The impactful problem of hospital acquired infections is explained, including a thoughtful discussion of the significance and impact of the problem. A complete PICO table and PICO question are provided. Five valid level I-III articles are identified in the evidence matrix. The description of evidence-based and non-evidence based is broad and does not fully describe the types of articles found during the research process. In aspect C2a, the article by (Shelly, et. al, 2014) is a research study incorrectly identified as non-research. Discussion about each of these articles is underdeveloped and they are not clearly marked as research or non-research articles. In the evidence matrix, the research designs for every article listed are incorrect as they are too vague and do not accurately reflect the design of each article. The identification of one specific recommended practice change that relates to the PICO intervention of maintaining improved hand hygiene by healthcare workers cannot be located. Discussion about how each of the identified stakeholders is involved in the recommended practice change cannot be found.