NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

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 being here. My name is Lisa. Today, I will focus on a critical medical security issue in the Intensive Care Unit (ICU): Diagnostic Error (DE) due to a communication gap during a nursing shift change. The failure to effectively communicate vital clinical information led to a delayed diagnosis of a pulmonary embolism in a ventilated patient. This in-service session will highlight the serious impact of DE and present evidence-based strategies to improve staff handoff practices, strengthen interdisciplinary communication, and enhance patient safety and clinical outcomes.

Part 1: Agenda and Outcomes

This session addresses a critical patient safety issue of DE stemming from communication gaps during nursing shift changes in the ICU. Our primary focus is enhancing nurses’ communication skills to ensure accurate, thorough handoffs and reduce the risk of DE. In high-acuity environments like the ICU, ineffective handoffs are risky, as even minor lapses can result in DE. It leads to treatment delays, prolonged institutional visits, escalated medical expenses and mortality (Atinga et al., 2024).

This in-service session equips nursing staff with evidence-based tools and approaches, such as SBAR (Situation, Background, Assessment, Recommendation) and structured handoff procedures, to enhance communication and guarantee continuity of care. A recent sentinel event involved a ventilated, sedated patient who suffered a DE when a pulmonary embolism went undetected due to a communication lapse during shift change. The outgoing nurse failed to report subtle but critical changes in the patient’s condition, delaying diagnosis. This case underscores the urgent need for consistent, detailed, standardized handoff practices to prevent fatal diagnostic oversights.

Goals

Specific goals have been established to address the DE issue and support the implementation of a targeted patient safety initiative. A primary objective is to assess the key factors contributing to communication failures during nursing handoffs in the ICU, which are a leading cause of DE. Based on facility data and current evidence, several critical issues have contributed to inadequate handoffs: insufficient training opportunities, time constraints during shift changes, lack of standardized handoff protocols, system inefficiencies, and ongoing staff shortages.

Poor communication during handoffs is a major contributor to DE, with studies showing that communication gaps account for a significant proportion of preventable patient harm (Zimolzak et al., 2021). In the ICU, where timely and accurate diagnoses are essential, DE can have severe consequences. A diagnosis of a condition like pulmonary embolism results in delayed treatment and potentially fatal outcomes. This underscores the urgent need for structured, consistent, and evidence-based improvements in handoff communication practices.

This session will explore effective strategies for improving patient handoffs in the ICU. It addresses communication gaps that contribute to DE during nursing shift changes. One primary goal is to decrease the hazard of DE ensuing from unclear information transfer. Key methods include adopting the SBAR tool to ensure clear, concise communication. Implement bedside handoff protocols that engage the incoming nurse directly in the patient’s care and leverage the Electronic Health Record (EHR) system for accurate, real-time transfer of patient data.

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Establishing a standardized handoff communication protocol, utilizing structured tools, and emphasizing the precise reporting of critical patient details are essential steps in enhancing care continuity. These improvements boost nursing efficiency and reduce the likelihood of DE, a major cause of preventable harm in the ICU (Browning et al., 2025).We will discuss the importance of addressing communication breakdowns during patient handoffs in the ICU to prevent DE. Failure to properly transfer critical patient information during shift changes can result in diagnostic errors and compromised patient safety. These DEs affect patient outcomes and increase healthcare costs (Atinga et al., 2024).

This training session will conclude with a practical demonstration of key communication skills. It enables staff to apply the diagnostic safety improvement plan in their daily nursing practice. Attending will strengthen participants’ ability to recognize and mitigate communication risks and promote accurate and complete handoffs. It reduces the occurrence of DE, ensuring safer, effective and continuous patient care in the ICU. 

Outcomes 

The anticipated outcomes of this in-service session are:

• Understanding the root causes of communication breakdowns during ICU shift changes will help nursing staff recognize vulnerabilities in handoff procedures. Nurses will strengthen their risk assessment skills by identifying gaps such as poor documentation and missed critical patient cues. Adopting timely, accurate handoff practices will enhance patient safety and help prevent DE, like the missed diagnosis of a pulmonary embolism.
• Staff will be introduced to evidence-based handoff practices, including the SBAR framework, structured bedside reporting, and effective use of the EHR system. These tools have been proven to reduce DE and handoff-related ICU errors. This training will empower nurses to apply standardized communication protocols. It fosters a culture of ICU safety, diagnostic accuracy, and professional accountability (Browning et al., 2025).
• Through this session, ICU staff will develop and refine practical handoff skills applicable to every shift transition. Reducing communication gaps will directly prevent DE and other critical events. As Zimolzak et al. (2021) emphasized, ongoing training and awareness are essential for ICU staff to avoid adverse incidents caused by inexperience or missed clinical cues. Regular reinforcement of these skills builds confidence, strengthens interdisciplinary collaboration, and ensures the accurate transfer of vital patient information. It improves diagnostic reliability and patient outcomes.

