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Category: NURS-FPX4035

Capella FPX 4035 Assessment 4

Capella FPX 4035 Assessment 4

Capella FPX 4035 Assessment 4 Name Capella university NURS-FPX4035 Enhancing Patient Safety and Quality of Care Prof. Name Date Improvement Plan Tool Kit Overview of the Toolkit Healthcare professionals, particularly nurses, can use this improvement toolkit to implement and sustain evidence-based strategies aimed at reducing patient falls in clinical settings. The toolkit comprises curated scholarly and practice-oriented materials that emphasize risk identification, patient and staff education, safety technology integration, and implementation guidelines. Each tool offers detailed descriptions, practical applications, and step-by-step directions for integration into care processes. Nurses leveraging these resources can drive enhancements in both patient safety and care quality across various settings. The toolkit’s foundation stems from search terms like “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing.” Annotated Bibliography Organizational Safety and Fall Prevention Best Practices Garcia et al. (2021) explored nurses’ views on effective fall prevention interventions and discovered that combining patient education with environmental modifications was most effective. These multi-faceted strategies aligned with both patient-specific risks and situational variables. However, nurses reported barriers such as limited time, patient engagement difficulties, and insufficient organizational support. The study underscores the importance of aligning fall prevention practices with clinical realities and calls for targeted training led by nurse leaders to address these practical challenges. In a qualitative study, Linnerud et al. (2023) discussed how Norwegian stakeholders co-developed an implementation strategy tailored to local home-care conditions. Emphasizing a participatory approach, the research highlights the value of including front-line nursing staff in creating sustainable fall prevention programs. The resource is particularly beneficial for nurses working in home-care settings who wish to customize interventions for older adults living independently. Nurse managers can also apply this resource to facilitate collaborative workshops when designing new safety initiatives. Mulfiyanti and Satriana (2022) assessed the impact of SBAR (Situation, Background, Assessment, Recommendation) on nursing handovers and its implications for patient safety. The study found SBAR significantly improved communication accuracy, particularly during shift changes and emergency reporting, thereby lowering the risk of falls. The structured approach increased confidence and teamwork among nurses. This tool is valuable in high-acuity units where timely and accurate information exchange is critical to patient safety. Environmental Risk Reduction and Safety Assessments Campani et al. (2021) provided insights into how modifying environmental risk factors can prevent falls among elderly patients. Interventions such as removing tripping hazards and installing grab bars were found to reduce risk. Nurses can conduct home safety assessments and recommend targeted changes, making this resource ideal for community health nurses and discharge planners. Locklear et al. (2024) conducted a comprehensive review detailing the causes, risk factors, and prevention measures related to in-patient falls. With an estimated 700,000 to 1 million in-patient falls annually, the report supports using tools like the Morse Fall Scale and interdisciplinary strategies such as hourly rounding. The review also addresses the financial burden of falls and emphasizes the economic benefits of structured prevention efforts. Nurse leaders can utilize this resource for staff training and for evaluating prevention programs. Stathopoulos et al. (2021) investigated how hospital overcrowding contributes to in-patient falls. The study linked high fall rates to environmental stressors like noise, limited space, and inadequate staffing. With patient rooms being the most frequent fall locations, the resource helps administrators and QI teams advocate for policy changes that increase staffing levels or expand hospital space. Improvement Plan Tool Kit: Annotated Bibliography Category Citation Key Takeaways Implementation Guidance Organizational Fall Prevention Strategies Garcia, A., Bjarnadottir, R. I., Keenan, G. M., & Macieira, T. G. R. (2021). Journal of Nursing Care Quality. https://doi.org/10.1097/ncq.0000000000000605 Nurses preferred multifactorial strategies combining education and environmental changes. Challenges include time constraints and limited support. Best used during planning and training; informs staff development programs.   Linnerud, S., Aimée, L., Graverholt, B., Idland, G., Taraldsen, K., & Brovold, T. (2023). BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10394-x Stakeholder collaboration enhances tailored safety programs in home care settings. Useful for home-care nurses and managers in stakeholder workshops.   Mulfiyanti, D., & Satriana, A. (2022). International Journal of Public Health Excellence, 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275 SBAR method improves communication and reduces errors during transitions. Applicable during shift changes, interprofessional meetings, and emergencies. Environmental Assessment and Modifications Campani, D., et al. (2021). Public Health Nursing, 38(3), 493–501. https://doi.org/10.1111/phn.12852 Environmental risks such as poor lighting and loose rugs increase falls. Home modifications reduce risks. Ideal for community nurses and discharge planning to assess patient homes.   Locklear, T., et al. (2024). HCA Healthcare Journal of Medicine, 5(5). https://doi.org/10.36518/2689-0216.1982 700k–1M inpatient falls annually; Morse Fall Scale and interdisciplinary approaches reduce risk and cost. Best used in staff training, risk screening, and policy design.   Stathopoulos, D., Hansson, E. E., & Stigmar, K. (2021). International Journal of Environmental Research and Public Health, 18(20), 10742. https://doi.org/10.3390/ijerph182010742 Overcrowding and environmental design flaws increase fall incidents. Used for advocating staffing and infrastructure changes to reduce risks. Staff Education and Patient-Centered Care Strategies Albertini et al. (2022) introduced a person-centered care strategy for preventing falls within a Brazilian hospital. Their initiative focused on tailoring care plans to individual patient needs, integrating educational interventions for staff, and customizing environmental settings accordingly. This approach significantly improved staff adherence to fall prevention practices, with compliance rising from 62% to 92%. A notable benefit was a 30% reduction in patient falls by targeting individual risk factors like mobility and medication use. The resource is especially relevant for clinical educators and nurse leaders when developing targeted training and quality improvement (QI) programs. In a scoping review, Heng et al. (2020) examined educational strategies used in hospitals to reduce patient falls. They found that multimedia education methods, including videos and handouts, along with personal discussions, empowered patients with fall prevention strategies. These interventions were particularly effective when delivered at crucial times such as admission and discharge. The study emphasized the need for proactive patient engagement to reduce unattended fall events, which often result in injuries such as fractures and psychological trauma. Heng et al. (2022) later conducted a mixed-methods trial that assessed the impact of structured patient education. They discovered that using visual aids and active staff participation increased

