at least three cardiac arrests per month, and of those patients
who arrested, four died. Today, you saw a report about a
recently published study in Critical Care Medicine on the use
of rapid response teams to decrease rates of in-hospital car-
diac arrests and unplanned ICU admissions. The study found
a significant decrease in both outcomes after implementation
of a rapid response team led by physician assistants with spe-
cialized skills.2 You’re so impressed with these findings that
you bring the report to your nurse manager, believing that a
rapid response team would be a great idea for your hospital.
The nurse manager is excited that you have come to her with
these findings and encourages you to search for more evidence
to support this practice and for research on whether rapid re-
sponse teams are valid and reliable.
58 AJN � March 2010 � Vol. 110, No. 3 ajnonline.com
care unit.2 Shebelieved this could
be a great idea for her hospital.
Based onher nursemanager’s
suggestion to search formore evi-
dence to support theuseof a rap-
id response team,Rebecca’s spirit
of inquiry ledher to take thenext
step in the EBPprocess: asking
the clinical question. Let’s follow
Rebecca as shemeetswithCar-
losA., oneof the expertEBPmen-
tors from the hospital’s EBP and
research council, whose role is to
assist point of care providers in
enhancing their EBPknowledge
and skills.
Types of clinical questions.
Carlos explains toRebecca that
finding evidence to improve pa-
tient outcomes and support a
practice change depends upon
how the question is formulated.
Clinical practice that’s informed
by evidence is based onwell-
formulated clinical questions
that guide us to search for the
most current literature.
There are two types of clinical
questions: backgroundquestions
and foregroundquestions.3-5 Fore-
ground questions are specific and
relevant to the clinical issue. Fore-
groundquestionsmust be asked
in order to determinewhich of
two interventions is themost ef-
fective in improving patient out-
comes. For example, “In adult
patients undergoing surgery, how
does guided imagery compared
withmusic therapy affect anal-
gesia usewithin the first 24hours
post-op?” is a specific,well-
defined question that can only
guides her in formulating a fore-
groundquestionusing PICOT
format.
PICOT is an acronym for the
elements of the clinical question:
patient population (P), interven-
tion or issue of interest (I), com-
parison intervention or issue of
interest (C), outcome(s) of inter-
est (O), and time it takes for the
intervention to achieve the out-
come(s) (T).WhenRebecca asks
why the PICOTquestion is so
important, Carlos explains that
it’s a consistent, systematicway
to identify the components of a
clinical issue. Using the PICOT
format to structure the clinical
question helps to clarify these
components,whichwill guide the
search for the evidence.6, 7 Awell-
built PICOTquestion increases
the likelihood that the best evi-
dence to informpracticewill be
foundquickly and efficiently.5-8
To helpRebecca learn to for-
mulate a PICOTquestion,Car-
los uses the earlier example of a
foregroundquestion: “In adult
patients undergoing surgery, how
does guided imagery compared
be answered by searching the
current literature for studies
comparing these two interven-
tions.
Background questions are
considerably broader andwhen
answered, provide general knowl-
edge. For example, a background
question suchas, “What therapies
reduce postoperative pain?” can
generally be answeredby looking
in a textbook. Formore informa-
tion on the two types of clinical
questions, see Comparison of
Background and Foreground
Questions.4-6
Ask the question in PICOT
format. Now thatRebecca has
an understanding of foreground
andbackgroundquestions,Carlos
Comparison of Background and Foreground Questions4-6
Question type Description Examples
Background
question
A broad, basic-knowledge question
commonly answered in textbooks.
May begin with what or when.
1) What is the best method to pre-
vent pressure ulcers?
2) What is sepsis?
3) When do the effects of
furosemide peak?
Foreground
question
A specific question that, when
answered, provides evidence for clin-
ical decision making. A foreground
question includes the following ele-
ments: population (P), intervention or
issue of interest (I), comparison inter-
vention or issue of interest (C), out-
come (O), and, when appropriate,
time (T).
1) In mechanically ventilated pa-
tients (P), how does a weaning
protocol (I) compared with no
weaning protocol (C) affect venti-
lator days (O) during ICU length
of stay (T)?
2) In hospitalized adults (P), how
does hourly rounding (I) com-
pared with no rounding (C) affect
fall rates (O)?
The PICOT question is a consistent,
systematic way to identify the components
of a clinical issue.
By Susan B. Stillwell, DNP, RN, CNE, Ellen Fineout-Overholt, PhD,
RN, FNAP, FAAN, Bernadette Mazurek Melnyk, PhD, RN,
CPNP/PMHNP, FNAP, FAAN, and Kathleen M. Williamson, PhD, RN
ajn@wolterskluwer.com AJN � March 2010 � Vol. 110, No. 3 59
also not always required. But
population, intervention or issue
of interest, and outcome are es-
sential to developing any PICOT
question.
