Capella 4035 Assessment 3

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Hello everyone, and thank you for joining today’s in-service training. My name is __________. Today, we will address a critical issue in patient safety involving a communication breakdown during a nurse shift change. In this case, a 68-year-old COPD patient’s deteriorating respiratory condition and recent medication updates were not properly conveyed to the incoming nurse, which led to a delay in care and a medical emergency. The breakdown stemmed from a combination of short staffing, lack of EHR documentation, and inadequate verbal communication. This presentation focuses on the implications of such communication failures and outlines evidence-based strategies to enhance handoff communication, mitigate risks, and protect patient safety.

Part 1: Agenda and Outcomes

This training addresses communication breakdowns during nurse shift changes, particularly when caring for patients with chronic conditions such as COPD. Emphasis is placed on implementing structured handoff processes to avoid missed care, medication errors, and delayed interventions. The sentinel event in question highlights the failure of the outgoing nurse to communicate vital updates, exacerbated by factors like high workload, environmental distractions, the absence of standardized protocols, and poor documentation.

The session explores strategies such as SBAR (Situation, Background, Assessment, Recommendation), I-PASS, closed-loop communication, and designated handoff zones. Incorporating these tools, along with structured training, EHR integration, and institutional policies, aims to improve communication and reinforce a safety-oriented culture in nursing practice.

Goals

The primary goal is to address communication failures that resulted in the sentinel event involving a COPD patient and initiate a targeted safety intervention. Underlying causes identified include understaffing, hasty handoffs, unclear role delineation, and lack of documentation of the patient’s deteriorating status. Communication failures during handoffs are a significant contributor to preventable harm, often leading to delayed interventions and adverse outcomes (Schroers et al., 2021).

This session highlights strategies to eliminate such gaps by utilizing standardized tools and structured bedside handoffs that involve active participation from both nurses (Risani et al., 2024). Real-time EHR updates and closed-loop communication protocols improve message accuracy and accountability. Establishing quiet, interruption-free zones also helps reduce distractions and cognitive overload during critical exchanges.

By deploying these measures, we aim not only to prevent patient harm but also to streamline the nursing workflow. Communication failures during transitions not only harm patient outcomes but also add emotional strain to staff and lead to increased scrutiny and resource demands (Louis et al., 2024). The session concludes with a practical demonstration of proper handoff, offering staff an opportunity to apply their learning.

Outcomes

The expected results from this session include:

Outcome	Description
Enhanced Recognition	Staff will identify root causes of medication errors, such as distractions and communication lapses, enhancing situational awareness.
Technology Integration	Nurses will be trained to use BCMA and EHR workflows to verify medications and reduce manual errors (Atinga et al., 2024).
Skill Development	Practical strategies for minimizing distractions and ensuring verbal and electronic verification of data will be taught, leading to safer medication practices (Louis et al., 2024).

Part 2: Safety Improvement Plan

Patient Handoff Interruptions

Handoff processes remain a significant safety risk, especially in high-acuity areas like ICUs. These transitions, whether between shifts or departments, often result in omitted or miscommunicated information due to fragmented systems and environmental disruptions.

Research shows that over 80% of sentinel events are linked to communication failures during handoffs (Reime et al., 2024). Unstructured or incomplete handoffs can lead to missed treatments, medication errors, or misdiagnoses, many of which are avoidable. Tools such as SBAR can bring clarity and consistency to handoff communication. Studies have demonstrated that SBAR enhances report completeness and care continuity (Risani et al., 2024).

Heavy workloads, time constraints, and multitasking reduce the ability of nurses to deliver detailed reports. These pressures often result in overlooked clinical indicators, increasing patient acuity. Standardized tools, protected handoff time, and institution-wide interruption-reduction policies are necessary to combat these challenges and foster safer transitions.

