Capella 4035 Assessment 3

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Introduction

Good day, everyone. I appreciate your participation in this essential in-service training. My name is ____, and today we will examine a critical issue affecting patient safety: communication breakdown during nurse shift transitions. This discussion stems from a sentinel event involving a 68-year-old COPD patient whose deteriorating condition and medication updates were not communicated to the incoming nurse. As a result, appropriate respiratory interventions were delayed, leading to significant patient distress and emergency escalation.

The communication gap was rooted in high workloads, insufficient electronic health record (EHR) documentation, and a lack of structured verbal communication. The session will explore the implications of handoff failures and outline structured, evidence-based interventions that can transform nursing communication and reinforce a patient safety-focused culture.

Part 1: Agenda and Outcomes

Agenda and Objectives

This session is centered on mitigating communication failures during handoffs, particularly in patients with chronic conditions such as COPD. The agenda targets the improvement of structured communication through standardized handoff protocols like SBAR and I-PASS, which are crucial for ensuring continuity of care.

The adverse event under review highlights systemic issues—overwhelmed staff, time-pressured handoffs, unclear roles, and missing documentation. Through this training, participants will be introduced to solutions including real-time EHR integration, closed-loop communication, and designated handoff zones.

Goals Table

Objective	Description
Identify root causes	Recognize elements such as time pressure, unclear roles, and poor documentation.
Implement structured tools	Employ SBAR, I-PASS, and bedside handoff protocols to improve information transfer.
Utilize technology	Integrate EHR tools and BCMA for real-time, verifiable medication handoffs.
Strengthen communication	Reduce distractions and employ mindfulness strategies during shift transitions.

Expected Outcomes

This session aims to improve clinical outcomes and reduce medication errors by developing staff competencies in recognizing and responding to handoff-related vulnerabilities. Participants will:

1. Understand the root causes of medication errors related to communication breakdowns and interruptions.
2. Gain hands-on experience using BCMA systems and EHR-integrated handoff templates.
3. Learn distraction-minimization techniques and closed-loop communication methods.
4. Participate in simulation exercises that enhance real-world handoff communication under pressure.
5. Recognize the emotional and systemic consequences of handoff errors and their prevention strategies.

Part 2: Safety Improvement Plan

Patient Handoff Interruptions

Transitions in care—especially during shift changes or interdepartmental transfers—are highly susceptible to communication failures. Research suggests that over 80% of sentinel events are rooted in poor handoff communication (Reime et al., 2024). Contributing factors include environmental distractions, time constraints, and lack of standardization.

The use of standardized frameworks like SBAR has proven effective in improving handoff accuracy. Risani et al. (2024) highlighted that SBAR implementation reduced missed information and ensured complete transfer of clinical data. Additionally, protected time and space for handoffs help avoid interruptions that compromise care continuity.

Safety Improvement Process

Process Table

Phase	Activities	Desired Outcome
Policy Formation	Establish protocols for quiet zones, BCMA use, and handoff templates.	Institutional alignment and stakeholder engagement.
Staff Training	Hands-on training for SBAR, BCMA, and EHR integration.	Proficiency and readiness in executing safety protocols.
Protocol Implementation	Supervision of real-time application and adherence checks.	Consistent execution of handoff policies across all units.
Monitoring and Feedback	Use of audits, error reports, and staff surveys to assess progress.	Identification of gaps and continuous quality improvement.
Evaluation and Improvement	Annual reviews and analytics-based adjustments.	Sustainable safety practices and performance refinement.

Implications for Healthcare Organizations

The cost of handoff errors extends beyond clinical setbacks. These breakdowns can lead to extended hospital stays, increased resource utilization, and potential legal repercussions. According to Reime et al. (2024), unresolved communication failures threaten both patient safety and institutional credibility. Implementing distraction-reduction policies and EHR-integrated handoff templates can prevent these issues and enhance diagnostic reliability.

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Part 3: Audience’s Role and Importance

Audience Role in the Improvement Plan

The success of this initiative hinges on active collaboration among nurses, physicians, informatics teams, and leadership. Nurses are central to executing structured handoffs using tools like SBAR. Their feedback and adherence to quiet zone protocols and EHR updates determine the plan’s effectiveness. Leadership plays a key role in resource allocation and setting accountability standards.

Stakeholder Importance

Nursing staff are instrumental in minimizing handoff errors. Their use of structured templates ensures accurate information exchange and prevents diagnostic delays. Lazzari (2024) illustrated how failure to follow standard protocols contributed to missed diagnoses in high-risk patients. Engaged participation by nurses and support from clinical and administrative teams are indispensable for meaningful improvements.

Benefits of Active Participation

The integration of tools like SBAR and EHR-enhanced handoff templates improves workflow, reduces communication redundancies, and ensures timely medication administration. Atinga et al. (2024) emphasized that ongoing training and familiarity with communication protocols significantly reduce errors and improve staff confidence. Through systematic adoption, the nursing workforce can elevate care quality and reduce stress related to clinical ambiguity.

Part 4: New Process and Skills Practice

New Communication Processes

The improvement strategy incorporates digital innovations like EHR-synced handoff templates and emphasizes structured communication models such as SBAR. These approaches guarantee the accuracy of transmitted information and reduce risks associated with medication errors and communication lapses. Reliable frameworks ensure that important details—such as dosage changes and pending tasks—are not overlooked.