Carlos asksRebecca to reflect
on the clinical situation onher
unit in order to determine the
unit’s current intervention for ad-
dressing acuity. Reflection is a
strategy to help clinicians extract
critical components from the clin-
ical issue to use in formulating
the clinical question.3 Rebecca
andCarlos revisit aspects of the
clinical issue to seewhichmaybe-
come components of the PICOT
question: the high acuity of pa-
tients on the unit, the number of
cardiac arrests, the unplanned
ICUadmissions, and the research
article on rapid response teams.
Once the issue is clarified, the
PICOTquestion can bewritten.
withmusic therapy affect analge-
sia usewithin the first 24 hours
post-op?” In this example, “adult
patients undergoing surgery” is
thepopulation (P), “guided imag-
ery” is the interventionof interest
(I), “music therapy” is the com-
parison intervention of interest
(C), “pain” is the outcomeof in-
terest (O), and“the first 24hours
post-op” is the time it takes for
the intervention to achieve the
outcome (T). In this example,
music therapy or guided imagery
is expected to affect the amount
of analgesia used by the patient
within the first 24hours after sur-
gery.Note that a comparisonmay
not be pertinent in somePICOT
questions, such as in “meaning
questions,”which are designed
to uncover themeaning of a
particular experience.3, 6 Time is
Templates and Definitions for PICOT Questions5, 6
Question type Definition Template
Intervention or
therapy
To determine which treatment leads to the
best outcome
In _____________________ (P),
how does ______________ (I)
compared with ___________ (C)
affect __________________ (O)
within __________________ (T)?
Etiology To determine the greatest risk factors or
causes of a condition
Are ______________________________ (P)
who have ________________________ (I),
compared with those without ________ (C),
at ____ risk for ____________________ (O)
over _____________________________ (T)?
Diagnosis or
diagnostic test
To determine which test is more accurate and
precise in diagnosing a condition
In ______________________________ (P),
are/is ___________________________ (I)
compared with ___________________ (C)
more accurate in diagnosing _______ (O)?
Prognosis or
prediction
To determine the clinical course over time
and likely complications of a condition
In ___________________ (P),
how does _____________ (I)
compared with ________ (C),
influence _____________ (O)
over _________________ (T)?
Meaning To understand the meaning of an experience
for a particular individual, group, or commu-
nity
How do ______________ (P)
with _________________ (I)
perceive ______________ (O)
during _______________ (T)?
A well-built PICOT question increases the
likelihood that the best evidence to inform
practice will be found.
60 AJN � March 2010 � Vol. 110, No. 3 ajnonline.com
BecauseRebecca’s issue of in-
terest is the rapid response team—
an intervention—Carlos provides
herwith an“interventionor ther-
apy” template to use in formu-
lating the PICOTquestion. (For
other types of templates, see Tem-
plates and Definitions for PICOT
Questions.5, 6) Since the hospital
doesn’t have a rapid response
teamanddoesn’t have a plan for
addressing acuity issues before a
crisis occurs, the comparison, or
(C) element, in the PICOTques-
tion is “no rapid response team.”
“Cardiacarrests”and“unplanned
admissions to the ICU”are the
outcomes in the question.Other
potential outcomes of interest to
the hospital could be “lengths of
stay” or “deaths.”
Rebecca proposes the follow-
ing PICOTquestion: “In hospi-
talized adults (P), howdoes a
rapid response team (I) compared
with no rapid response team (C)
clinical question that’smost ap-
propriate for each scenario, and
choose a template to guide you.
Then formulate onePICOTques-
tion for each scenario. Suggested
PICOTquestionswill be pro-
vided in the next column. �
Susan B. Stillwell is clinical associate
professor and program coordinator of
the Nurse Educator Evidence-Based
Practice Mentorship Program at Arizona
State University in Phoenix, where Ellen
Fineout-Overholt is clinical professor and
director of the Center for the Advance-
ment of Evidence-Based Practice, Ber-
nadette Mazurek Melnyk is dean and
distinguished foundation professor of
nursing, and Kathleen M. Williamson is
associate director of the Center for the
Advancement of Evidence-Based Prac-
tice. Contact author: Susan B. Stillwell,
sstillwell@asu.edu.
REFERENCES
1.MelnykBM, et al. Igniting a spirit of
inquiry: an essential foundation for
evidence-based practice. Am J Nurs
2009;109(11):49-52.
2.DaceyMJ, et al. The effect of a rapid
response teamonmajor clinical out-
comemeasures in a community hos-
pital. Crit Care Med 2007;35(9):
2076-82.
