NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
Name
Capella university
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Improvement Plan Toolkit
The Riverside Community Hospital uses the improvement plan toolkit to improve diagnosis and protect patients, after a critical incident where a 67-year-old patient with sepsis was not correctly diagnosed. The event highlights the importance of making changes, particularly in recognizing sepsis early and communicating effectively during shifts. The toolkit aims to prevent similar mistakes by examining issues with communication, assessments, and the initiation of protocols. Its main parts are: Understanding and Preventing Diagnostic Errors, Analyzing the Reasons for Missed Diagnoses, Strategies That Enhance Patient Safety, and Improving Communication and Handover Practices. All the elements rely on scientific research, providing a strong foundation for better and safer patient care (Marshall et al., 2022).
Annotated Bibliography
Understanding and Preventing Diagnostic Errors
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
The research examined the frequency of diagnostic errors, their causes, and the impact on patients who died or required intensive care unit (ICU) care in 29 academic medical centers. It was discovered that errors primarily stemmed from issues with clinical evaluation, ordering, and reading diagnostic tests, so these areas should be improved. It highlights the most common places where diagnostic errors are likely to occur, including cases involving ICU admission or death. It recommends that hospitals work on improving assessment skills and test accuracy to protect patients. Nurses may use what they learn to seek further training, assist in accurate diagnosis, and support better communication with other teams, particularly in situations where patients are critically ill or nearing death.
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
The resource emphasizes diagnostic stewardship, which helps doctors use tests wisely to avoid mistakes and offer better care. It enables clinicians to make more informed choices by applying findings from behavioral economics. In circumstances where Clostridioides difficile infection is suspected, doctors may control testing by avoiding PCR for those taking medications that can cause diarrhea and by adding toxin tests to enhance the accuracy of the diagnosis. It is useful because it illustrates that using tests correctly can reduce the likelihood of misdiagnosis and improve treatment outcomes. With this knowledge, nurses can better support and practice diagnostic stewardship, particularly by selecting tests and interpreting results. It becomes crucial when developing or updating protocols to minimize errors in diagnosis and prevent unnecessary or incorrect tests.
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
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
This study finds that around 795,000 people in the US are seriously hurt every year by diagnostic errors, which can often result in death or permanent disability. It stresses that most of these problems are caused by vascular events, infections, and cancers, which are the “Big Three” high-risk conditions. The resource emphasizes that accurate diagnosis is crucial for keeping patients safe, particularly when dealing with life-threatening conditions. It helps us understand the various ways diagnostic errors can harm patients and identifies areas where safety needs improvement. They can utilize this knowledge to advocate for and implement diagnostic safety strategies, particularly in high-risk settings such as emergency rooms and intensive care units.
Analyzing the Reasons for Missed Diagnosis
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
The study by Barwise et al. (2021) offers important insights into the factors contributing to diagnostic delays and errors in acute care settings. Through input from 64 clinicians across various departments, the research identified key barriers involving organizational systems, coordination, communication, individual clinicians, and patient-related issues that affect timely and accurate diagnosis. It highlights how these elements interact throughout the diagnostic process—during information collection, analysis, and decision-making. This resource is valuable for identifying specific areas to target in safety improvement efforts, such as enhancing communication methods and improving the management of clinical information. Nurses can apply these findings to enhance teamwork, ensure precise documentation, and actively participate in collaborative diagnostic decisions. It is particularly helpful when creating or revising protocols or training programs aimed at minimizing diagnostic errors and improving overall patient safety.
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
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
Dixit et al. (2023) examine, in their review, the relationship between EHR systems and diagnostic errors. The review, based on 11 studies, points out that technical problems, poor usability, and workflow issues with EHRs can make it more difficult to diagnose patients. Due to issues such as poor interoperability, inaccurate data, and unsuitable layouts on the display, clinicians struggle to interpret medical data accurately. This resource demonstrates how errors in EHR systems can impact the accuracy of diagnoses and provides guidance on improving patient safety by addressing system design issues. This information enables nurses to identify and work around EHR issues in their daily work and to advocate for EHR systems that are easier to use. It is most useful when EHRs are implemented or updated, as it highlights major issues that, if addressed, can significantly reduce the risk of diagnostic errors.
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
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
The study by Politi et al. (2022) examines cases where diagnosis, treatment, or surgery was delayed in Veterans Health Administration hospitals, using Root Cause Analysis (RCA) reports from October 2016 to September 2019. It highlights important causes, including the absence of formal care processes, poor communication between departments, and the violation of established policies and procedures. It is useful for guiding safety improvements because it reveals the main reasons behind delays and unfavorable events. It helps create plans to stop similar issues and improve the safety of all patients. Nurses can learn from these examples to better understand why delays occur and help create more effective systems for communication and workflow. It helps a lot when working on protocols, building teamwork, or joining projects aimed at making care more efficient and effective.