Part 2: Safety Improvement Plan

Overview of Diagnostic Errors and the Need to Address the Issue

Ineffective patient handoffs in the ICU remain a pressing challenge. It compromises patient safety and organizational efficiency. As highlighted in recent sentinel events, communication gaps during care transitions can result in critical DE. These lapses contribute to a cascade of negative outcomes, including patient harm, diminished quality of care, extended hospitalizations, increased financial burdens and even mortality (Atinga et al., 2024). The root causes of DE during ICU handoffs include fragmented communication, the absence of standardized handoff protocols and systemic inefficiencies.

Communication breakdown between healthcare experts during verbal and written patient handover explanations for 26% to 40% of opposing medical measures, 27% of medical misbehavior cases, and above 71% of clinically threatening events. A review of 23,000 medicinal misconduct proceedings revealed that communication failures during handoffs contributed to over 7,000 cases. It leads to around 2,000 avoidable deaths and 80% of severe diagnostic mistakes (Lazzari, 2024). In the U.S. alone, communication gaps result in an estimated $12.1 billion in annual costs due to medical errors and inefficiencies (Janagama et al., 2020). These findings underscore the urgent need to enhance handoff processes to prevent DE and protect patient outcomes in high-acuity settings like the ICU.

Process for Safety Improvement 

Step 1: Standardize Communication with SBAR Framework

The safety improvement plan is to improve communication during patient handoffs to reduce DE. The desired outcome is safeguarding the consistent and complete transfer of critical patient data during every care transition. The facility will develop and approve SBAR handoff templates. This standardized communication tool will help close gaps contributing to sentinel events (Lazzari, 2024).

Step 2: Reinforce System Safeguards through Monitoring & Alarm Management

The plan is to enhance surveillance to reduce DE in high-risk patients, such as those on ventilators. The desired outcome is faster identification of patient deterioration, alarm management and improved diagnostic accuracy. To support this goal, quiet zones will be designated and prepared within the ICU and high-acuity units, accompanied by awareness sessions to educate staff on the importance of minimizing distractions during critical monitoring tasks. 

Step 3: Integrate Technological Tools (EHRs Templates)

The safety plan integrates advanced technological tools to reduce reliance on memory and support timely clinical decision-making. The desired outcome is to guarantee clearer patient data transmission and enhance the efficiency of handoff processes. The facility will develop standardized handoff templates. These templates will help streamline communication and reduce DE due to missed or forgotten details. These templates will be fully deployed as part of the hospital-wide handoff protocol, ensuring consistent use across all units (Singh et al., 2022).

Step 4: Conduct Constant Staff Training and Certification

The safety improvement plan enhances staff diagnostic competency, constant follow-up and reduces fatigue-related errors. The desired outcome is to increase staff accountability and foster a stronger safety culture within the ICU. The hospital will launch training programs on diagnostic reasoning and structured communication to support this goal and ensure all team members have the essential skills. Staffing policy changes, including shift limits and rest period enforcement, will be implemented to mitigate fatigue and promote alertness during critical care periods. 

Implications for Diagnostic Errors and Its Importance for the Medical Organization

Addressing the persistent issue of ineffective patient handoffs in the ICU is critical, as communication lapses are a leading cause of DE and can result in life-threatening consequences. Breakdowns in communication during shift transitions are among the primary causes of DE and misdiagnosed conditions. It leads to unnecessary escalation of care and increased operational costs. Poor communication contributes to an estimated $12.2 billion in annual healthcare expenses across the U.S. (Janagama et al., 2020). These inefficiencies jeopardize patient safety, prolong hospital stays, and expose healthcare institutions to reputational harm, reduced safety ratings, and legal liabilities, many of which stem from incorrect diagnoses.

Moreover, unclear handoff processes contribute to staff dissatisfaction and workflow disruption, increasing the risk of DE and compromising the quality of care. Implementing a standardized handoff protocol, such as SBAR and an EHR-integrated handover tool, will reduce the incidence of costly and preventable DE. These structured communication strategies promote interprofessional collaboration and support patient safety and compliance with accreditation standards. The organization will improve diagnostic accuracy, enhance patient outcomes and strengthen staff confidence and morale by prioritizing clear, consistent communication and equipping ICU nurses with vital tools and training. It reinforces a strong safety and clinical accountability culture.