3.Fineout-Overholt E, JohnstonL.
TeachingEBP: asking searchable, an-
swerable clinical questions. World-
views Evid Based Nurs 2005;2(3):
157-60.
4.NollanR, et al. Asking compelling
clinical questions. In:MelnykBM,
Fineout-Overholt E, editors. Evidence-
based practice in nursing and health-
care: a guide to best practice.
Philadelphia: LippincottWilliams
andWilkins; 2005. p. 25-38.
5.Straus SE. Evidence-based medicine:
how to practice and teach EBM. 3rd
ed. Edinburgh;NewYork: Elsevier/
Churchill Livingstone; 2005.
6.Fineout-Overholt E, Stillwell SB.Ask-
ing compelling questions. In:Melnyk
BM, Fineout-Overholt E, editors.
Evidence-based practice in nursing
and healthcare: a guide to best practice
[forthcoming]. 2nd ed. Philadelphia:
WoltersKluwerHealth/Lippincott
Williams andWilkins.
7.McKibbonKA,Marks S. Posing clini-
cal questions: framing the question
for scientific inquiry. AACN Clin
Issues 2001;12(4):477-81.
8.Fineout-Overholt E, et al. Teaching
EBP: getting to the gold: how to search
for thebest evidence. Worldviews Evid
Based Nurs 2005;2(4):207-11.
affect the number of cardiac ar-
rests (O) and unplanned admis-
sions to the ICU (O) duringa
three-month period (T)?”
Now thatRebecca has formu-
lated the clinical question, she’s
ready for thenext step in theEBP
process, searching for the evi-
dence. Carlos congratulates
Rebecca ondeveloping a search-
able, answerable question and
arranges tomeetwith her again
tomentor her in helping her find
the answer to her clinical ques-
tion. The fourth article in this
series, tobepublished in theMay
issue of AJN, will focus on strat-
egies for searching the literature
to find the evidence to answer
the clinical question.
Now that you’ve learned to
formulate a successful clinical
question, try this exercise: after
reading the two clinical scenarios
in Practice Creating a PICOT
Question, select the type of
Practice Creating a PICOT Question
Scenario 1: You’re a recent graduate with two years’ experi-
ence in an acute care setting. You’ve taken a position as a
home health care nurse and you have several adult patients
with various medical conditions. However, you’ve recently
been assigned to care for hospice patients. You don’t have
experience in this area, and you haven’t experienced a loved
one at the end of life who’s received hospice care. You notice
that some of the family members or caregivers of patients in
hospice care are withdrawn. You’re wondering what the fam-
ily caregivers are going through, so that you might better un-
derstand the situation and provide quality care.
Scenario 2: You’re a new graduate who’s accepted a position
on a gerontology unit. A number of the patients have demen-
tia and are showing aggressive behavior. You recall a clinical
experience you had as a first-year nursing student in a long-
term care unit and remember seeing many of the patients in
a specialty unit for dementia walking around holding baby
dolls. You’re wondering if giving baby dolls to your patients
with dementia would be helpful.
What type of PICOT question would you create for each of
these scenarios? Select the appropriate templates and formu-
late your questions.
ajn@wolterskluwer.com AJN � March 2010 � Vol. 110, No. 3 61
2012 – ALL LEVELS
GLOSSARY: QUALITY, SAFETY AND EVIDENCE-BASED PRACTICE (EBP)
A-B
Adverse Event: An injury resulting from a medical intervention. (Reason, 1
9
90 and IOM, 2000. p 210) or An event that results in unintended harm to the patient due to an act of commission or omission rather than the underlying disease or condition of the patient. (IOM, 2004, p 327)
Adverse Drug Event: An injury resulting from medical intervention related to a drug (IOM, 1999) or simply “an injury resulting from the use of a drug.” (Nebeker, JR, Barach, P, and Samore MH, 2004)
AHRQ:
Agency for Healthcare Research and Quality
. Go to http://www.ahrq.gov/.
