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, an improvement plan toolkit was implemented following a serious diagnostic oversight involving a 67-year-old patient with sepsis. The failure to diagnose the condition correctly underscored the urgent need for reform, particularly in early sepsis identification and communication during clinical handovers. This toolkit is designed to reduce diagnostic errors and enhance patient safety by focusing on communication, clinical assessments, and timely activation of protocols. The toolkit is structured into four essential categories: Understanding and Preventing Diagnostic Errors, Analyzing the Reasons for Missed Diagnoses, Strategies That Enhance Patient Safety, and Improving Communication and Handover Practices. Each section is grounded in evidence-based practice and is intended to guide healthcare professionals toward safer, more effective patient care (Marshall et al., 2022)

Understanding and Preventing Diagnostic Errors

Citation	Summary and Application
Auerbach et al. (2024)	The study analyzed diagnostic mistakes in 29 academic hospitals, identifying clinical evaluation and diagnostic testing as major problem areas. For nursing, this research promotes the need for continued education and interdisciplinary communication, especially for patients in critical condition.
Morgan et al. (2023)	This article introduced the concept of diagnostic stewardship, recommending strategic testing to reduce misdiagnosis. It supports nurses in interpreting diagnostic data correctly and collaborating on test-related decisions to improve outcomes.
Newman-Toker et al. (2023)	Highlighting the “Big Three” diagnostic errors—vascular events, infections, and cancers—this study shows the large-scale impact of misdiagnoses in the U.S. Nurses can utilize this knowledge to prioritize timely assessments in high-risk cases like emergency care and ICUs.

Analyzing the Reasons for Missed Diagnosis

Citation	Summary and Application
Barwise et al. (2021)	This qualitative study identifies systemic and interpersonal barriers that delay diagnosis, such as ineffective coordination and communication. Nurses can improve care by enhancing documentation practices and team collaboration.
Dixit et al. (2023)	The review addresses how poorly designed EHRs contribute to diagnostic errors. Nurses are encouraged to recognize and report system limitations and advocate for user-friendly digital tools to reduce mistakes.
Politi et al. (2022)	Based on RCA findings from VA hospitals, this study reveals that breakdowns in protocol and communication cause delays. Nurses can use this evidence to advocate for clearer procedures and better interdepartmental coordination.

Strategies That Enhance Patient Safety

Citation	Summary and Application
Al-Dossary (2022)	The study links a supportive nursing environment—characterized by leadership and teamwork—to improved patient safety. Nurses should advocate for better resource allocation and stronger safety cultures.
Labrague (2024)	This research shows that adherence to safety protocols reduces adverse events. It empowers nurses to monitor compliance levels, especially in fall prevention and pressure ulcer management.
McHugh et al. (2021)	Investigating nurse-to-patient ratios, the findings reveal fewer adverse events and readmissions in well-staffed hospitals. Nurses can use this data to push for legislative changes promoting safer staffing levels.

Improving Communication and Handover Practices

Citation	Summary and Application
Scolari et al. (2022)	An analysis of SBAR tool use among ICU nurses showed communication lapses during nurse-physician calls. Training in SBAR techniques can enhance the clarity of shift handovers and emergency communications, reinforcing safety during care transitions.

References

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. (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, S., Dhillon, S., Griffin, M., Ahmed, M., & Mohamed, Z. (2022). Quality improvement toolkit for reducing diagnostic errors in emergency settings. BMJ Open Quality, 11(1), e001800. https://doi.org/10.1136/bmjoq-2021-001800

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

Capella 4035 Assessment 4

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

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

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.202