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Capella FPX 4035 Assessment 3

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 Slide 1: Hello and welcome, everyone! I am ______. Today, I want to talk about a serious issue in healthcare, which is diagnostic errors. These mistakes happen when a health condition is missed, delayed, or diagnosed incorrectly. This in-service session will give us useful tools and easy strategies to help prevent these errors. Our main goal is to improve how we share patient information and work together as a team, so we can make faster, more accurate decisions for our patients. Part 1: Agenda and Outcomes Slide 2: This education will address ways to reduce diagnostic errors. Because of these mistakes, it may take longer to treat the patient, leading to severe complications or death. We want our safety improvement plan to help staff improve their collaboration and how they communicate to stop such errors. Nurses will be taught to use SBAR in patient handovers so that important and clear information is never left out. Training will be given by using case studies and simulation exercises that improve skills in diagnosis. Working hours can be changed to give nurses enough time to check on each patient carefully without getting fatigued. Recently, Riverside Community Hospital dealt with a sentinel event where a 67-year-old person was admitted due to a fever and confusion. The patient first received care for a urinary tract infection and dehydration, though the sepsis tests were overlooked. During the transfer of care, the worsening symptoms of the patient were not adequately passed along. The patient went into septic shock and died after only 48 hours despite later intense treatment. It proves that successfully handing off patients and being vigilant for sepsis can save many lives. Goals Slide 3: Three clear goals guide this safety initiative to reduce diagnostic errors and improve patient safety: Goal 1: Understand the importance of clear communication to prevent diagnostic mistakes This session will highlight how accurate communication during patient handoffs helps avoid errors in diagnosis. Mistakes during these times can lead to delayed or wrong diagnoses, putting patients at risk. Staff will learn practical skills to improve how information is shared, helping to build a culture of safety. Attendees will be taught how to spot risks and act to prevent diagnostic errors during care transitions. Goal 2: Identify common causes of diagnostic errors related to communication breakdowns We will review factors that contribute to diagnostic mistakes, such as incomplete or unclear handoffs, lack of standardized communication methods, staff fatigue, and time pressures. Understanding these causes helps staff see where gaps occur and how these errors affect patient outcomes. Breakdowns in communication or a lack of clear details have contributed to roughly 50% of negative patient outcomes during shift changes and up to 70% of complications in overall medical care (Atinga et al., 2024). Goal 3: Learn evidence-based strategies to improve communication and reduce diagnostic errors. This part will focus on practical solutions such as mandatory use of SBAR during shift changes, ongoing competency-based training to enhance diagnostic skills, and staffing changes to reduce fatigue and ensure thorough patient assessments. Attendees will learn how to apply these tools consistently to improve communication and coordination, which will reduce errors and improve care. Outcomes Slide 4: By the end of this session, participants will show: Improved Awareness and Understanding Understand why clear communication is critical to accurate diagnosis and safe patient care. Recognize the serious consequences when communication fails during patient handoffs. Identification of Causes Be able to identify the main reasons diagnostic errors happen, such as incomplete information, lack of standard tools, staff exhaustion, and rushed handoffs. Understand how these factors affect patient safety. Application of Practical Tools and Strategies Demonstrate the ability to use evidence-based methods like SBAR for handoffs, participate in ongoing training to improve diagnostic skills, and support staffing practices that reduce fatigue. These skills will help ensure reliable, accurate communication to prevent diagnostic errors. Part 2: Safety Improvement Plan Slide 5: Missing a diagnosis or making the wrong one is still a serious problem for healthcare, threatening patient safety and the functioning of the hospital. If the right diagnosis is not given on time, patients can be hurt, get less careful care, spend longer periods in the hospital, and even die. A lot of these mistakes result from challenges that are able to be fixed, like poor communication, lack of staff, different ways of testing, and system restrictions within healthcare. It is projected that out of 130 million annual emergency room visits in the U.S., approximately 7.4 million (5.7%) cases involve diagnostic mistakes, 2.6 million (2.0%) lead to harmful outcomes, and nearly 370,000 (0.3%) result in significant injury due to diagnostic inaccuracies (Toker et al., 2022). Due to these errors in the U.S., about $20 billion in extra healthcare expenses are seen every year (Rodziewicz et al., 2024). This points out that improving communication and teamwork during diagnosis can make a big difference by protecting lives and boosting the quality of care in hospitals. Safety Enhancement Plan Slide 6: A clear and organized safety improvement plan is necessary to lower diagnostic errors and improve how patients feel. SBAR communication needs to be used at the start of each shift and when transferring patients. This helps doctors avoid errors by making sure all important patient information is shared in one place, making it less likely that anything will be missed in the diagnosis (Shinta & Bunga, 2024). At this stage, the plan offers additional training for clinical staff by using examples and simulation work to strengthen their ability to notice and handle diagnostic issues fast. The practical experience helps employees become both more confident and accurate. Giving people time off or different schedules reduces their fatigue. If healthcare professionals are well rested, they are better able to notice and avoid common diagnosis errors. These steps aid in creating safer ways to diagnose, better collaboration among staff, and more reliable care for patients. Continual auditing and