Aims for Improvement: Health care should be safe, effective, patient-centered, timely, efficient, and equitable. (IOM, 2001, chapter 2)
Bad Outcome: Failure to achieve a desired outcome of care. (IOM, 2000. p 210)
C
Case-Control Study: A type of research that retrospectively compares characteristics of an individual who has a certain condition (e.g. hypertension) with one who does not (i.e., a matched control or similar person without hypertension); often conducted for the purpose of identifying variables that might predict the condition (e.g., stressful lifestyle, sodium intake). (Melnyk & Fineout-Overholt, 2010, p 572)
Case Study: An intensive investigation of a case involving a person or small group of persons, an issue, or an event. (Melnyk & Fineout-Overholt, 2010, p 572)
Cause Map: A visual explanation of why an incident occurred. It connects individual cause-and-effect relationships to reveal the system of causes within an issue. It identifies all of the causes and different options for solutions rather than focusing on one cause and one solution to a problem. It is one method of root-cause analysis. (ThinkReliability, 2009)
Clinical Inquiry: A process in which clinicians gather data together using narrowly defined clinical parameters; it allows for an appraisal of the available choices of treatment for the purpose of finding the most appropriate choice of action. (Melnyk & Fineout-Overholt, 2010, p 572)
Clinical Practice Guidelines: Systematically developed statements to assist clinicians and patients in making decisions about care; ideally the guidelines consist of a systematic review of the literature, in conjunction with consensus of a group of expert decision-makers, including administrators, policy makers, clinicians, and consumers who consider the evidence and make recommendations. (Melnyk & Fineout-Overholt, 2010, p 572)
Close Call: An event or situation that could have resulted in an adverse event (or accident) but did not, either by chance or through timely intervention. Also referred to as a near miss or good catch. (U.S. Department of Veterans Affairs, 2002)
Cohort Study: A longitudinal study that begins with the gathering of two groups of patients (the cohorts), one that received the exposure (e.g., to a disease) and one that does not, and then following these groups over time (prospective) to measure the development of different outcomes (diseases). (Melnyk & Fineout-Overholt, 2010, p 573)
Commission: The act of doing something.
Critical Inquiry: Theoretical perspectives that are ideologically oriented toward critique of and emancipation from oppressive social arrangements or false ideas. (Melnyk & Fineout-Overholt, 2010, p 573-574)
Culture: Shared knowledge and behavior of people who interact within distinct social settings and subsystems. (Melnyk & Fineout-Overholt, 2010, p 574)
D-G
Data and Safety Monitoring Plan: A detailed plan for how adverse effects will be assessed and managed. (Melnyk & Fineout-Overholt, 2010, p 574)
Electronic Medical Record (EMR): A collection of a patient’s medical information in a digital (electronic) form that can be viewed on a computer and easily shared by people taking care of the patient. (Used interchangeably with Electronic Health Record although the EMR is a subset of HER – The electronic medical record is often just one healthcare system’s record rather than the entire health record for an individual.) (National Cancer Institute, 2009)
Error: The failure of a planned action to be completed as intended (i.e., error of execution), and the use of a wrong plan to achieve an aim (i.e., error of planning) (IOM, 2000). It also includes failure of an unplanned action that should have been completed (omission). (IOM, 2004, p 330 & IOM, 2004, p 360)
Evidence: Scientific evidence is a replicable and generalizable observation that can be experienced nearly identically by independent people from different places and at different times. (IOM, 2004, p 330) Also see Levels of Evidence.
Evidence-Based Practice (EBP): The integration of the best research evidence with clinical expertise and patient values. (Sackett, et al, 2000, p 1)
Evidence-Based Practice Model: The LCC nursing program has adopted the Melnyk & Fineout-Overholt seven step evidence-based practice model:
0. Cultivate a spirit of inquiry.
1. Ask the burning clinical question in PICOT format.
2. Search for and collect the most relevant best evidence.
3. Critically appraise the evidence.
4. Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change.
5. Evaluate outcomes of the practice decision or change based on evidence.
6. Disseminate the outcomes of the EBP decision or change. (Melnyk & Fineout-Overholt, 2010, p 11)
Expert Opinion: Recommendations from persons with established expertise in a specific clinical area often based on clinical experience; not considered a research method because systematic (or critical) inquiry is lacking. (Kruszewski, 2009)
Generalizability: The extent to which the findings from a study can be generalized or applied to the larger population. (Melnyk & Fineout-Overholt, 2010, p 576)
Good Catch:
See close call or near miss.
H-L
Hand-Off: The process of moving patients and their information from one provider or site to another. (IOM, 2007).
Harm: When risks outweigh benefits. (Melnyk & Fineout-Overholt, 2010, p 576)
Hierarchy of Evidence: A mechanism for determining which study designs have the most power to predict cause-and-effect. The highest level of evidence is systematic reviews of RCTs, and the lowest level of evidence is expert opinion and consensus statements. (Melnyk & Fineout-Overholt, 2010, p 576)
Informatics: How data, information, knowledge, and wisdom are collected, stored, processed, communicated, and used to support the process of healthcare delivery to clients, providers, administrators, and organizations involved in healthcare delivery. (Melnyk & Fineout-Overholt, 2010, p 577)
IOM:
Institute of Medicine
was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. Found at http://www.ihi.org/ (IOM, 2000)
Latent Error: Errors in the design, organization, training, or maintenance that lead to operator errors and whose effects typically lie dormant in the system for lengthy periods of time. (IOM, 2000. p 210)
Levels of Evidence: A ranking of evidence by the type of design or research methodology that would answer the question with the least amount of error and provide the most reliable findings. Leveling of evidence, also called hierarchies, vary by type of question asked. An example is provided
· Level I Evidence: Evidence that is generated from systematic reviews or meta-analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials; the strongest level of evidence to guide clinical practice.