Scenario-Based Workshop

Participants will engage in interactive training involving a mock handoff situation where a patient’s medication has been modified. They will practice relaying condition updates, treatment plans, and safety concerns while managing real-world distractions like time constraints and technical issues. Feedback from facilitators will guide improvements and highlight effective communication strategies (Lee & Lim, 2021).

Workshop Elements Table

Component	Description
Scenario Simulation	Simulated patient transition involving medication updates.
Realistic Challenges	Introduce time pressures and distractions to simulate real scenarios.
Feedback Session	Post-activity evaluation to reinforce strengths and correct communication gaps.
Protocol Practice	Hands-on application of SBAR and EHR handoff templates.

Team-Based Q\&A Session

To promote engagement and critical thinking, a collaborative Q\&A session will be conducted. Sample questions include:

• “What strategies will you apply to ensure accurate medication handoff?”
• “How do you validate medication information during patient transfers?”

These interactions will encourage nurses to internalize communication protocols and share best practices (Wong et al., 2021).

Part 5: Soliciting Feedback

Feedback Collection Process

Feedback is vital for continuous improvement. Anonymous surveys and open-ended questionnaires will be distributed at the end of the session. Staff will evaluate the usability of tools such as SBAR and the EHR-integrated templates and comment on practical challenges and solutions. This participatory method ensures improvements align with frontline needs (Meyer et al., 2021).

Feedback Strategy Table

Method	Purpose
Anonymous Surveys	Gauge understanding and ease of tool use.
Open-Ended Feedback Forms	Capture personal experiences and actionable insights.
Thematic Analysis	Identify recurring themes and improvement areas.

Conclusion

Effective communication during patient handoffs is critical to reducing adverse events and enhancing patient outcomes. The sentinel case discussed underscores the high stakes of incomplete information transfer. By integrating tools like SBAR and I-PASS, enhancing EHR workflows, and enforcing protected handoff zones, healthcare providers can build a more reliable and safer care system. This initiative requires active participation across roles and disciplines to ensure that the improvements are sustained and embedded in the institutional culture.

Through training, consistent feedback, and commitment to structured protocols, we can achieve a high-reliability system that reduces handoff errors, promotes accountability, and improves both staff and patient experiences.

References

Atinga, R. A., Gmaligan, M. N., Ayawine, A., & Yambah, J. K. (2024). “It’s the patient that suffers from poor communication”: Analysing communication gaps and associated consequences in handover events from nurses’ experiences. SSM – Qualitative Research in Health, 6(100482), 100482–100482. https://doi.org/10.1016/j.ssmqr.2024.100482

Janagama, S. R., Strehlow, M., Gimkala, A., Rao, G. V. R., Matheson, L., Mahadevan, S., & Newberry, J. A. (2020). Critical communication: A cross-sectional study of signout at the prehospital and hospital interface. Cureus, 12(2), e7114. https://doi.org/10.7759/cureus.7114

Capella 4035 Assessment 3

Lazzari, C. (2024). Implementing the verbal and electronic handover in general and psychiatric nursing using the introduction, situation, background, assessment, and recommendation framework: A systematic review. Iranian Journal of Nursing and Midwifery Research, 29(1), 23. https://doi.org/10.4103/ijnmr.ijnmr_24_23

Lee, D.-H., & Lim, E.-J. (2021). Effect of a simulation-based handover education program for nursing students: A quasi-experimental design. International Journal of Environmental Research and Public Health, 18(11), 5821. https://doi.org/10.3390/ijerph18115821

Louis, M. G., Sharath , C. K. A., & Sai, J. K. (2024). Clinical audit on implementation of the I-Pass handoff bundle in reduction in number of code blue. Journal of Cardiovascular Disease Research, 15(10). https://jcdronline.org/admin/Uploads/Files/672329a1803174.71704461.pdf

Meyer, A. N. D., Upadhyay, D. K., Collins, C. A., Fitzpatrick, M. H., Kobylinski, M., Bansal, A. B., Torretti, D., & Singh, H. (2021). A program to provide clinicians with feedback on their diagnostic performance in a learning health system. The Joint Commission Journal on Quality and Patient Safety, 47(2), 120–126. https://doi.org/10.1016/j.jcjq.2020.08.014

Risani, A.-A., Mohammadkhah, F., Pourhabib, A., Fotokian, Z., & Khatooni, M. (2024). Comparison of the SBAR method and modified handover model on handover quality and nurse perception in the emergency department: A quasi-experimental study. BioMed Central Nursing, 23(1). https://doi.org/10.1186/s12912-024-02266-4

Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: A qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38–53. https://doi.org/10.1016/j.jcjq.2020.09.010

Capella 4035 Assessment 3

Wong, E. Y., Ha, A.-T., Kolyouthapong, K., Cheng, G., Matin, S., & Hernandez, E. A. (2021). Students’ perceptions of a new transitions of care elective course in the pharmacy curriculum. Currents in Pharmacy Teaching and Learning, 13(9), 1215–1220. https://doi.org/10.1016/j.cptl.2021.06.045