Capella 4035 Assessment 3

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Welcome and Overview

Good day, and thank you all for attending today’s in-service presentation. I’m Lori, and I will address a pressing patient safety issue that occurred during a shift transition involving a failure in communication. This failure led to a significant adverse event affecting a 68-year-old patient diagnosed with COPD. Critical updates regarding the patient’s declining respiratory condition and recent medication changes were not communicated to the incoming nurse, delaying respiratory intervention and resulting in respiratory distress requiring urgent care. The contributing factors included insufficient staffing, poor EHR documentation, and inadequate verbal communication. This session emphasizes the seriousness of such breakdowns and proposes evidence-based strategies to improve handoff processes, reduce risks, and safeguard patient outcomes.

Part 1: Agenda and Outcomes

Agenda and Objectives

This session focuses on a communication failure during the handoff of a high-risk COPD patient that led to delayed care. The objective is to highlight the importance of structured handoff communication to prevent similar incidents in the future. Factors such as lack of standardized procedures, environmental interruptions, and incomplete documentation contributed to the sentinel event. We will explore solutions like SBAR, I-PASS, closed-loop communication, and the creation of protected handoff zones to ensure effective information transfer. By incorporating these strategies into routine practice along with staff training and institutional support, we aim to foster a robust safety culture.

Goals of the Session

The primary aim is to identify root causes of communication breakdowns during nurse shift transitions and implement a structured safety program. Key issues included inadequate documentation, unclear role expectations, and rushed handoffs due to understaffing. These gaps are known to contribute to preventable harm such as delayed care and patient deterioration (Schroers et al., 2021). The session promotes the adoption of evidence-based tools like SBAR and I-PASS, real-time EHR updates, and distraction-free communication environments to enhance information accuracy and handoff quality (Risani et al., 2024).

Expected Outcomes

The session is designed to improve nurses’ awareness of vulnerabilities in medication administration caused by interruptions. Nurses will recognize how distractions and inconsistent communication practices lead to medication errors and delayed treatments. Training will include technologies such as BCMA and EHR integration, which support verification and reduce cognitive load (Atinga et al., 2024). Practical skills in maintaining focus during medication administration and using quiet zones and mindfulness will be developed. Additionally, structured communication strategies will be demonstrated, promoting collaborative and accurate handoffs that lead to improved patient outcomes (Louis et al., 2024).

Part 2: Safety Improvement Plan

Patient Handoff Interruptions

Handoff communication during transitions of care is a high-risk process, especially in high-acuity environments like ICUs. These transitions, whether during shift changes or interdepartmental transfers, are susceptible to information loss or miscommunication. Research shows that handoff failures contribute significantly to sentinel events, accounting for more than 80% of such cases (Reime et al., 2024). Incomplete or hurried exchanges, often due to lack of standardized tools like SBAR, lead to treatment delays, medication errors, and adverse outcomes. Heavy workloads, multitasking, and time constraints worsen the problem. Addressing these issues requires the implementation of structured handoff protocols, protected handoff time, and supportive institutional policies to prevent interruptions.

Process for Safety Improvement

Improvement Phase	Actions	Expected Outcome
Policy Formation and Stakeholder Engagement	Develop protocols for quiet zones, closed-loop communication, and BCMA-EHR integration. Involve nursing and pharmacy staff early.	Collaborative policy alignment and support for change initiatives across departments.
Staff Training and System Configuration	Conduct mandatory training on BCMA, EHR synchronization, and communication protocols. Simulated learning experiences included.	Enhanced staff readiness, technical proficiency, and confidence in new safety systems (Nawawi & Ibrahim, 2024).
Policy Rollout and Enforcement	Implement new procedures unit-wide, supervise compliance, and provide real-time coaching.	Consistent use of protocols and accountability in communication and medication practices.
Monitoring and Feedback Collection	Conduct audits, collect feedback, and track medication error rates and system usability.	Identify improvement areas and address issues through refresher training and system refinement.
Evaluation and Continuous Improvement	Perform one-year post-implementation review using safety metrics and staff surveys. Introduce data-driven updates.	Sustainable culture of safety and reduction in medication errors using predictive analytics.

Organizational Implications of Handoff Failures

Errors during handoffs have serious consequences, including delayed diagnoses, incorrect treatments, and preventable harm. These issues lead to increased hospital stays, resource utilization, readmission risks, and even regulatory noncompliance. Moreover, communication failures erode staff morale and contribute to burnout. Using structured handoff tools like SBAR, distraction-reduction strategies, and EHR-integrated templates ensures safe transitions, enhances diagnostic accuracy, and upholds institutional safety standards (Reime et al., 2024).

Part 3: Audience’s Role and Importance

Staff Role in Plan Implementation

The success of this safety improvement initiative depends on the active involvement of nursing staff, physicians, IT personnel, and hospital administrators. Nurses play a central role by participating in simulation-based training, adhering to quiet zone guidelines, and consistently using standardized communication tools. As Janagama et al. (2020) highlight, minimizing distractions significantly reduces the risk of diagnostic delays and patient harm. Leadership must provide clear directives, allocate resources, and ensure policy compliance, reinforcing the safety culture and driving system-wide improvement.

Critical Contributions to Success

Nursing staff, who are primarily responsible for conducting handoffs, are crucial to the success of communication-centered safety reforms. Their frontline insights and consistent engagement in structured communication formats such as SBAR and EHR-integrated templates will determine the plan’s effectiveness. Their role in daily patient transitions places them in a unique position to lead by example and champion patient safety across all care environments.

References

Atinga, R. A., Abekah‐Nkrumah, G., & Domfeh, K. A. (2024). Integration of health information systems: The role of technology in reducing medication errors. Journal of Nursing Administration, 54(2), 76–83. https://doi.org/10.1097/NNA.0000000000001268

Janagama, R., Anugula, D., & Reddy, D. (2020). Reducing communication errors in healthcare through standardized handoff training. International Journal of Health Care Quality Assurance, 33(5), 489–501. https://doi.org/10.1108/IJHCQA-10-2019-0217

Capella 4035 Assessment 3

Louis, R. R., Gupta, S., & Kim, H. J. (2024). Handoff communication: Interdisciplinary approaches to improving medication safety. American Journal of Health-System Pharmacy, 81(1), 25–31. https://doi.org/10.1093/ajhp/zxad276

Nawawi, R. A., & Ibrahim, M. N. (2024). Enhancing medication safety through simulation-based training and closed-loop communication. Journal of Patient Safety & Risk Management, 29(1), 18–26. https://doi.org/10.1177/25160435231109876

Reime, B., Petersen, M. S., & Müller-Staub, M. (2024). Communication errors and their contribution to sentinel events: A review of evidence and strategies. International Journal for Quality in Health Care, 36(1), 1–10. https://doi.org/10.1093/intqhc/mzaa054

Risani, H. A., Thomas, M., & Shenoy, M. (2024). Standardizing shift handoff: Effectiveness of SBAR and I-PASS protocols. Nursing Management, 31(2), 44–49. https://doi.org/10.7748/nm.2024.e2107

Schroers, G., Ross, J., & Landstrom, G. (2021). Nurses’ perceptions of barriers to effective handoff communication. Journal of Nursing Care Quality, 36(4), 288–294. https://doi.org/10.1097/NCQ.0000000000000511

Capella 4035 Assessment 3