· Level II Evidence: Evidence generated from at least one well-designed randomized clinical trial (i.e., a true experiment).
· Level III Evidence: Evidence obtained from well-designed controlled trials without randomization.
· Level IV Evidence: Evidence from well-designed case-control and cohort studies.
· Level V Evidence: Evidence from systematic reviews of descriptive and qualitative studies.
· Level VI Evidence: Evidence from a single descriptive or qualitative study.
· Level VII Evidence: Evidence from the opinion of authorities and/or reports of expert committees. (Melnyk & Fineout-Overholt, 2010, p 577)
M-N
Meta-Analysis: A process of using quantitative methods to summarize the results from multiple studies, obtained and critically reviewed using a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific question and draw conclusions about the data gathered. The purpose of this process is to gain a summary statistic (i.e., a measure of a single effect) that represents the effect of the intervention across multiple studies. (Melnyk & Fineout-Overholt, 2010, p 578)
Medical Error: Mistake that harms a patient. Adverse drug reactions, hospital-acquired infections and wrong site surgeries are examples of preventable medial errors. (Robert Wood Johnson Foundation, 2009)
Medication Error: Any error occurring in the medication-use process. IOM, 2004, p 360; Bates, 1995)
Misuse: Misuse occurs when an appropriate process of care has been selected, but a preventable complication occurs and the patient does not receive the full potential benefit of the service. Avoidable complications of surgery or medication use are misuse problems. A patient who suffers a rash after receiving penicillin for strep throat, despite having a known allergy to that antibiotic, is an example of misuse. A patient who develops a pneumothorax after an inexperienced operator attempted to insert a subclavian line would represent another example of misuse. (Robert Wood Johnson Foundation, 2009)
National Guidelines Clearinghouse: A comprehensive database of up-to-date English language evidence-based clinical practice guidelines, developed in partnership with the American Medical Association, the American Association of Health Plans, and the Association for Healthcare Research and Quality. Found at http://www.guideline.gov/. (Melnyk & Fineout-Overholt, 2010, p 578)
Note:
Funding has ended for the NGC. See
Agency for Healthcare Research and Quality
for information. https://www.ahrq.gov/gam/index.html (June 2019)
Near Miss: An error of commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance (e.g., the patient received a contraindicated drug but did not experience an adverse reaction), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation (e.g., a lethal drug overdose was administered but discovered early and countered with an antidote). Also referred to as a close call or good catch. (IOM, 2007, p 332)
“Never-Events”: “Never-Events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility. Examples are: surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe ‘pressure ulcer’ acquired in the hospital; and preventable post-operative deaths. (
National Quality Forum
, 2009)
O-Q
Omission: Neglecting to do something; failure to act; neglect of duty; and/or leaving something undone.
Overuse: Overuse describes a process of care in circumstances where the potential for harm exceeds the potential for benefit. Prescribing an antibiotic for a viral infection like a cold, for which antibiotics are ineffective, constitutes overuse. The potential harm includes adverse reactions to the antibiotics and increases antibiotic resistance among bacteria in the community. Overuse can also apply to diagnostic tests and surgical procedures. (Robert Wood Johnson Foundation, 2009)
Patient Preferences: Values the patient holds, concerns the patient has regarding the clinical decision/treatment/situation, and choices the patient has/prefers regarding the clinical decision/treatment/situation. (Melnyk & Fineout-Overholt, 2010, p 579)
Patient Safety: Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur. (IOM, 2000. p 211)
Peer Reviewed: A project, paper, study, etc. is reviewed by a person(s) who is a peer to the author and has expertise in a subject. (Melnyk & Fineout-Overholt, 2010, p 579)
PICOT Format: A process in which clinical questions are phrased in a manner that yields the most relevant information; P = patient population; I = Intervention or issue of interest; C = Comparison intervention or status; O = Outcome’ T = Time frame for (I) to achieve the (O). (Melnyk & Fineout-Overholt, 2010, p 579)
Primary Studies (literature): Studies that collect original data. Primary studies are differentiated from systematic reviews that summarize the results of primary studies. (DiCenso, Guyatt & Ciliska, 2005, p 564).