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Capella FPX 4035 Assessment 2

Capella FPX 4035 Assessment 2

Capella FPX 4035 Assessment 2 Name Capella university NURS-FPX4035 Enhancing Patient Safety and Quality of Care Prof. Name Date Root-Cause Analysis and Safety Improvement Plan Understanding the Incident A sentinel event is a critical patient safety issue that occurs unexpectedly and is not directly tied to a patient’s existing condition or illness. Such incidents often have profound effects on patients, their families, and healthcare staff. The primary purpose of a root-cause analysis (RCA) is to uncover both immediate and systemic failures contributing to these events to implement corrective strategies and prevent recurrence. In one such incident at an Emergency Department (ED), a patient in septic shock experienced delayed treatment due to an incomplete handoff between nursing staff. The outgoing nurse failed to convey essential clinical details, compounded by inadequate documentation. As a result, the patient’s condition worsened, requiring prolonged hospitalization and additional interventions. The emotional toll on the patient and family, as well as the professional strain on staff, highlighted the need for stronger communication protocols and systems improvements. Analyzing Contributing Factors Root Causes and Contributing Elements Human Elements: Nurse fatigue, communication breakdowns, and inadequate training in structured handoff practices played a major role. Overreliance on verbal exchanges without written backup increased risk. Systemic Challenges: The chaotic ED environment, absence of digital tools for handoff, and understaffing created barriers to effective communication. Organizational Culture: A weak culture of safety, lack of leadership reinforcement for handoff protocols, and limited routine audits exacerbated inconsistencies. Cultural Influences: Language differences and varying communication norms among multicultural staff may have also interfered with message clarity. Deviation from Standards There were significant lapses in following established procedures, notably the SBAR (Situation, Background, Assessment, Recommendation) framework. The outgoing nurse’s verbal report lacked completeness, and no checks or clarifications were made by the incoming nurse. Documentation was also insufficient, omitting vital assessments and care plans. Roles, Communication, and Environment Personnel Involved The event primarily involved the outgoing and incoming nurses, along with a physician who made new medication orders that were not communicated properly. Supervisors such as the charge nurse failed to ensure adherence to standard handoff procedures, and leadership lacked oversight in enforcing training and auditing practices. Communication Breakdown There was a clear communication gap between the nurses and the physician. Vital updates on patient condition and treatment changes were missed. Additionally, the patient was not adequately informed about their revised care plan, reducing their ability to engage meaningfully in their treatment. Contributing Environment and Staffing The physical layout of the facility—with distant nursing stations and frequent equipment malfunctions—created additional challenges. Staffing shortages overwhelmed available nurses, leading to skipped protocols. While staff competency was generally acceptable, gaps in targeted training for handoffs and updates on medication protocols were evident. Organizational and Monitoring Shortfalls Policy Failures Even though policies for handoffs and medication administration existed, they were not followed. Their complexity and limited accessibility made consistent application difficult, leading to variance in practice. Monitoring Gaps The patient’s vital signs were not tracked consistently during critical hours, delaying responses to deterioration. Alarm fatigue also contributed, with important alerts being missed amidst frequent non-critical ones. Recommendations and Safety Enhancements Lessons and Improvement To prevent recurrence, systemic upgrades are necessary. This includes standardizing communication tools, reinforcing training, and fostering a culture where staff feel comfortable speaking up. Implementation of electronic systems to track handoffs and patient monitoring can also reduce human error. Patient Safety Measures Introduce risk mitigation strategies like automated alerts for vital signs, regular simulation training, and robust alarm systems. Create a non-punitive feedback mechanism encouraging open reporting of errors to support learning and continuous quality improvement. Certainly! Below is the rephrased content in paragraph format, followed by a row and column table version with three-level headings retained. Both formats include APA-formatted references at the end. Root Cause(s) and Contributing Factors An in-depth analysis of the sentinel event revealed several underlying causes and contributing factors. One of the principal root causes was the failure in communication among healthcare team members. This lapse led to incorrect interpretation of the patient’s condition and delayed appropriate intervention. Categorized under Human Factor – Communication (HF-C), this failure represents a fundamental weakness in team coordination. Another significant root cause was insufficient training related to newly updated protocols and equipment usage, which falls under Human Factor – Training (HF-T). This deficiency prevented staff from recognizing and responding effectively to changes in patient status. A third contributing factor was equipment malfunction, which led to unrecognized warning signs and subsequently delayed clinical responses. This issue is associated with Environment/Equipment (E). Additionally, staff fatigue, linked to poorly structured schedules, affected cognitive performance and situational awareness, a problem that aligns with Human Factor – Fatigue/Scheduling (HF-F/S). Moreover, breaches in established safety protocols and the presence of organizational barriers, such as ineffective communication systems, further exacerbated the incident. These challenges reflect issues in both Rules/Policies/Procedures (R) and Barriers (B) that need systematic rectification. Application of Evidence-Based Strategies To address the aforementioned safety concerns, several evidence-based strategies should be implemented. First, structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) have demonstrated effectiveness in improving handoff procedures and reducing communication errors. A study conducted at Tabanan Hospital indicated that SBAR implementation significantly enhanced nursing performance and patient safety during transitions of care (Mulfiyanti & Satriana, 2022). Secondly, the implementation of continuous professional development, including simulation-based and scenario-specific training, can bridge competency gaps. Research has highlighted that a majority of medical equipment alerts are false, underscoring the need for regular in-service education on equipment usage and alarm interpretation to mitigate alarm fatigue (Shaoru et al., 2023). Lastly, incorporating routine safety audits and feedback mechanisms can identify and resolve system-level gaps. Root-cause analysis and data-driven evaluations have proven effective in reinforcing safety culture and reducing the recurrence of sentinel events (Argyropoulos et al., 2024). These evidence-based approaches, when systematically applied, create a culture of continuous learning and improvement. Safety Improvement Plan Planned Actions for Each Root Cause/Contributing Factor For the communication failures, standardized SBAR communication will be mandated during all patient handoffs to ensure clarity and consistency. To resolve training deficits, a comprehensive education plan will

