Capella 4035 Assessment 4
Capella 4035 Assessment 4
Name
Capella university
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Improvement Plan Toolkit
At Riverside Community Hospital, the Improvement Plan Toolkit was introduced as a corrective strategy following a serious incident involving the misdiagnosis of a 67-year-old patient with sepsis. This event underscored the urgency of improving early detection of sepsis and strengthening communication during shift transitions. The toolkit’s primary objective is to mitigate future diagnostic failures by identifying and addressing breakdowns in clinical assessment, communication, and procedural activation. The toolkit includes four critical components: Understanding and Preventing Diagnostic Errors, Analyzing the Reasons for Missed Diagnoses, Strategies That Enhance Patient Safety, and Improving Communication and Handover Practices. Each component is grounded in scientific literature to support safer clinical environments (Marshall et al., 2022).
Understanding and Preventing Diagnostic Errors
Auerbach et al. (2024) investigated diagnostic inaccuracies among hospitalized patients who died or required ICU admission. Their study across 29 academic hospitals revealed that most errors stemmed from ineffective clinical evaluations, improper test utilization, and misinterpretation of diagnostic results. These findings highlight the need for refining diagnostic workflows and enhancing clinicians’ assessment skills. Nurses can support improvements by pursuing diagnostic education and encouraging interprofessional collaboration in high-risk scenarios.
Morgan, Malani, and Diekema (2023) emphasized the importance of diagnostic stewardship. By promoting rational use of diagnostic tests based on behavioral economics, clinicians can improve decision-making. For instance, careful use of Clostridioides difficile testing can prevent false positives and unnecessary treatments. Nurses can reinforce this practice by ensuring appropriate test selection and interpretation in patient care protocols.
Newman-Toker et al. (2023) found that diagnostic errors result in approximately 795,000 serious harm incidents annually in the U.S. These are often associated with infections, vascular events, and cancers—the so-called “Big Three” conditions. The study calls for enhanced diagnostic safety strategies in emergency and intensive care settings, where timely and accurate diagnoses are essential for reducing mortality and long-term complications.
Analyzing the Reasons for Missed Diagnoses
Barwise et al. (2021) conducted a qualitative analysis involving 64 clinicians from diverse acute care environments to explore causes of diagnostic delays. Their findings identified systemic issues, poor communication, inadequate coordination, and clinician-level errors as contributing factors. These insights are valuable for designing targeted improvements in documentation practices and collaborative diagnostic strategies, especially during protocol development.
Dixit et al. (2023) reviewed the impact of electronic health records (EHRs) on diagnostic accuracy, highlighting usability problems, interoperability challenges, and interface issues as common barriers. These system flaws contribute to misinterpretation of patient data, resulting in delayed or incorrect diagnoses. Nurses can address these challenges by advocating for user-friendly EHR designs and reporting system-related concerns.
Politi et al. (2022) examined root cause analyses of delays in diagnosis, surgery, and treatment in Veterans Health Administration hospitals. Common issues included poor interdepartmental communication, lack of standardized procedures, and non-adherence to policies. The findings emphasize the need for structured communication protocols and process optimization. Nurses can contribute by participating in safety audits and process redesign initiatives.
Strategies That Enhance Patient Safety
Al-Dossary (2022) identified how the nursing work environment influences patient safety. Factors such as leadership support, teamwork, and access to resources are positively correlated with increased incident reporting and better outcomes. Nurses can leverage this evidence to advocate for supportive workplace environments that prioritize safety culture.
Labrague (2024) explored the link between nurses’ adherence to safety protocols and adverse event reporting. The study revealed that higher compliance with safety practices, including fall risk assessments and pressure ulcer prevention, led to better patient outcomes. Nurses should use this information to reinforce protocol adherence and participate in quality improvement initiatives.
McHugh et al. (2021) examined the impact of minimum nurse-to-patient ratio legislation in Australia. The implementation led to reduced mortality rates, shorter hospital stays, and fewer readmissions, validating the importance of adequate staffing. Nurses can utilize this evidence to support staffing policy reforms that ensure safe workloads and improved diagnostic accuracy.
Improving Communication and Handover Practices
Scolari et al. (2022) evaluated the effectiveness of the SBAR communication tool in ICU nurse-physician phone interactions. Their study of 290 calls revealed a mean SBAR usage score of only 41%, indicating room for improvement. Variables such as prior training, ICU experience, and language proficiency significantly influenced SBAR quality. The findings underscore the importance of standardized communication protocols and targeted training to reduce miscommunication during handoffs.
