| Course | D221 Organizational Systems and Healthcare Transformation |
|---|---|
| Task | Task 2 |
| Paper type | Practice improvement plan |
| Length | About 1,200 words, 5 pages |
| Format | APA 7 |
| School | Western Governors University (WGU) |
| Program | RN to BSN |
| Updated | September 2026 |
Free sample paper for D221 Task 2
Practice Improvement Plan: Reducing Refused and Missed Doses of Venous Thromboembolism Prophylaxis on a 34-Bed Medical Unit
Student Name
Leavitt School of Health, Western Governors University
D221: Organizational Systems and Healthcare Transformation, Task 2
Course Instructor
Month Day, Year
Practice Improvement Plan: Reducing Refused and Missed Doses of Venous Thromboembolism Prophylaxis on a 34-Bed Medical Unit
Situation and Background
On the composite 34-bed adult medical unit in this plan, most patients are ordered pharmacologic venous thromboembolism (VTE) prophylaxis, usually subcutaneous heparin two or three times a day or once-daily enoxaparin. A pharmacy report for the last quarter showed that 17% of ordered doses on the unit were not given, most often documented as 'patient refused', and that a small group of patients accounted for most of the missed doses. Nurses describe patients who dislike the injections, who say they are walking and do not need them, or who are asleep when the 2200 dose is due, and nurses who accept the refusal and move on. Two patients on the unit developed hospital-acquired deep vein thrombosis during the same quarter; both had missed several doses.
The unit's experience matches published patterns. In a review of more than 103,000 ordered prophylaxis doses in one academic hospital, 11.9% were not administered, medicine floors missed a larger share than other floor types, and the 20% of patients who missed two or more doses accounted for 80% of all missed doses (Shermock et al., 2013). Because the order is correct but the dose is not reaching the patient, this is a systems-level concern: it affects every patient on prophylaxis and sits in how the unit educates patients and responds when a dose is declined.
Evidence Supporting the Change
A nonrandomized controlled trial tested a real-time, patient-centered education bundle: when a dose of VTE prophylaxis was not given, the patient received targeted education, including a short video and a written sheet, and the nurse revisited the conversation. On the four intervention units, nonadministration fell from 9.1% to 5.6% of doses, and nonadministration due to patient refusal fell from 5.9% to 3.4%, with no change on 12 control units (Haut et al., 2018). The strategy has since been carried into a community hospital, where a scenario-based nurse education module combined with the patient bundle, triggered by an alert to the charge nurse when a dose was missed, reduced missed doses from 12.9% to 9.3% across seven floors (Haut et al., 2025).
Two points from this evidence shape the plan. First, missed doses are concentrated in a few patients, so a response triggered by the first missed dose reaches most of the problem with limited effort. Second, nurses' own beliefs matter: the community hospital program worked by educating nurses first, so they could explain prophylaxis confidently rather than treating a refusal as the end of the conversation.
Recommended Practice Change
The unit will adopt a two-part bundle. Every nurse will complete a 30-minute scenario-based module on VTE risk, the purpose of prophylaxis and how to respond when a patient declines. When any dose is documented as not given, the electronic health record will send an alert to the charge nurse, who will confirm within the shift that the patient has received the patient education sheet and short video on why prophylaxis matters, and that the assigned nurse has returned to discuss the patient's concerns, such as injection site bruising or the timing of doses. A refusal after education will be accepted and documented, and the provider will be notified after two refused doses so the plan can be reconsidered, for example by switching to once-daily enoxaparin or adding mechanical prophylaxis.
Change Model
The plan follows the three-stage model of change described by Lewin (1947). To unfreeze current practice, the clinical nurse specialist will share the unit's 17% missed-dose rate and the two hospital-acquired clots at huddles for two weeks, framed as a system problem rather than individual blame. Moving is the education module, the alert and the patient materials, introduced with super-users on each shift. Refreezing will come from the alert remaining active, monthly posting of the missed-dose rate by shift and the addition of the prophylaxis conversation to annual competency checks. The model fits because accepting a refusal without discussion has become normal; the plan needs a reason to change that habit and structures that keep the new response in place.