Process for Safety Improvement

Phase	Action	Desired Outcome
Policy Formation	Develop protocols including quiet zones, BCMA-EHR integration, and closed-loop standards; engage stakeholders.	Department-wide alignment and ownership of new safety measures.
Staff Training	Train clinical staff on BCMA, EHR integration, and communication techniques; include simulations.	Increased proficiency and readiness in safe medication administration (Nawawi & Ibrahim, 2024).
Protocol Implementation	Enforce new procedures across units; monitor adherence and provide feedback.	Consistent and accountable practice of safety protocols.
Feedback & Monitoring	Track ME reports and staff feedback for continual system improvements.	Ongoing system enhancement and gap reduction.
Evaluation	Analyze ME rates, staff surveys, and safety metrics post-implementation.	Sustainable safety culture and ongoing improvement efforts.

Implications of Handoff Interruptions

Interruptions during handoffs pose a significant risk by disrupting the transfer of vital information. This can cause diagnostic delays, improper treatment, and preventable adverse events. Over 80% of hospital sentinel events stem from communication breakdowns (Reime et al., 2024). Consequences for organizations include increased patient deterioration, longer hospital stays, readmissions, litigation risks, and diminished staff morale.

Structured handoff tools like SBAR, distraction-reduction strategies such as quiet zones, and EHR-based templates are necessary to support safe transitions and cultivate a robust safety culture that aligns with quality care standards.

Part 3: Audience’s Role and Importance

Audience’s Role in Implementing and Driving the Improvement Plan

The success of this safety plan relies on collaborative efforts among nurses, physicians, IT professionals, and leadership. Nurses are central to this initiative, with their participation in simulation training, real-time feedback sharing, and adherence to quiet zones being vital. According to Janagama et al. (2020), reducing communication distractions significantly decreases diagnostic delays and harm.

Leadership plays a pivotal role by establishing clear policies, funding BCMA-EHR upgrades, and monitoring compliance. This multidisciplinary engagement ensures that safe, standardized handoffs are integrated into daily operations, thus enhancing diagnostic accuracy and reducing patient harm.

Audience Critical for Plan’s Success

Nurses are the cornerstone of successful handoff processes. Their frontline role in patient transitions underscores the importance of their adherence to structured formats such as SBAR and EHR templates. Their consistent participation will ensure communication remains clear, timely, and complete, reducing the risk of adverse outcomes and reinforcing a high-reliability safety culture.

References

Atinga, R. A., Abekah-Nkrumah, G., & Domfeh, K. A. (2024). Integrating health information systems to improve medication safety. BMC Health Services Research, 24(1), 75. https://doi.org/10.1186/s12913-024-09934-1

Janagama, R. R., Divatia, J. V., & Naik, B. N. (2020). Reducing distractions during handoffs in the intensive care unit. Indian Journal of Critical Care Medicine, 24(8), 696–702. https://doi.org/10.5005/jp-journals-10071-23538

Capella 4035 Assessment 3

Louis, C. A., Dhanani, S., & Thompson, R. (2024). Communication failures and medication errors: A systems-based approach to improving safety. Journal of Patient Safety, 20(1), e130–e138. https://doi.org/10.1097/PTS.0000000000000965

Nawawi, R., & Ibrahim, N. (2024). Clinical training in the digital era: Preparing nurses for barcode medication administration systems. Nurse Education in Practice, 71, 103368. https://doi.org/10.1016/j.nepr.2024.103368

Reime, T., Lunde, L. E., & Skjæret, N. (2024). Risk factors in nurse shift handoffs and their implications for safety. BMJ Open Quality, 13(2), e002121. https://doi.org/10.1136/bmjoq-2023-002121

Risani, A., Shakeri, H., & Rahimi, A. (2024). Impact of standardized SBAR communication on patient safety outcomes. Journal of Nursing Management, 32(3), 789–796. https://doi.org/10.1111/jonm.13888

Capella 4035 Assessment 3

Schroers, G., Ross, C. A., & Chaperon, C. (2021). Improving patient handoffs with standardized communication tools. The Journal of Nursing Administration, 51(9), 462–468. https://doi.org/10.1097/NNA.0000000000001042