NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Part 1: Agenda and Outcomes

Overview of the Safety Issue

Good day, everyone. Thank you for joining today’s in-service session. My name is Lori, and I will be discussing a significant patient safety concern arising from ineffective communication during nursing handoffs. In a recent incident, a 68-year-old patient with chronic obstructive pulmonary disease (COPD) experienced respiratory distress due to missed updates about their deteriorating condition and medication changes during a shift transition. This delay in care led to an adverse event and was traced to a combination of factors including a high workload, lack of standardized protocols, poor EHR documentation, and absence of verbal communication. This session focuses on strategies to enhance communication during handoffs and prevent similar events from recurring.

Session Objectives

This in-service aims to address the risks associated with communication failures during nurse shift changes, especially in patients with chronic conditions such as COPD. The session highlights the importance of structured communication frameworks like SBAR (Situation, Background, Assessment, Recommendation), I-PASS, and the use of protected handoff zones to promote the reliable transfer of patient information. These tools help ensure consistency, clarity, and completeness of handoffs, especially in high-risk cases. Incorporating such standardized methods will foster a culture of safety and reduce the incidence of adverse outcomes (Risani et al., 2024).

Goals and Strategic Focus

The central goal is to address the root causes of the sentinel event and implement structured solutions to prevent recurrence. Factors such as insufficient documentation, unclear role expectations, and rushed handoffs contributed to the incident. Evidence suggests that communication errors during transitions are among the top causes of preventable harm (Schroers et al., 2021). Thus, we will examine how tools like real-time EHR updates, closed-loop communication, and standardized bedside handoff protocols improve accountability and information accuracy. Through these interventions, we aim to improve workflow efficiency, protect patients from harm, and support a culture of continuous safety improvement (Louis et al., 2024).

Expected Outcomes

The outcomes expected from this session include:

Expected Outcome	Details
Increased awareness of communication-related risks	Recognize vulnerabilities during transitions and adopt safer practices.
Improved use of technology and tools	Utilize BCMA and EHR-integrated solutions to enhance medication safety.
Mastery of distraction-reduction strategies	Practice mindfulness, quiet zones, and closed-loop communication.
Enhanced team collaboration and communication confidence	Foster interprofessional dialogue and consistent information transfer.

Part 2: Safety Improvement Plan

Patient Handoff Interruptions

Patient handoffs are critical junctures in healthcare where communication lapses can lead to severe consequences. High-acuity environments such as ICUs are particularly vulnerable to these interruptions. Studies show that communication breakdowns during handoffs are a contributing factor in over 80% of sentinel events (Reime et al., 2024). Contributing issues include time constraints, staff shortages, environmental distractions, and the absence of standardized communication models. These factors compromise continuity of care, delay treatment, and increase the risk of errors.

To reduce these risks, implementing communication structures such as SBAR can provide clarity and ensure that essential clinical data are conveyed consistently. Protected handoff time, distraction-free zones, and enforced protocols help reduce cognitive overload and foster accountability.

Process for Safety Improvement

The safety improvement initiative will follow a multi-phased approach:

Phase	Action Plan	Outcome
Policy Development	Create new handoff and medication protocols, including BCMA and quiet zones.	Standardized and collaborative communication processes.
Staff Training	Provide simulation-based training on BCMA, EHR workflows, and communication protocols.	Competence and confidence in new systems and handoff tools.
System Configuration	Align BCMA devices with existing EHR infrastructure.	Real-time medication tracking and reduced documentation errors.
Policy Implementation	Roll out protocols with supervision and real-time coaching.	Full compliance and consistent use across all clinical areas.
Monitoring and Feedback	Collect audit data and staff feedback; adjust procedures accordingly.	Identification of gaps and ongoing system improvement.
Evaluation and Continuous Review	Analyze outcomes and refine strategies with predictive analytics and updated training.	Sustained patient safety culture and reduced medication error rates.