Stakeholders and Their Roles
The nurse manager sponsors the project and protects time for training. A clinical nurse specialist leads it, adapts the education module and runs weekly check-ins. Charge nurses respond to every missed-dose alert and check that the patient conversation has happened. Staff nurses deliver the education and document the patient's concerns. The unit pharmacist reviews patients with two or more refusals and suggests alternatives such as once-daily dosing. Hospitalists and advanced practice providers reassess prophylaxis orders when notified. Informatics staff build the alert and the report. Patients and families are stakeholders as well, and two volunteers from the hospital's patient advisory group will read the education sheet and suggest changes before launch.
Implementation Timeline
Weeks one to four: build the alert and missed-dose report, adapt and review the education sheet and video, and finalize the nurse module. Weeks five and six: unfreezing huddles and super-user training. Weeks seven and eight: all nurses complete the module. Week nine: the alert and bundle go live on all shifts. Weeks 10 to 22: weekly check-ins for the first month, then monthly review of the measures below, with a decision at 90 days on whether to extend the bundle to the surgical units.
Teaching Plan
Nurse teaching uses scenarios rather than lectures. In the 30-minute module, nurses watch three short patient conversations, a patient who is walking the halls and says they do not need injections, a patient upset about bruising and a patient asleep at 2200, and practice a response to each. The module covers who is at risk of VTE, what prophylaxis prevents, what the evidence shows about missed doses, and how to respect a patient's informed refusal once they understand the risk. Patient teaching uses a one-page sheet at a sixth-grade reading level, available in English and Spanish, and a two-minute video on the bedside tablet. The nurse uses teach-back to confirm understanding before documenting the outcome.
Evaluation
The primary indicator is the proportion of ordered VTE prophylaxis doses not administered on the unit, reported monthly by pharmacy and compared with the baseline of 17%. The target is 10% or less within six months. Secondary measures are the proportion of missed doses documented as refused and the proportion of missed-dose alerts with documented patient education within the same shift, with a target of 90%. Hospital-acquired VTE events on the unit will be reviewed individually, although the number is too small to show a statistical change within six months. A balancing measure, the number of alerts per charge nurse per shift, will show whether the workload is sustainable.
Sustaining the Change
The alert and missed-dose report will remain in place after the pilot, and the monthly rate by shift will be posted and discussed at the unit practice council. The nurse module will be added to orientation for new hires and float staff, and the prophylaxis conversation will be part of annual competency validation. If the unit reaches its target and holds it for six months, the clinical nurse specialist will present the results to the hospital's quality committee to support spreading the bundle to other units.
References
Haut, E. R., Aboagye, J. K., Shaffer, D. L., Wang, J., Hobson, D. B., Yenokyan, G., Sugar, E. A., Kraus, P. S., Farrow, N. E., Canner, J. K., Owodunni, O. P., Florecki, K. L., Webster, K. L. W., Holzmueller, C. G., Pronovost, P. J., Streiff, M. B., & Lau, B. D. (2018). Effect of real-time patient-centered education bundle on administration of venous thromboembolism prevention in hospitalized patients. JAMA Network Open, 1(7), e184741. https://doi.org/10.1001/jamanetworkopen.2018.4741
Haut, E. R., Owodunni, O. P., Shaffer, D. L., McQuigg, D., Samuel, D., Hobson, D. B., Kraus, P. S., Wang, J., Webster, K. L. W., Kantsiper, M., Harris, J. E., Jr., Holzmueller, C. G., Varasteh Kia, M., Streiff, M. B., & Lau, B. D. (2025). Implementing a patient-centered education bundle to improve venous thromboembolism prevention. JAMA Surgery, 160(12), 1326-1332. https://doi.org/10.1001/jamasurg.2025.4136
Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5-41. https://doi.org/10.1177/001872674700100103
Shermock, K. M., Lau, B. D., Haut, E. R., Hobson, D. B., Ganetsky, V. S., Kraus, P. S., Efird, L. E., Lehmann, C. U., Pinto, B. L., Ross, P. A., & Streiff, M. B. (2013). Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: Implications for novel intervention strategies. PLOS ONE, 8(6), e66311. https://doi.org/10.1371/journal.pone.0066311
What the D221 Task 2 instructions ask
The second D221 task asks you to plan how a practice change would actually happen. Most versions want the situation and background, evidence supporting the change, the recommended change itself, a change model or theory applied to the plan, the stakeholders and their roles, a timeline, a teaching plan for staff or patients, an evaluation method and a way to sustain the change. The plan may build on the concern from Task 1 or address a new one. The evaluator reads for a plan that fits a real unit, with named roles and weeks, rather than a list of good intentions. A change model that is described but never applied to the steps is a common gap.