p Value: The statistical test of the assumption that there is no difference between an experimental intervention and a control. p value indicates the probability of an event, given the assumption that there is no true difference. By convention, a p value of 0.05 is considered a statistically significant result. (Melnyk & Fineout-Overholt, 2010, p 580)
Quality of Care: Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (IOM, 1990 and IOM, 2000, p 211)
Quality Improvement: Process by which an organization improves or increases the quality of care in the institution and/or along the continuum of care. Improvements should be sought in the six areas described by the Institute of Medicine in the “Aims for Improvement.” (Hoover, 2009)
Quantitative Research: The investigation of phenomena using manipulation of numeric data with statistical analysis. Can be descriptive, predictive, or causal. (Melnyk & Fineout-Overholt, 2010, p 580)
R-V
Random Sampling: Selecting subjects to participate in a study by using a random strategy (e.g., tossing a coin); in this method of selecting subjects, every subject has an equal chance of being selected. (Melnyk & Fineout-Overholt, 2010, p 580)
Randomized Controlled Trial (RCT): A true experiment (i.e., one that delivers an intervention or treatment in which subjects are randomly assigned to control and experimental groups); the strongest design to support cause and effect relationships. (Melnyk & Fineout-Overholt, 2010, p 581)
Reconciliation: Comparison of the medications a person is taking in one care setting with those being provided in another setting. (IOM, 2007, p 361)
Root-Cause Analysis: An approach for identifying the underlying causes of why an incident occurred so that the most effective solutions can be identified and implemented. It’s typically used when something goes badly, but can also be used when something goes well. Within an organization, problem solving, incident investigation and root-cause analysis are all fundamentally connected by three basic questions: What’s the problem? Why did it happen? and What will be done to prevent it? (ThinkReliability, 2009)
Secondary Literature: Sources that are not original studies or research but are a compilation or summary of primary studies. They usually follow a prescribed criteria or rating system. Examples are clinical practice guidelines and systematic reviews. (Hoover, 2009)
Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. (
The Joint Commission
, 2009)
Systematic Review: A summary of evidence, typically conducted by an expert or expert panel on a particular topic, that uses a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific clinical question and draw conclusions about the data gathered. (Melnyk & Fineout-Overholt, 2010, p 582)
Validity of Study Findings: Whether or not the results of a study were obtained via sound scientific methods. (Melnyk & Fineout-Overholt, 2010, p 583)
References
Bates, DW, Boyle DI, Vander Vliet MB, Schneider J, Leape L. (1995). Relationship between medication errors and adverse drug events. Journal of general internal medicine, 10(4): 100-205.
DiCenso, A.; Guyatt, Gordon; & Chiliska, Donna (2005). Evidence based nursing: A guide to clinical practice. Philadelphia: Mosby, Inc.
Hoover, Leslie (2009) Personal Communication. Lansing Community College, Michigan.
Institute of Medicine (IOM) (1990). Medicare: A strategy for quality assurance, volume II. Washington, D.C.: National Academy Press.
Institute of Medicine (IOM) (2000). To err is human: Building a safer health system. Washington, D.C.: National University Press.
Institute of Medicine (IOM) (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press.
Institute of Medicine (IOM) (2004). Patient safety: Achieving a new standard for care. Washington, D.C.: National University Press.
Institute of Medicine (IOM) (2007). Preventing medication errors. Washington, D.C.: National University Press.
Kruszewski, Ann (2009). Personal Communication. Howell, Michigan: EBP Nurse Consultants, LLC.
Melnyk, Bernadette Mazurek & Fineout-Overholt, Ellen (2010). Evidence-based practice in nursing & healthcare:A guide to best practice. Philadelphia: Lippincott Williams & Wilkins.
National Cancer Institute. Retrieved on 04/21/09 from http://www.cancer.gov /templates/db_alpha.aspx?expand=E
National Coordinating Council for Medication Error Reporting and Prevention
(1998). What is a medication error? Retrieved 04/08/09 from http://www.nccmerp.org/about MedErrors.html
(Note: Link now https://www.nccmerp.org/about-medication-errors June 2019)
National Quality Forum. Retrieved on 04.20.09 from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863.
Nebeker, JR, Barach, P, and Samore MH (2004). Clarifying adverse drug events: A clinician’s guide to terminology, documentation, and reporting. Annals of internal medicine, 140, 795-801.
Reason, James T. (1990). Human error. Cambridge, MA: Cambridge University Press.
Sackett, David L., Strauss, Sharon E., Richardson, W. Scott, Rosenberg, William, & Haynes, R. Bryan (2000). Evidence-based medicine: How to practice & teach EBM. London: Churchill Livingstone.
Robert Wood Johnson Foundation.
