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

Riverside Community Hospital implemented an evidence-based improvement plan toolkit in response to a critical incident involving a missed sepsis diagnosis in a 67-year-old patient. This toolkit was designed to refine diagnostic accuracy and improve patient outcomes, with an emphasis on timely recognition of sepsis and effective inter-shift communication. The goal is to mitigate future diagnostic failures by addressing common vulnerabilities in clinical communication, patient evaluation, and protocol execution.

The toolkit integrates four major elements: reducing diagnostic errors, understanding why diagnoses are missed, enhancing patient safety practices, and improving communication during handovers. These components draw heavily from peer-reviewed research and clinical best practices. Together, they form a robust framework for preventing adverse events by promoting a culture of diagnostic diligence and teamwork (Marshall et al., 2022).

Annotated Bibliography

1. Understanding and Preventing Diagnostic Errors

Recent studies underline the severity and prevalence of diagnostic errors in hospital settings. Auerbach et al. (2024) found that patients who died or were transferred to the ICU were often victims of diagnostic missteps rooted in flawed clinical evaluation and test misinterpretation. This highlights the need for improved clinician training and more precise diagnostic tools. Nurses can play a critical role by advocating for better interprofessional communication and refining their assessment techniques.

Morgan, Malani, and Diekema (2023) advocate for diagnostic stewardship, where clinicians utilize behavioral economics to optimize test selection and interpretation. For example, they recommend more discerning use of PCR testing for Clostridioides difficile to avoid false positives. Nurses can support these efforts by understanding diagnostic pathways and advocating for evidence-based test application.

Newman-Toker et al. (2023) estimated that nearly 800,000 Americans suffer serious harm annually due to diagnostic errors, particularly in high-risk conditions such as infections, cancers, and vascular events. Their work emphasizes the urgent need for systems that ensure timely and accurate diagnoses, especially in emergency and ICU environments where nurses are integral to early warning systems.

Study Key Focus Nurse Implication
Auerbach et al. (2024) Diagnostic errors in ICU/deaths Advocate for better assessments
Morgan et al. (2023) Diagnostic stewardship Support appropriate test use
Newman-Toker et al. (2023) Harm from diagnostic error Enhance vigilance in high-risk cases

2. Analyzing the Reasons for Missed Diagnosis

Barwise et al. (2021) conducted a qualitative exploration across various acute care settings, identifying how poor communication, system inefficiencies, and patient complexity contribute to diagnostic delays. This study provides useful insights for improving collaboration, documentation, and information flow. Nurses can help bridge gaps by promoting teamwork and accurate data management.

Dixit et al. (2023) reviewed how technical limitations in Electronic Health Records (EHRs)—including poor usability, layout challenges, and interoperability issues—can impede correct diagnosis. Their findings reinforce the importance of designing EHR systems that align with clinical workflows. Nurses should be proactive in highlighting EHR-related challenges and participating in usability feedback sessions.

Politi et al. (2022) analyzed root causes of delayed care in the Veterans Health Administration, pointing to protocol violations, lack of formal processes, and interdepartmental communication breakdowns. Their findings underscore the need for systematic improvements and ongoing staff education. Nurses should focus on reinforcing policy compliance and contributing to the design of reliable care delivery systems.

Study Key Contributors to Missed Diagnosis Suggested Actions
Barwise et al. (2021) Communication, system gaps Enhance collaboration
Dixit et al. (2023) EHR limitations Report and address usability issues
Politi et al. (2022) Policy violations, poor coordination Strengthen procedural adherence

3. Strategies That Enhance Patient Safety and Communication

A. Patient Safety Strategies

Al-Dossary (2022) explored how positive nursing environments—marked by leadership support, adequate staffing, and teamwork—directly affect patient safety outcomes. Nurses working in such environments are more likely to report errors, which helps drive safety improvements. These findings support organizational investments in leadership training and staff resources.

Labrague (2024) identified that adherence to safety protocols among nurses directly correlates with reduced adverse events. Specific gaps were found in fall prevention and pressure ulcer protocols. Understanding these patterns allows nurses to tailor interventions and reinforce compliance through audits and training.

McHugh et al. (2021) studied hospitals in Queensland, Australia, revealing that lower nurse-to-patient ratios significantly reduced mortality, readmissions, and hospital stays. These findings support the push for staffing legislation to improve outcomes. Nurses can use this data to lobby for safer work environments and sufficient staff coverage.

Study Focus Area Practical Impact
Al-Dossary (2022) Work environment Advocate for leadership and resources
Labrague (2024) Protocol adherence Audit and train for compliance
McHugh et al. (2021) Staffing ratios Support legislative reforms

B. Communication and Handover Practices

Scolari et al. (2022) evaluated SBAR communication during nurse-physician calls and found significant variability in effectiveness based on training and nurse experience. The research recommends structured SBAR training during nursing education and emphasizes consistent practice to minimize errors during critical conversations.

Labrague (2025) synthesized data from 19 studies, showing that positive nurse-physician collaboration improves job satisfaction and reduces moral distress and turnover. This supports efforts to build respectful, interdisciplinary relationships, especially in high-stress environments.

Toren et al. (2022) documented the success of ISBAR handoffs in Israeli hospitals, showing how structured communication reduced clinical errors and enhanced satisfaction. These findings provide a practical foundation for hospitals seeking to improve transitions of care through standardized communication protocols.

Study Communication Tool Benefit
Scolari et al. (2022) SBAR Better phone communication in ICU
Labrague (2025) Collaboration review Improved morale and retention
Toren et al. (2022) ISBAR Safer handoffs and greater teamwork

Conclusion

The Improvement Plan Toolkit adopted by Riverside Community Hospital effectively addresses critical weaknesses in diagnostic accuracy and communication that were exposed by a serious incident involving missed sepsis. By integrating evidence-based solutions—ranging from enhanced diagnostic practices and collaborative EHR usage to structured communication protocols—the toolkit fosters a safer clinical environment. Nurses play an essential role in applying this framework, promoting protocol adherence, and ensuring effective information sharing. Ultimately, the toolkit stands as a structured, research-informed initiative designed to reduce errors and improve patient care outcomes.

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., et al. (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., et al. (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., et al. (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., et al. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149(Supplement 3). https://doi.org/10.1542/peds.2020-045948d

McHugh, M., et al. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay. 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., et al. (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., et al. (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., et al. (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., et al. (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