How this D221 Task 2 example is built
The plan opens with the unit's problem and baseline rate, then summarizes a nonrandomized controlled trial that tested patient-centered education after missed doses. The recommended change is a two-part bundle, described in enough detail to build. Lewin's model is applied stage by stage to specific actions, such as sharing the unit's missed-dose rate to unfreeze practice. Stakeholders from the nurse manager to pharmacy each have a role. The timeline runs by weeks, the teaching plan uses scenarios rather than lecture, and evaluation names a primary indicator with its source. A sustaining section keeps the alert and report in place and assigns ongoing review to the unit practice council.
Where the D221 Task 2 rubric puts the marks
Evaluators score each D221 Task 2 aspect as competent, approaching competence or not evident. Evidence and change aspects check that the recommendation rests on research and is described specifically. The change model aspect wants a named model applied to the plan's steps. Stakeholder, timeline and teaching aspects look for concrete roles, dates and methods. The evaluation aspect asks for a measurable indicator with a data source, and a sustainability aspect asks how the change will last after the project ends. APA citations and professional writing are assessed throughout. Plans that read as proposals a manager could approve tend to meet the aspects most easily. Stronger papers also show that the evaluation indicator matches the problem described at the start, so the reader can see the plan closing the loop.
D221 Task 2 help: what sends it back
Improvement plans are returned most often because the change model is decorative. After naming Lewin or another model, show which actions belong to each stage. Second, timelines are vague; divide the work into weeks or months with a lead for each step. Third, teaching plans often say staff will be educated. Describe the format, length, content and how learning will be checked. Fourth, evaluation should use a number you can collect, such as missed doses from pharmacy reports, with a baseline and a target. Finally, plan for what happens after the pilot. Sustaining the change is its own aspect, and plans that stop at go-live leave it unmet.
Get a D221 Task 2 example written to your instructions
Send the Task 2 instructions and rubric from your D221 course of study, along with the causal analysis your plan has to answer. We write a custom example to those aspects, with each change owned by a role and tied to an indicator with a baseline, and return it in 24-48h. The first custom sample is free.
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D221 Task 2 questions, answered
How many changes should the plan contain?
Some versions fix the number, so read your instructions first. Where it is open, three or four changes that each carry an owner, a resource, a teaching plan and a measure hold up better than eight that carry none of those. Keeping the list short also lets you order the work truthfully and name the action a unit should finish before the others begin.
How is Task 2 different from Task 1 in D221?
The first works out why an event became possible. The second decides what the organization does about it and who does it. Causation feeds this task without being its subject, so it takes a paragraph and the room goes to actions, ownership, teaching and measurement. Resubmitting the analysis with a recommendations paragraph attached leaves the planning aspects thin.
Should the plan include costs?
Include the resource requirement even when you cannot price it. Say what the change needs in staff time, equipment, released hours for teaching or software configuration, and state your assumption wherever a figure would be invented. A plan naming what it consumes reads as feasible, while one appearing to cost nothing invites the question of why the unit has not already done it.
Which change model works best for D221 Task 2?
Lewin's three stages, Kotter's eight steps and the plan-do-study-act cycle are common. Choose one you can apply step by step; the sample maps Lewin's stages onto specific actions.
Where can I find a free D221 Task 2 sample paper?
The whole improvement plan is reproduced here with margin notes. For a plan built on your own unit's problem, send your D221 task and the first custom plan is prepared free.