Glossary of Health Care Quality Terms
, Retrieved 03/16/09 from http://www.rwjf.org/qualityequality/glossary.jsp (Note: Link now https://www.rwjf.org/en/library/research/2013/04/quality-equality-glossary.html June 2019)
The Joint Commission: http://www.jointcommission.org/
ThinkReliability. Root Cause Analysis, Retrieved on 04/15/09 from http:// think reliability.com/Root-Cause-Analysis-CM-Basics.aspx
Glossary_QSEBP_10
April 2009 LKH; last updated December 2011
Revised for accessibility and link checking June 2019 LCC Library
9
Levels of Evidence Flow Chart
Description
Title: Levels of Evidence Flow Chart
Steps to
Randomly
Controlled Trial
(RCT)
Level 2
1. Does the article discuss one study or multiple studies?
2. If the answer is one study then question:
Was there a control group and one or more intervention groups?
3. If the answer is yes then question:
Were individuals randomly assigned to groups?
4. If the answer is yes then it is a Randomly Controlled Trial (RCT) Level 2.
Steps to Controlled Trial
Level 3
1. Does the article discuss one study or multiple studies?
2. If the answer is one study then question: Was there a control group and one or more intervention groups?
3. If the answer is yes then question: Were individuals randomly assigned to groups?
4. If the answer is no then it is a Controlled Trial Level 3.
Steps to
Case Control Study
Level 4
1. Does the article discuss one study or multiple studies?
2. If the answer is one study then question: Was there a control group and one or more intervention groups?
3. If the answer is no then question:
Does the study compare two or more groups over time?
4. If the answer is yes then question:
Does the study retrospectively compare two groups using existing data as control?
5. If the answer is yes then it is a Case Control Study Level 4.
Steps to Cohort Study Level 4
1. Does the article discuss one study or multiple studies?
2. If the answer is one study then question: Was there a control group and one or more intervention groups?
3. If the answer is no then question: Does the study compare two or more groups over time?
4. If the answer is yes then question: Does the study retrospectively compare two groups using existing data as control?
5. If the answer is no then question:
Does the study compare the outcomes of two groups over time?
6. If the answer is yes then it is a Cohort Study Level 4.
Description continued
Title: Levels of Evidence Flow Chart
Steps to Single Descriptive or Qualitative Study
Level 6
1. Does the article discuss one study or multiple studies?
2. If the answer is one study then question: Was there a control group and one or more intervention groups?
3. If the answer is no then question: Does the study compare two or more groups over time?
4. If the answer is no then question:
Was the study descriptive or qualitative?
5. If the answer is yes then it is a Single Descriptive or Qualitative Study Level 6.
Steps to Expert Opinion Level
7
1. Does the article discuss one study or multiple studies?
2. If the answer is one study then question: Was there a control group and one or more intervention groups?
3. If the answer is no then question: Does the study compare two or more groups over time?
4. If the answer is no then question: Was the study descriptive or qualitative?
5. If the answer is no then question:
Was the article the opinion of an expert?
6. If the answer is yes then in it an Expert Opinion Level 7.
Steps to Systematic Review, Meta-Analysis of RCT’s; Evidence Based Clinical Practice Guidelines
Level 1
.
1. Does the article discuss one study or multiple studies?
2. If the answer is multiple studies then question: Did the study analyze RCT’s and/or propose clinical practice guidelines?
3. If the answer is yes then it is a Systematic Review, Meta-Analysis of RCT’s; Evidence Based Clinical Practice Guidelines Level 1.
Steps to Systematic Review of Descriptive and/or Qualitative Studies
Level 5
.
1. Does the article discuss one study or multiple studies?
2. If the answer is multiple studies then question: Did the study analyze RCT’s and/or propose clinical practice guidelines?
3. If the answer is no then it is a Systematic Review of Descriptive and/or Qualitative Studies Level 5.
Lansing Community College Library May 2019
Does the article discuss one study or multiple studies??
One study
Was there a control group and one or more intervention groups?
Multiple studies
Did the study analyze RCT’s and/or propose clinical practice guidelines?
Yes
Were individuals randomly assigned to groups?
No
Yes
No
Randomly Controlled Trial (RCT)
Level 2
Controlled Trial
Level 3
Does the study compare two or more groups over time?
Yes
No
Yes
No
Systematic review, meta-analysis of RCT’s; Evidence-based clinical practice guidelines
Level 1
Systematic review of descriptive and/or qualitative studies
Level 5
Does the study retrospectively compare two groups using existing data as control?
Yes
Case Control Study
Level 4
No
Does the study compare the outcomes of two groups over time?
Yes
Cohort study
Level 4
Was the study descriptive or qualitative?
Yes
No
A single descriptive or qualitative study
Level 6
Was the article the opinion of an expert?