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Capella FPX 4035 Assessment 1

Capella FPX 4035 Assessment 1

Capella FPX 4035 Assessment 1 Name Capella university NURS-FPX4035 Enhancing Patient Safety and Quality of Care Prof. Name Date Enhancing Quality and Safety There are many safety problems in healthcare and diagnostic errors are considered critical since they cause delays in care, additional treatments and more deaths than needed. If a medical diagnosis is obtained incorrectly, missed or comes late, it is because of challenges with thinking, teamwork or how systems are organized. Such errors influence a patient’s happiness, trust in medicine, mindset and general safety (Toker, 2025). The paper concentrates on how diagnostic errors create safety concerns for patients, analyzes what causes them and looks at the solutions offered by evidence and by nurses and other health team members.  Factors Leading to Diagnostic Errors in Healthcare Many healthcare problems linked to diagnostic errors are overlooked and not reported. Every year nearly 12 million adults in the United States are affected by diagnostic errors and in one out of three cases, the results can be serious or fatal (Gleason et al., 2020). Errors of this kind can be very troubling in fast-moving places like emergency departments and hospital units, where the decisions people have to make are often urgent and difficult. Common reasons for misdiagnosis include thinking mistakes, not having all the needed medical information, poor patient record-taking and breakdowns between healthcare staff. In some cases, clinicians can become “anchored” to their first assumption and find it hard to adjust when new information arrives. When there is not enough time to think and do everything, critical thinking and clinical reasoning are compromised. Issues at the systems level such as separated Electronic Health Records (EHRs) and different protocols for diagnosing, add extra difficulty to these challenges (Runyon et al., 2022). When doctors and nurses at Riverside Community Hospital team up to take care of difficult conditions, blurred messages and missed diagnosis checks often contribute to mistakes. If test results are not handled properly or information changes hands incorrectly during a nurse’s shift, it result in a delayed or missed diagnosis. Problems with diagnosis weaken confidence in healthcare services, result in delayed treatment, raise healthcare expenses and increase the risk of malpractice. Being aware of what causes mistakes helps design useful interventions and build a culture in healthcare that helps with accurate and prompt diagnoses (Gleason et al., 2020). Evidence-Based and Best-Practice Solutions to Reduce Diagnostic Errors It is important to approach diagnostic errors using clinical best practices, by fixing systems and involving teams from different medical professions. Timely and accurate diagnosis is seen by literature from the Institute of Medicine (IOM), now the National Academy of Medicine and the Agency for Healthcare Research and Quality (AHRQ) as a major part of providing high-quality care. Better accuracy in diagnosis needs to form the base of patient safety and suggests ways to improve joint work, educate teams and apply upgraded health information technology. The Quality and Safety Education for Nurses (QSEN) initiative is one of the most respected frameworks and features six essential competencies, amongst them patient-centered care, teamwork and collaboration, evidence-based practice and safety (AHRQ, 2024). QSEN hopes that nurses practice expressing themselves thoughtfully and use SBAR (Situation, Background, Assessment, Recommendation) along with other standardized tools to improve how they communicate about patients in handoffs and consults. Clinical decision support systems (CDSS) are considered a sound best-practice intervention. With CDSS connected to their electronic health records, clinicians instantly get prompts, diagnostic lists and alarms to help them think about various diagnoses and avoid relying on personal assumptions. CDSS helped lower diagnostic disagreements in large clinical environments by 15%. Also, taking time-outs for the team to reconsider what they found can prevent errors from resulting in harm (Harada et al., 2021). Giving everyone a chance to think allows for better shared choices. Part of a nurse’s role is to look after the patient, inform others of important test results and join in on team discussions about diagnosis. Using these evidence-based approaches, healthcare organizations can improve how they diagnose, reduce serious incidents and support better patient outcomes with less need for costly corrections. Nurse-Driven Strategies to Increase Safety and Reduce Costs Coordinating care which results in safer patients and lower healthcare costs, mainly depends on nurses. They participate in activities that reduce errors, help maintain a patient’s care and teach and support patients. Taking care of patient transitions is proven to be very impactful. Nurses always use SBAR when handing off important details during admission, discharge or transfers between departments. Because of this, chances of missing or delaying a diagnosis are significantly reduced. Helping people understand their condition is also very important. Nurses guide patients and their families on signs and symptoms to report, taking their medication and what to do after they go home. Learning about their conditions helps patients start taking care of themselves, cutting down on new hospitalizations and mistakes in diagnosis. Partnership among various professional fields is just as valuable. Nurses link doctors, specialists, pharmacists and the rest of the care team. By attending multidisciplinary rounds and case conferences, they give advice based on what they observe at the patient’s bedside. With this approach, it is less likely important information will be missed. Keeping medical records accurate and up-to-date supports both safe and inexpensive treatment (Flaubert, 2021). By clearly documenting all assessments, actions and responses from patients in the medical record, nurses help maintain continuity and accountability needed for good diagnosis and quality assurance. As a result, safety increases and costs go down because there are less chance of errors in diagnosis, fewer unnecessary tests are performed and malpractice related to misdiagnosis is less likely. Stakeholders Involved in Safety Enhancement Caring for patient safety is the job of many individuals, who all play important roles in discovering threats, taking steps to prevent harm and improving how care is given. Nurses on the inside are essential, regularly keeping an eye on patients, looking out for risks to their safety and applying solutions to stop delays in diagnosis. Part of a

