Capella 4035 Assessment 3

Capella 4035 Assessment 3

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Hello and welcome, everyone. Thank you for attending this critical in-service session. My name is _______. Today, we will explore a significant issue concerning patient safety, particularly focusing on communication failures during nursing shift transitions. This presentation highlights a sentinel event involving a 68-year-old patient with COPD, whose declining respiratory condition and recent medication changes were not properly handed over to the incoming nurse. As a result, urgent respiratory care was delayed, leading to a medical emergency. This breakdown in communication stemmed from abbreviated handoffs, staff shortages, lack of documentation in the Electronic Health Record (EHR), and omitted verbal updates. This session aims to underline the implications of such communication failures and present actionable, evidence-based strategies for improving handoff communication to safeguard patient outcomes.

Part 1: Agenda and Outcomes

Agenda and Goals

This session addresses the vulnerabilities associated with communication lapses during the care of patients with chronic conditions like COPD. We will focus on improving the structure and clarity of nurse-to-nurse handoffs using proven frameworks such as SBAR (Situation, Background, Assessment, Recommendation) and I-PASS. The failure to communicate essential clinical details during shift change in the presented case led to a delay in care and significant respiratory distress. Factors contributing to this include a disorganized environment, unclear responsibilities, insufficient documentation, and understaffing.

The primary goal is to reduce communication breakdowns by standardizing the handoff process. This involves identifying contributing causes—such as rushed transitions and inadequate EHR updates—and replacing them with structured tools and policies. Research demonstrates that communication failures during handoffs are a leading cause of preventable harm in healthcare settings (Schroers et al., 2021). Hence, this in-service training introduces structured communication strategies, closed-loop techniques, and dedicated quiet zones for handoffs.

Intended Outcomes

The outcomes of this training session are as follows:

Outcome	Description
Increase awareness	Staff will recognize how interruptions and informal handoffs lead to medication errors and delayed care.
Implement tech solutions	Training on BCMA and EHR-integrated handoff tools will support error reduction.
Enhance practical skills	Participants will develop methods to minimize distractions using mindfulness and designated quiet zones.
Improve safety culture	Reinforcement of structured communication will support safer workflows and reduce stress among staff.

According to Louis et al. (2024), structured communication reduces medication error syndrome (MES), fosters professional confidence, and improves team coordination. This session concludes with an example of proper handoff communication to help staff apply the skills in real clinical contexts.

Part 2: Safety Improvement Plan

Patient Handoff Interruptions

Handoffs during shift changes or between departments are critical junctures where miscommunication can easily occur, especially in high-stress areas like the ICU. Fragmented information exchange and workplace distractions frequently compromise patient safety. Reime et al. (2024) report that over 80% of sentinel events stem from communication failures during handoffs, highlighting their impact.

One contributing factor is the absence of a uniform communication protocol. Tools like SBAR and I-PASS provide a standard format that reduces ambiguity and ensures completeness. Risani et al. (2024) found that SBAR implementation significantly improved handoff quality and minimized avoidable errors. Time constraints and multitasking further erode communication quality, often leading to missed updates on vital signs or medication adjustments.

To address these challenges, a structured reform plan is necessary. This includes the implementation of standard protocols, protected time for shift reports, and EHR-integrated handoff tools that ensure no vital information is lost during transitions.

Safety Process and Policy Implementation

The safety improvement plan follows a staged approach:

Stage	Action	Outcome
Policy Formation	Create protocols for BCMA, closed-loop communication, and distraction-free handoff zones	Stakeholder buy-in and cross-departmental collaboration
Staff Training	Hands-on training with EHR and BCMA tools, role-play simulations	Improved readiness, reduced resistance to new practices
Protocol Rollout	Enforce new standards with support from supervisors	Consistent application of safety practices
Monitoring & Feedback	Collect real-time data on handoff efficiency and medication errors	Data-driven improvement and refinement
Continuous Evaluation	Review outcomes annually and update policies accordingly	Sustained culture of safety and lower error rates

Nawawi and Ibrahim (2024) affirm that combining technology adoption with comprehensive training improves safety performance and fosters continuous learning within healthcare systems.