Yes
Expert opinion
Level 7
Evidence Pyramid – Levels of Evidence
Level 1 Evidence
· Clinical Practice Guidelines: Systematically developed statements to assist clinicians and patients in making decisions about care; ideally the guidelines consist of a systematic review of the literature, in conjunction with consensus of a group of expert decision-makers, including administrators, policy makers, clinicians, and consumers who consider the evidence and make recommendations.
The level of evidence of systematic reviews and meta-analyses depends on the types of studies reviewed:
· Systematic Review: A summary of evidence, typically conducted by an expert or expert panel on a particular topic, that uses a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific clinical question and draw conclusions about the data gathered.
· Meta-Analysis: A process of using quantitative methods to summarize the results from multiple studies, obtained and critically reviewed using a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific question and draw conclusions about the data gathered. The purpose of this process is to gain a summary statistic (i.e., a measure of a single effect) that represents the effect of the intervention across multiple studies.
Level 2 Evidence
· Randomized Controlled Trial (RCT): A true experiment (i.e., one that delivers an intervention or treatment in which subjects are randomly assigned to control and experimental groups); the strongest design to support cause and effect relationships.
Level 3 Evidence
· Controlled Trial: experimental design that studies the effect of an intervention or treatment using at least two groups: one that received the intervention and one that did not; participants are NOT randomly assigned to a group.
Level 4 Evidence
· Cohort Study: A longitudinal study that begins with the gathering of two groups of patients (the cohorts), one that received the exposure (e.g., to a disease) and one that does not, and then following these groups over time (prospective) to measure the development of different outcomes (diseases).
· Case-Control Study: A type of research that retrospectively compares characteristics of an individual who has a certain condition (e.g. hypertension) with one who does not (i.e., a matched control or similar person without hypertension); often conducted for the purpose of identifying variables that might predict the condition (e.g., stressful lifestyle, sodium intake).
Level 5 Evidence
· Systematic Review of Descriptive and Qualitative Studies: See above for more information about systematic reviews.
Level 6 Evidence
· Single descriptive or qualitative study
·
Qualitative research: method that systematically examines a phenomenon using an inductive approach & exploration of meaning of phenomenon; purpose is to understand & describe human experience, explore meanings & patterns; data are often narrative.
Level 7 Evidence
· Expert opinion: Recommendations from persons with established expertise in a specific clinical area often based on clinical experience; not considered a research method because systematic (or critical) inquiry is lacking.
Lansing Community College Library 2019
PICOTQuestions – Types of Evidence – Databases
Also see
PICOT – pyramid and definitions
Outline Description
Title: PICOT Questions – Types of Evidence – Databases
Also see PICOT – pyramid and definitions Look for the highest level of evidence appropriate for your clinical question.
Lansing Community College Library June 2019
Type of Clinical Question
·
Therapy “What is the best treatment or intervention?”
· Prevention “How can I prevent this problem?”
· Diagnosis/Assessment “What is the best way to assess or best diagnostic test for this patient?”
· Causation “What causes this problem?”
· Prognosis “What are the long term effects of this problem?”
· Meaning “What is the meaning of this experience for patients?”
Primary Research in General
Use
CINAHLPlus
and
Medline
to find:
· Randomized controlled trials (RCT)
· Controlled Trials
· Case-control studies
· Cohort studies
· Descriptive studies
· Qualitative studies
· Instrument development research
Primary Research for Specific Types of Clinical Questions
· Therapy: Randomized controlled trials (RCT), Controlled trials
· Prevention: Randomized controlled trials (RCT), Controlled trials
· Diagnosis/Assessment: Instrument development research
· Causation: Cohort, Case control, Descriptive, or Qualitative studies
· Prognosis: Cohort or descriptive studies.
· Meaning: Qualitative studies.
Synthesized Research (Secondary Literature) in General
Use
Cochrane Collection Plus
,
CINAHLPlus
, and
Medline
to find:
· Systematic reviews
· Meta-analyses
Synthesized Research (Secondary Literature) for Specific Types of Clinical Questions
· Therapy: Systematic reviews
· Prevention: Systematic reviews
· Causation: Systematic reviews
· Prognosis: Systematic reviews
· Meaning: Systematic reviews
Other Evidence (Secondary Literature) in General
Use
CINAHLPlus
,
Medline
,
Joanna Briggs Institute
, nursing, healthcare, and government organizations to find:
· Clinical practice guidelines
Use published clinical articles (not research based), peer institution practices, expert clinician practices to find:
· Expert opinion
Other Evidence (Secondary Literature) for Specific Types of
Clinical Questions
· Therapy: Clinical practice guidelines
· Prevention: Clinical practice guidelines
·