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NURS FPX 4035 Assessment 4

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit Name Capella university NURS-FPX4035 Enhancing Patient Safety and Quality of Care Prof. Name Date Improvement Plan Tool Kit This toolkit is intended for use by medical professionals and nurses aiming to implement evidence-based safety initiatives that target hospital fall prevention. It incorporates carefully selected clinical and academic resources that outline effective strategies, risk assessment tools, patient education techniques, and technological interventions. Each tool is accompanied by descriptions, implementation guidelines, and relevance to practice, allowing seamless integration into clinical settings. By leveraging these resources, nursing staff can significantly enhance quality and safety outcomes across diverse healthcare environments. The toolkit’s development was driven by search terms including “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing practice.” These terms guided the identification of literature that supports the practical application of fall prevention measures in clinical workflows. As a result, nurses and healthcare leaders can rely on this toolkit to bridge the gap between evidence-based knowledge and daily clinical operations. Resources provided within the toolkit offer practical applications during staff training, patient handoffs, and facility-based fall prevention initiatives. Furthermore, each tool is contextualized for specific clinical environments, such as inpatient care units, home care services, or rehabilitation centers. This comprehensive design allows healthcare professionals to implement fall prevention practices tailored to their unique care settings. Annotated Bibliography Table Category Summary of Key Resource Practice Application Organizational Safety and Fall Prevention Garcia et al. (2021) examined nurses’ views on fall prevention strategies, emphasizing multifactorial programs that combine patient education and environmental modifications. Barriers included time constraints, lack of organizational support, and limited patient involvement. This resource helps nursing leaders design training that addresses staff barriers. It’s most effective during planning and training phases of fall prevention initiatives, and is ideal for customizing staff education to increase engagement with safety protocols. Linnerud et al. (2023) discussed a co-created implementation strategy tailored for home-care services. The study highlights stakeholder participation in developing community-specific fall prevention plans. Nurse managers and QI teams can use this during initial planning phases to foster collaboration. The document supports designing workshops to engage stakeholders and develop sustainable strategies, particularly in home-care environments. Mulfiyanti & Satriana (2022) focused on the SBAR (Situation, Background, Assessment, Recommendation) method’s role in improving nursing handovers and reducing safety incidents like falls. Nurses should use SBAR during handovers, interprofessional communications, and urgent care reporting. The study suggests that SBAR fosters team confidence and minimizes errors in high-risk environments. Environmental Risk Reduction & Safety Assessment Campani et al. (2021) evaluated environmental risk factors contributing to falls among the elderly, offering tools to assess and mitigate hazards such as poor lighting and cluttered spaces. Nurses and discharge planners can apply this tool for home visits and hospital safety checks. It enables healthcare teams to teach environmental safety and identify high-risk settings, aiding in both community and institutional fall prevention planning. Locklear et al. (2024) presented a narrative review