Capella FPX 4035 Assessment 3

Capella FPX 4035 Assessment 3

Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Introduction: Diagnostic Errors in the ICU

Greetings, and thank you for attending this session. I am Lisa, and today we will address a critical safety concern in the Intensive Care Unit (ICU): diagnostic errors (DEs) resulting from communication failures during nursing shift changes. A recent incident involving a sedated, ventilated patient highlights the urgency of this issue. Due to ineffective communication during handoff, a pulmonary embolism diagnosis was delayed, jeopardizing the patient’s outcome. This session will introduce evidence-based approaches to enhance staff handoff practices, foster interdisciplinary communication, and improve patient safety.

Part 1: Agenda and Intended Outcomes

Purpose of the Session

The primary aim of this session is to tackle diagnostic errors stemming from communication breakdowns during ICU shift transitions. In high-acuity environments, the margin for error is slim, and inadequate handoff communication often results in delayed diagnoses, prolonged hospitalizations, increased costs, and patient mortality (Atinga et al., 2024). We will explore methods such as SBAR (Situation, Background, Assessment, Recommendation), standardized bedside handoffs, and the effective use of Electronic Health Records (EHRs) to promote continuity of care and patient safety.

Objectives and Goals

We aim to identify and address the root causes of handoff-related communication failures contributing to DE. Institutional data reveals major issues such as insufficient training, lack of standardized protocols, time constraints, and understaffing. Studies suggest that poor handoff communication is responsible for a significant proportion of preventable medical harm (Zimolzak et al., 2021). The use of SBAR, real-time EHR updates, and direct engagement in patient care during bedside handoffs can mitigate these risks and ensure safe transitions.

Expected Outcomes

Upon completion of this training, nurses should be able to:

• Recognize and address communication vulnerabilities during shift changes.
• Apply evidence-based handoff strategies like SBAR and EHR-integrated templates.
• Demonstrate improved handoff communication and reduce risks of DE, especially in diagnosing conditions like pulmonary embolism (Browning et al., 2025).

Part 2: Safety Improvement Plan

Diagnostic Errors and Communication Breakdown

Patient handoffs in the ICU continue to be a high-risk process. Communication failures are associated with a considerable portion of adverse medical events, malpractice claims, and diagnostic delays (Lazzari, 2024). Fragmented information exchange, absence of standardized tools, and system inefficiencies are primary contributors. It is estimated that communication breakdowns during handoffs are involved in over 70% of sentinel events and cost the U.S. healthcare system more than \$12 billion annually (Janagama et al., 2020).

Step-by-Step Safety Improvement Plan

Organizational Implications

Addressing communication gaps during ICU handoffs is critical for both patient outcomes and operational efficiency. These lapses not only contribute to avoidable harm and prolonged care but also increase healthcare costs and legal risks. By investing in standardized handoff protocols, institutions can improve safety, boost staff morale, and align with accreditation standards (Singh et al., 2022). Structured communication tools foster collaboration and support quality improvement.

Part 3: Audience’s Role and Impact

Driving Implementation

Nurses and frontline staff play a central role in executing the safety plan. By consistently using SBAR and participating in training and feedback, they uphold the quality of ICU care. Administrators must provide technological resources and policy support to reinforce handoff improvements (Russo et al., 2024).

Stakeholder Responsibilities

Importance of Engagement

Active participation from all stakeholders ensures sustainability. Structured tools are ineffective without consistent application. Nursing insights into barriers like time pressure are vital for refining strategies. By embracing shared accountability, the care team ensures safer patient transitions, reduces DE, and enhances clinical performance.

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

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

Capella FPX 4035 Assessment 3

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

Capella FPX 4035 Assessment 3

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

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