Organizational Implications of Handoff Failures

Communication interruptions during handoffs not only affect patient outcomes but also strain healthcare organizations. They can lead to treatment delays, increased lengths of stay, legal liabilities, and resource wastage. Moreover, such failures negatively impact staff morale, contributing to burnout and turnover. Implementing standardized handoff formats and minimizing distractions are essential to improving care transitions and ensuring regulatory compliance (Reime et al., 2024).

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Part 3: Audience’s Role and Importance

Implementing the Plan: Staff Involvement

The successful implementation of the handoff improvement plan depends heavily on the involvement of clinical staff, especially nurses. Their participation in structured communication, compliance with protocols, and feedback sharing are pivotal to eliminating handoff-related risks. Nurses must consistently use SBAR and EHR-integrated templates and report issues faced during transitions. Leadership also plays a key role by allocating resources, providing oversight, and ensuring adherence to safety standards (Janagama et al., 2020).

Critical Role of the Nursing Team

Nurses are central to this initiative, acting as the primary conduits for information transfer during care transitions. Their familiarity with real-time clinical data makes their accurate reporting vital to patient safety. Research shows that lapses in structured handoff protocols can result in missed diagnoses and delayed interventions, especially in high-risk cases like pulmonary embolisms (Lazzari, 2024). Active participation from the nursing staff is thus non-negotiable.

Benefits of Embracing the Role

By adopting structured communication practices, nurses help reduce errors, accelerate medication administration, and improve workflow efficiency. Tools such as SBAR ensure that updates on pending medications or dosage changes are clearly conveyed. Ongoing training sessions increase staff confidence and reduce ambiguity during transitions (Atinga et al., 2024). These practices enhance patient outcomes and foster professional growth, promoting a culture of shared accountability and patient-centered care.

Part 4: New Processes and Skills Practice

New Processes and Tools

The improvement plan emphasizes integration of EHR with customized handoff templates and SBAR to ensure accurate medication tracking and transition reporting. These technologies support timely updates and eliminate ambiguity. SBAR provides a simple, effective framework for communication, ensuring nothing is overlooked during shift changes.

Tool/Process	Function
EHR-integrated templates	Capture key medication and clinical data in a standardized format.
SBAR Framework	Ensures structured communication: Situation, Background, Assessment, Recommendation.
BCMA	Confirms drug accuracy via scanning, preventing manual entry errors.

Scenario-Based Workshop

A practical, scenario-based workshop will allow nurses to simulate real-life handoff challenges. Participants will work in small teams, handling a mock patient with urgent medication adjustments amid simulated interruptions. Facilitators will provide feedback on performance, emphasizing strengths and areas needing improvement. Such experiential learning builds confidence and enhances real-world communication skills (Lee & Lim, 2021).

Interactive Q&A Session

A collaborative Q&A session will follow the workshop to reinforce learning. Participants will engage in critical thinking by answering practical questions such as:

• “What steps can you take to ensure medication accuracy during handoff?”
• “How can SBAR help you communicate patient needs clearly?”

This peer-to-peer interaction encourages knowledge sharing, reflection, and application of best practices (Wong et al., 2021).

Part 5: Soliciting Feedback

To continuously refine the handoff process, feedback collection is essential. Staff will be given anonymous surveys and open-ended forms at the end of the session to reflect on the training experience and identify barriers and successes with the new tools. This input will guide adjustments to the protocols and ensure alignment with clinical realities. Meyer et al. (2021) emphasize that feedback mechanisms support adaptive learning and improve implementation success. Ongoing analysis of this feedback will inform future revisions and promote an evidence-based approach to handoff communication.

Conclusion

Improving communication during nurse handoffs is critical to enhancing patient safety, especially in high-acuity settings. The sentinel event described demonstrates how lapses in information transfer can lead to adverse outcomes. Through standardized tools such as SBAR, EHR integration, quiet zones, and simulation training, nurses can ensure effective and complete transitions of care. This improvement plan calls for a collaborative effort across all stakeholders to foster a safety-first culture that prioritizes clarity, accountability, and consistency. With continuous evaluation and shared responsibility, we can achieve a sustainable reduction in medication errors and improve patient outcomes.

References

tinga, 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 

NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

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  

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 

NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

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