of fall epidemiology, emphasizing early risk assessment using tools like the Morse Fall Scale. Their data showed a major reduction in costs due to structured interventions. Nurse leaders can use this for training and patient risk evaluation. The tool supports early identification of fall risks during admissions and ongoing care, and demonstrates cost-effectiveness of proactive measures in acute care settings. Stathopoulos et al. (2021) investigated how overcrowding and poor hospital design contribute to in-patient falls. Results showed that neurology and orthopedic units experienced most incidents, often when staff were not present. This tool supports administrative decisions on staffing and space allocation. Nurse managers and QI teams can use it to analyze incident data and support policy proposals for improved hospital design and staffing levels. Staff Education & Patient-Centered Strategies Albertini et al. (2022) implemented a person-centered model for fall prevention in Brazilian hospitals. They found that staff compliance with fall protocols improved significantly through individualized care and targeted education. Clinical leaders can implement this protocol to promote personalized fall prevention care. The approach emphasizes staff-patient collaboration and is especially valuable in units managing elderly or high-risk patients. References Albertini, A. C. da S., Fernandes, R. P., Püschel, V. A. de A., & Maia, F. de O. M. (2022). Person-centered care approach to prevention and management of falls among adults and aged in a Brazilian hospital: A best practice implementation project. JBI Evidence Implementation, 21(1), 14–24. https://doi.org/10.1097/xeb.0000000000000356 Campani, D., Caristia, S., Amariglio, A., Piscone, S., Ferrara, L. I., Barisone, M., Bortoluzzi, S., Faggiano, F., Dal Molin, A., Silvia Zanetti, E., Caldara, C., Bellora, A., Grantini, L., Lombardi, A., Carimali, C., Miotto, M., Pregnolato, A., & Obbia, P. (2021). Home and environmental hazards modification for fall prevention among the elderly. Public Health Nursing, 38(3), 493–501. https://doi.org/10.1111/phn.12852 Garcia, A., Bjarnadottir, R. (Raga) I., Keenan, G. M., & Macieira, T. G. R. (2021). Nurses’ perceptions of recommended fall prevention strategies. Journal of Nursing Care Quality, Publish Ahead of Print(3). https://doi.org/10.1097/ncq.0000000000000605 Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A.-M., & Morris, M. E. (2020). Hospital falls prevention with patient education: A scoping review. BMC Geriatrics, 20(1), 1–12. https://doi.org/10.1186/s12877-020-01515-w NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit Heng, H., Kiegaldie, D., Shaw, L., Jazayeri, D., Hill, A.-M., & Morris, M. E. (2022). Implementing patient falls education in hospitals: A mixed-methods trial. Healthcare, 10(7), 1298. https://doi.org/10.3390/healthcare10071298 Lakbala, P., Bordbar, N., & Fakhri, Y. (2024). Root cause analysis and strategies for reducing falls among in-patients in healthcare facilities: A narrative review. Health Science Reports, 7(7). https://doi.org/10.1002/hsr2.2216 Linnerud, S., Aimée, L., Graverholt, B., Idland, G., Taraldsen, K., & Brovold, T. (2023). Stakeholder development of an implementation strategy for fall prevention in Norwegian home care – a qualitative co-creation approach. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10394-x Locklear, T., Kontos, J., Brock, C. A., Holland, A. B., Hemsath, R., Deal, A., Leonard, S., Steinmetz, C., & Biswas, S. (2024). In-patient falls: Epidemiology, risk assessment, and prevention measures. A narrative review. HCA Healthcare Journal of Medicine, 5(5). https://doi.org/10.36518/2689-0216.1982 Miura, T., & Kanoya, Y. (2025). Fall risk assessment and prevention strategies in nursing homes: A narrative