Strategies That Enhance the Safety of Patients
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
This article provides details on how various factors in the nursing environment, such as leadership, teamwork, and access to required resources, can significantly impact patient safety. It highlights the connection between a supportive work environment and error reporting, demonstrating that management and teamwork play a significant role. With these findings, nurses can more clearly see the impact of their workplace on patient safety and request appropriate changes, particularly in terms of improved leadership or resources. It is especially helpful when participating in quality improvement initiatives, discussing policies, or working to enhance safety culture in healthcare organizations.
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
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
It explains how following patient safety guidelines by nurses is related to the number and reporting of adverse patient events. It helps identify regions where protocol compliance is lower, such as error reporting, assessing for falls, and preventing pressure ulcers. It also points out that following protocols more often leads to more reports of adverse events. Nurses can rely on this resource to identify what influences their commitment to safety rules and to pinpoint areas that need improvement. When nurses apply these findings, they can implement specific plans to ensure the rules are followed, which benefits patient safety. This is a valuable resource for designing or evaluating safety initiatives, particularly for clinics seeking to reduce adverse events and promote honest reporting and improvement.
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
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
The study examined the impact of implementing minimum nurse-to-patient ratios on hospital staffing and patient outcomes in Queensland, Australia. The research showed that hospitals enforcing the rules had better outcomes in terms of 30-day mortality, 7-day readmissions, and patient length of stay. Having slightly fewer patients per nurse improved health outcomes, and the savings from fewer readmissions and faster hospital discharges were greater than the expenses incurred for hiring additional staff. It demonstrates that having sufficient nurses on staff leads to improved patient outcomes and encourages the implementation of policies to ensure safety and better care. Nurses can use this evidence to advocate for safer staffing levels and influence laws that help reduce diagnostic errors and improve patient health.
Improving Communication and Handover Practices
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
Scolari et al. (2022) examined how ICU nurses use the SBAR (Situation-Background-Assessment-Recommendation) tool during phone conversations with doctors. According to a study of 290 calls by 99 nurses, the average score for SBAR was only 41%. Several factors positively influenced SBAR quality, including the nurse’s age, native language, experience in the ICU, and whether they had received SBAR training during their nursing education.
It provides valuable insights into how SBAR is applied in practice and highlights the need for improved communication. Recognizing that SBAR can be used differently and that certain factors influence its effectiveness supports efforts to train staff and standardize work. This knowledge enables nurses to refine their SBAR communication, reduce the risk of diagnostic errors, and improve patient safety. The research is highly useful for identifying weaknesses in training and communication among ICU staff and for implementing strategies to support teamwork in critical situations.
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
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
The review synthesizes and examines findings from 19 studies to elucidate the relationship between nurse-physician collaboration and nursing workforce outcomes. It makes clear how working together effectively affects motivation, performance at work, staff’s desire to leave, job satisfaction, and the feeling of moral distress among nurses. The resource utilizes these findings to help nurses gather information and evidence to support better collaboration among different healthcare professionals. For any safety improvement initiatives that require teamwork and communication to benefit patients, this understanding is crucial. Nurses can rely on this resource to identify areas where collaboration can be improved to make their workplace more supportive and effective. It is most suitable when trying to improve how a team works, lower staff turnover, and encourage everyone to take responsibility in clinical settings.
Toren, O., Lipschuetz, M., Lehmann, A., Regev, G., & Arad, D. (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
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
This resource provides insights into how ISBAR is applied in Israeli hospitals, particularly in the transfer of patients between intensive care units and other medical or surgical wards. It gives details on statistics and offers practical advice on how regular communication helps share patient data and enhances team satisfaction. It was found that using structured communication effectively leads to fewer errors, improved teamwork, and nurses enjoying their jobs more. Because of this, ISBAR is a valuable resource for observing the positive effects it has in practical medical settings. Based on these results, nurses can see the importance of following a consistent handoff process and recommend using ISBAR where they work. It is particularly useful when creating or updating safety plans, participating in communication training sessions, or exploring methods to prevent diagnostic and patient handoff errors.
Conclusion
At Riverside Community Hospital, the Improvement Plan Toolkit addresses issues with early sepsis detection and communication by employing evidence-based strategies. To avoid errors, it is essential to enhance diagnosis, improve the sharing of information when a nurse changes shifts, and foster a positive nursing environment. Nurses play a crucial role in implementing these improvements to keep patients safe. All in all, the toolkit provides a well-organized, research-based system for reducing diagnostic errors and improving 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., 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
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
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
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. (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., Rinke, M. L., Olson, A. P. J., & Brady, P. W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149(Supplement 3). https://doi.org/10.1542/peds.2020-045948d
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
NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit
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
Toren, O., Lipschuetz, M., Lehmann, A., Regev, G., & Arad, D. (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