Capella 4035 Assessment 4

Capella 4035 Assessment 4

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan Toolkit

At Riverside Community Hospital, a structured improvement plan toolkit was developed in response to a critical event involving a 67-year-old patient who was not accurately diagnosed with sepsis. This case emphasized the urgent need to refine diagnostic practices and improve inter-shift communication. The toolkit is designed to prevent similar incidents by targeting issues in patient assessment, communication, and protocol adherence. The key focus areas of the toolkit include: Understanding and Preventing Diagnostic Errors, Analyzing the Reasons for Missed Diagnoses, Strategies That Enhance Patient Safety, and Improving Communication and Handover Practices. Each section draws from current evidence-based practices to establish a safer clinical environment and ensure more reliable patient outcomes (Marshall et al., 2022).

Annotated Bibliography

Understanding and Preventing Diagnostic Errors

Citation	Summary
Auerbach et al. (2024)	This study analyzed diagnostic errors among hospitalized adults who either died or were transferred to intensive care units across 29 academic medical centers. It found that most errors were due to shortcomings in clinical judgment, diagnostic test ordering, and interpretation. The authors recommend focused training to strengthen assessment accuracy and interprofessional collaboration during high-acuity care.
Morgan et al. (2023)	The authors highlight the concept of diagnostic stewardship, which advocates for responsible use of diagnostic tests. Using principles from behavioral economics, they illustrate how unnecessary testing can be minimized, thereby reducing misdiagnoses. This guidance assists clinicians, especially nurses, in making informed test-related decisions to support accurate diagnosis.
Newman-Toker et al. (2023)	This paper reveals that nearly 795,000 individuals suffer serious harm each year due to diagnostic errors in the U.S., predominantly involving vascular conditions, infections, and cancers. It urges healthcare providers to prioritize diagnostic accuracy, especially in high-risk scenarios like emergency departments and intensive care units.

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Analyzing the Reasons for Missed Diagnoses

Citation	Summary
Barwise et al. (2021)	Through qualitative interviews with clinicians, this research identifies organizational, communication, and clinician-related barriers as major contributors to diagnostic delays in acute care settings. It suggests that improvements in coordination, information management, and collaborative decision-making are critical for enhancing diagnostic safety.
Dixit et al. (2023)	This scoping review highlights that electronic health record (EHR) systems often contribute to diagnostic mistakes due to poor design, usability issues, and fragmented workflows. Addressing these shortcomings is essential to make EHRs more effective in supporting accurate diagnoses.
Politi et al. (2022)	The study examines delays in diagnosis and treatment within Veterans Health Administration hospitals. Findings indicate that procedural lapses, communication failures, and inadequate adherence to policies are primary culprits. It proposes targeted actions to mitigate these root causes, offering valuable guidance for healthcare improvements.

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Strategies That Enhance Patient Safety

Citation	Summary
Al-Dossary (2022)	This study underscores how leadership, teamwork, and adequate resource allocation in the nursing environment directly influence patient safety. It emphasizes the value of a supportive workplace in reducing errors and promoting accountability through improved teamwork and leadership practices.
Labrague (2024)	The author connects nurses’ adherence to safety protocols with adverse patient events. The study notes that better compliance correlates with more frequent reporting of safety incidents, suggesting a culture of transparency and a proactive approach to reducing risks.
McHugh et al. (2021)	This research explores how legislating minimum nurse-to-patient ratios positively affects patient mortality, readmissions, and length of hospital stay. The findings advocate for policy reforms that ensure adequate staffing, demonstrating that improved nurse availability significantly enhances patient outcomes.

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Improving Communication and Handover Practices

Citation

Summary

Scolari et al. (2022)

This observational study evaluates the quality of nurse-to-physician communication using the SBAR (Situation-Background-Assessment-Recommendation) format in ICU settings. It reveals that only 41% of the evaluated phone calls met satisfactory SBAR standards, with factors like training, age, and language proficiency influencing outcomes. The study recommends targeted SBAR training as a means of enhancing communication effectiveness during critical care transitions.

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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.202

Auerbach, A. D., Lee, T. M., Hubbard, C. C., Ranji, S. R., Raffel, K., Valdes, G., … & 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

Barwise, A., Leppin, A., Dong, Y., Huang, C., Pinevich, Y., Herasevich, S., … & 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

Capella 4035 Assessment 4

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, J., Thompson, G., Lewis, B., & Greene, R. (2022). Implementing diagnostic improvement strategies in acute care: A toolkit approach. Patient Safety & Quality Healthcare, 19(3), 22-28.

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

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., … & 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

Capella 4035 Assessment 4

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