Organizational Impact of Handoff Errors

Incomplete handoffs carry both clinical and organizational consequences. Diagnostic delays, treatment errors, and patient harm not only prolong hospitalization and inflate costs but also increase litigation risks and staff turnover. Interruptions also diminish morale and elevate burnout rates. Solutions such as SBAR, quiet zones, and EHR templates help create resilient communication frameworks, ensuring safer transitions and enhancing organizational integrity (Reime et al., 2024).

Part 3: Audience’s Role and Importance

Role in Implementing the Plan

Nurses, physicians, IT personnel, and hospital leadership must work collaboratively to enforce the improvement strategies. Nurses are at the forefront, applying SBAR, EHR-integrated templates, and closed-loop communication during every handoff. Their participation in training, feedback mechanisms, and adherence to structured handoffs directly affects the success of this initiative. According to Janagama et al. (2020), minimizing communication interruptions during patient handoffs reduces diagnostic delays and enhances outcomes.

Leadership is equally vital in setting expectations, ensuring compliance, and providing resources for implementation. This collective engagement fosters a culture of reliability and enhances interprofessional collaboration.

Key Contributors to Success

The nursing team is instrumental to the plan’s success. Their accurate application of structured handoffs reduces data loss, especially in time-sensitive cases. For instance, Lazzari (2024) describes a pulmonary embolism case where failure to follow standard protocols caused misdiagnosis. EHR systems alone are insufficient; it is the consistent, competent use of these tools by nurses that truly minimizes errors.

Moreover, nurses’ on-ground insights into the limitations of current workflows are vital for refining protocols. Building a culture of shared accountability ensures that handoffs become safer and more effective.

Benefits of Embracing Their Role

Nurses benefit from structured communication through improved workflow, reduced delays, and enhanced patient outcomes. SBAR and EHR tools make it easier to transfer crucial medication data, ensuring timely interventions. These tools reduce redundancy and the need for repeated clarifications. According to Atinga et al. (2024), regular training reinforces communication habits and reduces the likelihood of medication-related errors, thereby creating a more reliable and less stressful work environment.

Part 4: New Process and Skills Practice

Implementation of New Processes

The handoff safety improvement initiative integrates EHR systems with tailored templates and the SBAR framework. These tools ensure consistent, accurate sharing of clinical updates, especially regarding medications. Using SBAR allows healthcare providers to clearly present the patient’s status and needs. This structured process limits confusion and ensures timely follow-up care.

Skills Practice: Workshop and Interactive Session

A scenario-based workshop will be conducted to reinforce these processes. Nurses will be grouped and tasked with performing mock handoffs, including updates on medication changes and pending treatments. Simulated challenges such as time pressures or technological malfunctions will be introduced to mirror real-life conditions. Facilitators will then offer feedback to highlight improvement opportunities and prevent common handoff pitfalls (Lee & Lim, 2021).

Additionally, an interactive Q&A session will challenge nurses to reflect on their approach. Example questions include:

Question	Purpose
“How will you ensure accurate medication handoff during shift change?”	Promote the use of structured tools like SBAR
“What methods can you apply to verify orders during transitions?”	Encourage EHR validation and checklist use

This activity fosters peer-to-peer learning and ensures the internalization of communication best practices (Wong et al., 2021).

Part 5: Soliciting Feedback

To evaluate the effectiveness of the new handoff strategy, anonymous surveys and open-ended questionnaires will be distributed. These tools allow nurses to share insights on SBAR implementation, EHR use, and practical challenges. Meyer et al. (2021) emphasize that such feedback ensures continuous adaptation based on frontline experiences.

Collected data will inform protocol adjustments and guide future training. By identifying recurring themes and gaps, this approach strengthens the feedback loop and supports ongoing quality improvement in handoff procedures.

Conclusion

Addressing breakdowns in handoff communication is critical for advancing patient safety. The case presented today illustrates how missed information during shift changes can result in dire consequences. By adopting structured communication tools like SBAR and I-PASS, reinforcing EHR use, and creating protected handoff zones, we can significantly reduce preventable harm. Success hinges on collaboration among nursing staff, administrators, and interdisciplinary teams. This initiative not only enhances clinical outcomes but also fosters a more dependable and satisfying work environment. Through sustained effort and evaluation, we can build a robust model for safer patient transitions and care continuity.

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

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

Capella 4035 Assessment 3

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

The post Capella 4035 Assessment 3 appeared first on MSN Writing Services.