Summary Table of Toolkit Components and Contributions
| Toolkit Component | Primary Focus | Key Contribution to Patient Safety | Nursing Implication |
|---|---|---|---|
| Understanding and Preventing Diagnostic Errors | Identifying diagnostic error causes and strategies for prevention | Improved accuracy in high-risk diagnoses (sepsis, infections, cancers) | Supports advanced diagnostics training and stewardship practices |
| Analyzing Reasons for Missed Diagnoses | Exploring systemic and EHR-related barriers | Highlights root causes of delays and misdiagnosis | Enables nurses to lead improvements in workflow and documentation practices |
| Strategies Enhancing Patient Safety | Assessing nurse environment, staffing, and protocol compliance | Correlates staffing levels and leadership with reduced adverse events | Promotes safer work conditions and staff-to-patient ratios |
| Improving Communication and Handover Practices | Evaluating structured communication tools (e.g., SBAR) | Highlights training and language proficiency as vital to communication safety | Empowers nurses to refine handover communication and undergo SBAR training |
References
Al-Dossary, R. N. (2022). The effects of nursing work environment on patient safety in Saudi Arabian hospitals. Frontiers in Medicine, 9, 872091. https://doi.org/10.3389/fmed.2022.872091
Auerbach, A. D., Lee, T. M., Hubbard, C. C., Ranji, S. R., Raffel, K., Valdes, G., Boscardin, J., Dalal, A. K., Harris, A., Flynn, E., Schnipper, J. L., UPSIDE Research Group, Feinbloom, D., Roy, B. N., Herzig, S. J., Wazir, M., Gershanik, E. F., Goyal, A., Chitneni, P. R., & Burney, S. (2024). Diagnostic errors in hospitalized adults who died or were transferred to intensive care. JAMA Internal Medicine. https://doi.org/10.1001/jamainternmed.2023.7347
Barwise, A., Leppin, A., Dong, Y., Huang, C., Pinevich, Y., Herasevich, S., Soleimani, J., Gajic, O., Pickering, B., & Kumbamu, A. (2021). What contributes to diagnostic error or delay? A qualitative exploration across diverse acute care settings in the US. Journal of Patient Safety, 17(4), 239–248. https://doi.org/10.1097/PTS.0000000000000817
Capella 4035 Assessment 4
Dixit, R. A., Boxley, C. L., Samuel, S., Mohan, V., Ratwani, R. M., & Gold, J. A. (2023). Electronic health record use issues and diagnostic error: A scoping review and framework. Journal of Patient Safety, 19(1), e25. https://doi.org/10.1097/PTS.0000000000001081
Labrague, L. J. (2025). A systematic review on nurse-physician collaboration and its relationship with nursing workforce outcomes. JONA: The Journal of Nursing Administration, 55(3), 157–164. https://doi.org/10.1097/nna.0000000000001549
Labrague, L. J. (2024). Nurses’ adherence to patient safety protocols and its relationship with adverse patient events. Journal of Nursing Scholarship, 56(2), 282-290. https://doi.org/10.1111/jnu.12942
Marshall, T. L., Rinke, M. L., Olson, A. P. J., & Brady, P. W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149(Supplement 3). https://doi.org/10.1542/peds.2020-045948d
McHugh, M., Aiken, L., Sloane, D., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. The Lancet, 397(10288), 1905–1913. https://doi.org/10.1016/S0140-6736(21)00768-6
Morgan, D. J., Malani, P. N., & Diekema, D. J. (2023). Diagnostic stewardship to prevent diagnostic error. JAMA, 329(15). https://doi.org/10.1001/jama.2023.1678
Newman-Toker, D. E., Nassery, N., Schaffer, A. C., Yu-Moe, C. W., Clemens, G. D., Wang, Z., Zhu, Y., Tehrani, A. S. S., Fanai, M., Hassoon, A., & Siegal, D. (2023). Burden of serious harms from diagnostic error in the USA. BMJ Quality & Safety, 33(2). https://doi.org/10.1136/bmjqs-2021-014130
Politi, R. E., Mills, P. D., Zubkoff, L., & Neily, J. (2022). Delays in diagnosis, treatment, and surgery: Root causes, actions taken, and recommendations for healthcare improvement. Journal of Patient Safety, 18(7). https://doi.org/10.1097/pts.0000000000001016
Capella 4035 Assessment 4
Scolari, E., Soncini, L., Ramelet, A., & Schneider, A. G. (2022). Quality of the Situation‐Background‐Assessment‐Recommendation tool during nurse‐physician calls in the ICU: An observational study. Nursing in Critical Care, 27(6). https://doi.org/10.1111/nicc.12743
Toren, O., Lipschuetz, M., Lehmann, A., Regev, G., & Arad, D. (2022). Improving patient safety in general hospitals using structured handoffs: outcomes from a national project. Frontiers in Public Health, 10, 777678. https://doi.org/10.3389/fpubh.2022.777678