NURS FPX 4035 Assessment 1 Enhancing Quality and Safety
NURS FPX 4035 Assessment 1 Enhancing Quality and Safety
Name
Capella university
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Enhancing Quality and Safety
The patient handover process within hospital emergency departments (EDs) is a critical juncture for maintaining quality and safety in healthcare delivery. Transitions of care become particularly vulnerable when communication falters, often leading to errors, delayed treatments, and adverse patient outcomes. The emergency setting is uniquely high-risk due to time constraints, high patient volume, and complex cases. Inefficient or inconsistent handoff protocols further complicate these challenges. This paper explores the implications of ineffective patient handoffs in EDs and evaluates evidence-based communication frameworks that can mitigate risks. It also emphasizes the role of nurses in promoting care coordination and highlights the involvement of essential stakeholders aimed at improving safety and reducing hospital costs.
Several factors contribute to elevated patient safety risks in ED handoffs. Ineffective communication combined with time pressure and clinical complexity significantly increases the likelihood of errors. Studies report that communication breakdowns during chaotic emergency care contribute to roughly 80% of severe medical errors during handoffs (Kinney-Sandefur, 2024). Non-compliance with standardized communication protocols and rushed interactions often result in missing or incorrect information transfer. Poor verbal communication and inadequate documentation are core contributors to suboptimal handovers.
Moreover, the time-sensitive nature of emergency care exacerbates the problem. Staff often operate under significant pressure to provide timely and accurate interventions, but handover delays and communication issues impact as much as 70% of healthcare outcomes and 50% of handoff-specific events (Atinga et al., 2024). Emergency care frequently involves multifaceted treatments requiring team coordination. When formal handoff procedures are absent, it leads to fragmented care, extended hospital stays, and increased risk of medical errors, adversely affecting both patient outcomes and healthcare costs.
Factors Leading to Patient Safety Risk
Effective solutions have been identified to address the risks associated with emergency department handoffs. One of the most widely accepted communication frameworks is SBAR (Situation, Background, Assessment, Recommendation). SBAR provides a structured and standardized method of communication that enhances clarity, reduces misunderstandings, and facilitates smooth transitions. Studies show that implementing SBAR improves handover efficiency, healthcare provider satisfaction, and patient safety (Ghosh et al., 2021). Additionally, SBAR usage correlates with cost savings by improving documentation accuracy, streamlining billing, and reducing unnecessary treatment errors.
The adoption of electronic health records (EHRs) with integrated handoff templates is another effective strategy. These systems enable real-time updates and consistent access to patient data, eliminating reliance on memory or handwritten notes (Tataei et al., 2023). Furthermore, conducting bedside shift reports encourages patient and family involvement, which improves communication clarity and increases patient satisfaction. These methods not only prevent adverse events but also contribute to shorter hospital stays and reduced litigation. Structured communication during handoffs significantly decreases the likelihood of preventable errors, ultimately optimizing operational efficiency and lowering healthcare expenditures.
Nurses play a central role in enhancing communication during patient transitions. As the primary caregivers, they ensure the continuity of care by verifying critical patient information before, during, and after handoffs. Active participation in multidisciplinary rounds enables nurses to collaborate with other healthcare professionals to create cohesive care plans and address gaps that may emerge before patient transfers (Shirley et al., 2024). Their involvement helps prevent miscommunication and reduces the risk of costly medical mistakes. Nurses also reinforce closed-loop communication, ensuring that receiving providers understand and acknowledge the handoff content—critical for reducing avoidable clinical errors and healthcare costs.
Stakeholders’ Involvement in Nursing Coordination
Patient handoff effectiveness in the emergency department depends on a broad coalition of stakeholders. Physicians rely on accurate and timely handoff information to make clinical decisions, so collaboration between nurses and physicians is vital. Communication errors between these parties can delay treatment, jeopardize patient safety, and raise care costs (Jemal et al., 2021). Pharmacists are another key group, especially in verifying medication orders during transitions. Their coordination with nurses reduces medication-related errors, which account for billions of dollars in wasted spending annually.
Hospital administrators are responsible for enforcing standardized handoff protocols, providing technological infrastructure, and offering staff training programs. Their leadership is crucial for empowering frontline healthcare professionals with tools that enable safe and effective patient transitions. Patient safety officers and quality improvement teams also play pivotal roles in analyzing errors and refining hospital policies in alignment with best practices. Including patients and their families in bedside handoffs increases transparency, improves continuity of care, and lowers readmission rates (Bucknall et al., 2020). Nurses, by facilitating communication among these various stakeholders, serve as vital links in the system of care that enhances both safety and financial performance in healthcare institutions.
Summary Table of Key Insights
| Section | Key Points | Evidence/Support |
|---|---|---|
| Enhancing Quality and Safety | ED handoffs are high-risk due to time pressure, case complexity, and inconsistent communication protocols. | 80% of severe errors linked to miscommunication (Kinney-Sandefur, 2024) |
| Factors Leading to Patient Safety Risk | SBAR and EHRs standardize communication, reduce costs, and improve outcomes. Bedside reporting involves patients and increases satisfaction. | SBAR improves satisfaction and safety (Ghosh et al., 2021); EHRs reduce memory reliance (Tataei et al., 2023) |
| Stakeholders’ Involvement | Effective handoffs rely on collaboration among nurses, physicians, pharmacists, administrators, and patients/families to reduce risk and cost. | Communication gaps with physicians cause delays (Jemal et al., 2021); Family involvement reduces readmissions (Bucknall et al., 2020) |
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. https://doi.org/10.1016/j.ssmqr.2024.100482
NURS FPX 4035 Assessment 1 Enhancing Quality and Safety
Bucknall, T. K., Hutchinson, A. M., Botti, M., McTier, L., Rawson, H., Hitch, D., Hewitt, N., Digby, R., Fossum, M., McMurray, A., Marshall, A. P., Gillespie, B. M., & Chaboyer, W. (2020). Engaging patients and families in communication across transitions of care: An integrative review. Patient Education and Counseling, 103(6), 1104–1117. https://doi.org/10.1016/j.pec.2020.01.017
Ghosh, S., Ramamoorthy, L., & Pottakat, B. (2021). Impact of structured clinical handover protocol on communication and patient satisfaction. Journal of Patient Experience, 8(1), 1–6. https://doi.org/10.1177/2374373521997733
Jemal, M., Kure, M. A., Gobena, T., & Geda, B. (2021). Nurse–physician communication in patient care and associated factors in public hospitals of Harari regional state and Dire-Dawa city administration, Eastern Ethiopia: A multicenter-mixed methods study. Journal of Multidisciplinary Healthcare, 14(1), 2315–2331. https://doi.org/10.2147/jmdh.s320721
Kinney-Sandefur, A. V. (2024). Improving patient handoff in the emergency department microsystem. University of New Hampshire Scholars’ Repository. https://scholars.unh.edu/thesis/1799
Shirley, S. G. A., Abdullah, B. F., & Dioso, R. I. (2024). Enhancing teamwork through effective handover practices among nurses in elder care setting. The Malaysian Journal of Nursing, 15(04), 100–108. https://doi.org/10.31674/mjn.2024.v15i04.0012
NURS FPX 4035 Assessment 1 Enhancing Quality and Safety
Tataei, A., Rahimi, B., Afshar, H. L., Alinejad, V., Jafarizadeh, H., & Parizad, N. (2023). The effects of electronic nursing handover on patient safety in general (non-covid-19) and COVID-19 intensive care units: A quasi-experimental study. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09502-8