Part 3: Audience’s Role and Importance

Audience’s Role in Implementing and Driving the Improvement Plan

The efficiency of the improvement plan targeting ICU handoff communication errors, contributing to DE of critical conditions like pulmonary embolism, relies on the active involvement of all healthcare stakeholders. It includes nurses, physicians, and hospital leadership. Russo et al. (2024) state that adequate nurse staffing ensures quality care and improves DE rates. During shift transitions and patient transfers in the ICU, healthcare providers must utilize structured communication strategies, such as SBAR, to ensure the seamless transmission of critical patient data.

In addition to adopting these tools, staff must engage in continuous training, participate in interdisciplinary rounds, and provide feedback on workflow inefficiencies to strengthen the use of standardized handoff procedures. When frontline clinicians take ownership of these changes, it fosters a culture of accountability and safeguards that improved handoff practices become an integral part of daily routines. Hospital administrators play a pivotal role by facilitating this change. They invest in digital handoff systems, allocating time for training, and embedding structured protocols within institutional policy. Their support empowers clinical staff to perform accurate and safe handoffs. It safeguards patient outcomes and operational performance in the ICU.

Audience Critical for Plan’s Success

The audience, including the nursing staff, represents the executors of ICU handoff procedures and is vital to executing the safety improvement plan to reduce DE. Their daily involvement in patient transitions means their engagement and adherence to structured communication protocols are critical to minimizing information gaps. As active participants in shift-to-shift communication, the audience’s commitment to standardized tools, such as SBAR and EHR, plays a pivotal role in preventing serious lapses like the one that led to the DE of a pulmonary embolism (Lazzari, 2024)

. Even the effective systems fail to address communication inefficiencies without support from administrative leaders and medical staff. When fully embraced, these tools can streamline handoffs, improve diagnostic accuracy, and enhance communication and patient satisfaction (Russo et al., 2024). Moreover, audience insights into real-time challenges, such as time constraints and workflow disruptions, are essential for shaping practical and sustainable improvements. The entire care team reinforces best practices by fostering a shared accountability culture. It improves patient outcomes and safety.

Benefits of Embracing Their Role

Incorporating their role in the ICU handoff proposal will help the audience, especially nursing staff, experience reduced stress, DEs and efficient workflows. Utilizing structured communication tools such as SBAR and EHR handoff templates streamlines the transfer of patient data, enhancing both speed and accuracy. Through SBAR, nurses can deliver concise and consistent updates on critically ill patients, decreasing the chance of DEs (Singh et al., 2022).

These improvements lead to enhanced patient outcomes, fewer clarification interruptions, and lower staff burnout rates associated with disorganized transitions. Regular training sessions equip staff with greater competence and assurance in applying standardized protocols. Atinga et al. (2024) emphasized that ongoing training strengthens communication skills and builds the confidence needed to minimize DEs during handoffs. These collective efforts reduce the incidence of DEs, elevate team morale, lower the frequency of adverse events, and encourage a culture of security within the ICU setting.

Part 4: New Process and Skills Practice

New Processes and Skills

This safety advancement plan for reducing DEs in the ICU integrates innovative strategies. It includes implementing the SBAR communication framework. SBAR empowers the medical team to convey critical patient condition details clearly and efficiently, reducing the likelihood of DEs (Russo et al., 2024). Nurses will apply SBAR during transitions to ensure accurate exchanges that support continuity of care during shift changes. Another key practice is the integration of EHR with specialized handoff templates.

These digital tools streamline the documentation process and ensure that essential clinical information is not overlooked. The standardized format provided by EHR-enhanced handoff reports promotes timely, relevant, and consistent data sharing. It minimizes communication gaps and improves the precision of verbal and written exchanges. Richters et al. (2023) emphasized that handoff standardization contributes to quality care. Adopting these evidence-based practices addresses the ongoing challenges of ICU handoffs, including DEs, ensuring the secure transfer of vital patient data and supporting improved patient outcomes.

Practical Activity 

A simulation-based activity will be developed to enhance nurses’ skills and ensure the efficient adoption of new practices. Richters et al. (2023), highlighted that simulation-based training improves handoff proficiency, boosts nurses’ confidence, and refines communication skills. Applicants will participate in a group simulation, where they will role-play patient handoffs involving a patient admitted to the ICU for pulmonary embolism care. Using the SBAR tool, each group will have two minutes to deliver an inclusive handoff of the patient’s condition, history, assessment findings and immediate care approvals.