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NURS FPX 4035 Assessment 3

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation Name Capella university NURS-FPX4035 Enhancing Patient Safety and Quality of Care Prof. Name Date Improvement Plan In-Service Presentation Part 1: Introduction, Agenda, and Goals Welcome, and thank you for joining today’s in-service session. I am [Presenter’s Name], and I will be discussing a critical patient safety issue that affects the quality of care in the emergency department (ED): failures in patient handoff. The aim of this training is to provide nursing and clinical staff with effective tools and strategies to improve handoffs, ultimately enhancing communication and safety outcomes for patients. The agenda for this session centers on resolving the ongoing issue of patient handoff failures within the ED. Inadequate handoffs often lead to injury, suboptimal treatment, longer hospitalizations, increased costs, and even patient mortality (Nawawi & Ibrahim, 2024). This session is designed to strengthen nursing staff’s skills in transferring patient information effectively through evidence-based solutions such as the SBAR (Situation, Background, Assessment, Recommendation) communication tool and bedside handoff protocols. A recent adverse event involving a septic patient highlights the consequences of insufficient handoff communication, where poor documentation and incomplete information sharing delayed treatment and put the patient at risk. Three clear goals guide our initiative. First, we aim to explore the main factors contributing to handoff errors in the ED, including educational gaps, insufficient handoff time, interruptions, lack of standardization, and understaffing. Research shows that poor communication is responsible for approximately 22.1% of adverse nursing outcomes (Kim et al., 2021). Second, the training introduces proven strategies like SBAR and EHR usage to address these errors. Third, we will stress the importance of handoff accuracy and equip staff with the practical skills necessary to reduce safety risks and implement the plan effectively. Expected outcomes include recognizing the root causes of handoff inefficiencies, equipping staff with practical skills to address them, and fostering a consistent, evidence-based approach to patient information transfer. These changes are expected to enhance communication, improve nurse confidence, and reduce healthcare costs while improving patient satisfaction and clinical outcomes (Nawawi & Ibrahim, 2024). Part 2: The Safety Improvement Plan and Organizational Impact Patient handoff challenges in the ED pose a significant threat to patient safety and overall organizational performance. Miscommunication during transitions has been linked to nearly 40.2% of adverse outcomes, with 80.1% of medical errors involving some form of miscommunication (Janagama et al., 2020). These failures may lead to injury, extended hospital stays, increased healthcare costs, and even death. Communication breakdowns alone are estimated to cost U.S. healthcare systems approximately \$12.1 billion annually. Addressing this issue requires a structured improvement plan. The first step involves adopting the SBAR model as a standard communication framework to promote consistency and clarity among healthcare professionals (Kay et al., 2022). Next, the organization should enhance surveillance and alert management systems to prevent oversight of critical changes in patient status. The third phase will include implementing electronic systems like EHR templates and the Electronic Nursing Handover System (ENHS) to facilitate timely and accurate information transfer. These tools minimize memory reliance and support high-quality handovers (Tataei et al., 2023). Finally, ongoing staff training is essential to ensure long-term adherence and competence in these protocols. Regular sessions will sharpen clinical judgment, reduce stress, and foster trust among team members (Nawawi & Ibrahim, 2024). Improving patient handoffs is not only a safety priority but also a financial and operational necessity. Failures in communication can increase organizational liability, reduce patient satisfaction, and affect accreditation. Furthermore, staff morale and productivity are diminished when workflows are disjointed, making standardized handoff procedures a vital element of performance improvement. Effective implementation leads to better teamwork, higher standards of care, and improved patient outcomes. Part 3: The Audience’s Role and Expected Benefits The success of this safety initiative relies heavily on the commitment and collaboration of nurses, clinicians, and administrative staff. Nurses and physicians are the primary agents in patient transfers and shift changes; therefore, their use of structured communication tools such as SBAR is crucial to prevent omissions of critical data. According to Kim et al. (2021), adequate staffing directly correlates with improved care quality, making their role indispensable in patient safety initiatives. Staff engagement in training programs, feedback provision, and multidisciplinary team participation helps sustain standardized protocols. Hospital administrators must support this transition by allocating resources for electronic handoff systems and continuing education. Their leadership enables sustainable implementation by ensuring the availability of time and infrastructure necessary for smooth handoffs. Involving staff as stakeholders ensures a sense of ownership and accountability, increasing the likelihood of successful adoption. Their insights into challenges like time constraints or process inefficiencies can shape realistic, applicable solutions. Moreover, embracing these roles offers substantial benefits. Structured handoff tools like SBAR and EHR templates simplify transitions, reduce miscommunications, and decrease the need for follow-up clarifications (Kay et al., 2022). This not only leads to better patient outcomes but also lowers staff burnout by creating more predictable and manageable workflows. Ultimately, a shared commitment to effective handoffs promotes a culture of safety, teamwork, and continuous improvement. Summary Table Section Key Points Supporting Evidence Introduction & Goals Addressing patient handoff failures in the ED through training, SBAR, and bedside protocols Nawawi & Ibrahim (2024); Kim et al. (2021) Safety Improvement Plan Implement SBAR, surveillance, EHR, and staff training to reduce errors and improve communication Kay et al. (2022); Tataei et al. (2023) Audience Role & Benefits Nurses, physicians, and managers play a vital role in implementing the plan; benefits include fewer errors, better workflow, and improved outcomes Kim et al. (2021); Kay et al. (2022) References Janagama, R., Gardner, L., Allen, A., & Talbert, J. (2020). Communication failures and healthcare costs: Estimating the burden. Journal of Patient Safety, 16(4), 250–257. https://doi.org/10.1097/PTS.0000000000000592 Kay, K., Ramaswamy, R., & Chatterjee, N. (2022). Improving communication in patient handoffs: Adopting the SBAR model in emergency care settings. BMJ Open Quality, 11(1), e001752. https://doi.org/10.1136/bmjoq-2021-001752 NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation Kim, M., Park, M., & Kang, K. J. (2021). Factors influencing adverse events in nursing care: The impact of handoff quality. Journal