To simulate real-world scenarios, distractions will be introduced to challenge participants’ ability to maintain clear communication. Following the simulation, facilitators will provide feedback, highlighting communication gaps and strengths, and guiding participants on addressing and reducing DE. This hands-on activity emphasizes the critical role of structured communication tools like SBAR in preventing delayed diagnosis and enhancing patient safety during care transitions.

Collaborative Question and Answer (Q/A) Activity

This exercise will include a Q&A session to engage nurses and highlight effective patient handoff techniques. Questions like “How will you ensure proper patient handoff during shift change to prevent DE?” will prompt nurses to reflect on methods like SBAR to ensure all critical information regarding the patient’s condition is conveyed. It minimizes the risk of misunderstanding. Another question, “How can you validate patient details during transition to avoid delayed diagnosis?” encourages nurses to explore tools such as EHR-integrated handoff reports.

It helps standardize the transfer of patient data, reducing DEs and improving communication efficiency. This Q&A session fosters collaborative brainstorming, enabling nurses to share insights and enhance their understanding of effective handoff practices. By promoting analytical thinking, this activity will empower staff to adopt reliable handoff protocols. It improves patient safety and reduces the risks of delayed diagnoses.

Part 5: Soliciting Feedback

Effective feedback methods will gather insights on the plan to improve patient handoff practices, particularly in addressing issues like DEs and communication gaps. First, anonymous survey questionnaires will be distributed at the end of the in-service session. It allows participants to evaluate the efficiency and thoroughness of handoff tools and methods like SBAR.

The audience will receive an open-ended feedback form, where staff can share their perspectives on the new practices and suggest practical improvements. This will enable them to discuss challenges, such as how communication gaps contribute to DEs, and successes in implementing patient handoff techniques. Meyer et al. (2021), emphasized that open-ended feedback helps safeguard adjustments align with staff experiences and needs. Finally, the collected feedback will be analyzed to identify trends, strengths, and areas for refinement, ensuring continuous improvement in patient handoff practices, minimizing communication gaps, and addressing the risks of DEs. It enhances patient safety.

Conclusion

This in-service presentation addresses a DEs issue in the ICU. It focuses on communication breakdowns during nursing shift changes that led to DEs from a pulmonary embolism. The session will highlight strategies to enhance nursing handoff practices, improve interdisciplinary communication, and reduce adverse outcomes. Using structured tools like SBAR and bedside handoff protocols and integrating the EHR system standardizes patient information transfer, enhances care continuity, and prevents critical lapses. Training will provide staff with the necessary skills to effectively manage shift transitions, ensuring timely and accurate communication that improves patient safety and care outcomes.

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

Browning, L., Khan, U., Leggat, S., & Boyd, J. H. (2025). The impact of electronic medical record implementation on the process and outcomes of nursing handover: A rapid evidence assessment. Journal of Nursing Management, 2025(1). https://doi.org/10.1155/jonm/5585723

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

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

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

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

Richters, C., Stadler, M., Radkowitsch, A., Schmidmaier, Fischer, M. R., & Fischer, F. (2023). Who is on the right track? Behavior-based prediction of diagnostic success in a collaborative diagnostic reasoning simulation. Large-Scale Assessments in Education, 11(1). https://doi.org/10.1186/s40536-023-00151-1

Russo, Tilly, J., Kaufman, L., Danforth, M., Graber, M. L., Austin, & Singh, H. (2024). Hospital commitments to address diagnostic errors: An assessment of 95 US hospitals. Journal of Hospital Medicine, 20(2), 120–134. https://doi.org/10.1002/jhm.13485

Singh, H., Mushtaq, U., Marinez, A., Shahid, U., Huebner, J., McGaffigan, P., & Upadhyay, D. K. (2022). Developing the “safer Dx checklist” of ten safety recommendations for health care organizations to address diagnostic errors. The Joint Commission Journal on Quality and Patient Safety, 48(11). https://doi.org/10.1016/j.jcjq.2022.08.003

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Zimolzak, A. J., Shahid, U., Giardina, T. D., Memon, S. A., Mushtaq, U., Zubkoff, L., Murphy, D. R., Bradford, A., & Singh, H. (2021). Why test results are still getting “lost” to follow-up: A qualitative study of implementation gaps. Journal of General Internal Medicine, 37(1), 137–144. https://doi.org/10.1007/s11606-021-06772-y