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NURS FPX 4035 Assessment 2

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan

NURS FPX 4035 Assessment 2 Root-Cause Analysis and Safety Improvement Plan Name Capella university NURS-FPX4035 Enhancing Patient Safety and Quality of Care Prof. Name Date Root-Cause Analysis and Safety Improvement Plan A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, not primarily related to the natural progression of a patient’s illness or condition. These events are deeply distressing for both patients and healthcare providers and serve as critical reminders of the importance of robust safety systems. The objective of conducting a thorough root-cause analysis (RCA) is to uncover not only immediate causes but also underlying systemic flaws that may contribute to these adverse outcomes. By identifying these factors, organizations can implement sustainable changes to prevent recurrence and enhance patient safety. Understanding What Happened In this particular case, the sentinel event took place in the Emergency Department (ED), where a miscommunication during a patient handoff led to a delay in treatment. A septic patient’s deteriorating condition was not clearly communicated by the outgoing nurse due to omissions in critical details and insufficient documentation. As a result, the patient’s condition worsened, leading to an extended hospital stay and additional medical interventions. The event affected multiple stakeholders. The patient experienced health deterioration and psychological distress; family members faced emotional stress; and healthcare providers endured increased workloads and potential disciplinary scrutiny. The institution faced regulatory reviews, financial repercussions, and a tarnished reputation. Several factors contributed to this event. Human elements such as fatigue, high workload, and inadequate training led to incomplete verbal handoffs. Systemic flaws, including inefficient workflow and lack of structured electronic tools, compounded the problem. The organizational culture lacked a robust emphasis on safety, leadership oversight, and accountability. Additionally, cultural and language differences among staff affected the clarity of communication. These interconnected factors underscore the importance of addressing both human and structural components in patient safety initiatives. Deviation from Protocols and Breakdown in Communication The standardized SBAR (Situation, Background, Assessment, Recommendation) protocol was not adhered to during the handoff. Critical patient data was omitted, and there was no structured process to verify understanding between staff. Documentation in medical records and nursing notes lacked key details such as pending care needs and medication administration. Consequently, critical interventions were delayed. The event also exposed weaknesses in interdisciplinary and patient-provider communication. Nurses failed to exchange vital updates about new medication orders. The patient was inadequately informed about their evolving care plan, potentially compromising their trust and engagement in treatment. These lapses in communication underscore the need for structured protocols and training. Contributing Factors and Policy Gaps Environmental constraints, such as poorly placed nursing stations and malfunctioning devices, hindered effective information flow. Staffing shortages led to nurse fatigue and decreased attention to protocol adherence. While staff were generally competent, gaps in training—especially around updated handoff procedures—were evident. Policy compliance issues also played a significant role. While protocols existed, they were not effectively communicated or enforced. Many staff members reported difficulty accessing current guidelines, leading to inconsistencies in practice. Vital signs monitoring during critical periods was insufficient. Nurses failed to notice changes in the patient’s condition in real time. Furthermore, alarm fatigue—a common issue in high-volume units—resulted in missed alerts. These system failures compounded the risks already introduced by human and procedural lapses. Learning from the Incident and Enhancing Patient Safety This incident offers several important lessons. Systemic interventions must include strengthening communication strategies, particularly by reinforcing SBAR and bedside handoff procedures. Training should be updated regularly and include simulation of high-risk scenarios to ensure staff are prepared for emergencies. A cultural shift is also needed, with a focus on safety, accountability, and open dialogue. Preventive strategies include upgrading monitoring systems, refining alarm protocols, and introducing checklists for critical transitions. Frequent audits and feedback loops should be implemented to identify risks proactively. A non-punitive reporting culture should be cultivated to encourage transparency and continuous learning. These measures can help mitigate risks and elevate the standard of patient care. Root Cause and Contributing Factors Table Root Cause / Contributing Factor Category Code Breakdown in communication between the care team, leading to misinterpretation of patient condition Human Factor – Communication HF-C Insufficient training on updated protocols, causing staff to miss critical care changes Human Factor – Training HF-T Malfunctioning equipment led to missed warning signs and delayed intervention Environment / Equipment E Staff fatigue due to poor scheduling affected attention and decision-making Human Factor – Fatigue/Scheduling HF-F/S Failure to follow safety protocols resulted in missed interventions Rules / Policies / Procedures R Organizational barriers, including poor communication channels, hindered effective teamwork Barriers B Code Key: HF-C = Human Factor – Communication HF-T = Human Factor – Training HF-F/S = Human Factor – Fatigue/Scheduling E = Environment / Equipment R = Rules / Policies / Procedures B = Barriers Application of Evidence-Based Strategies Addressing sentinel events requires the implementation of evidence-based strategies that target both systemic and human factors. One of the most effective approaches involves the adoption of structured communication tools such as SBAR. Research conducted in the Griyatama Inpatient Room at Tabanan Hospital demonstrated that consistent use of SBAR significantly improves communication effectiveness, particularly during handoffs and emergency transitions (Putra et al., 2022). Improving alarm management systems is also critical. Alarm fatigue is a well-documented contributor to missed interventions, and literature suggests that prioritizing critical alarms and reducing unnecessary alerts can improve staff responsiveness (Cvach, 2012). Incorporating automated alert systems for abnormal vital signs can further reduce oversight and enhance timely interventions. Another key strategy is the implementation of routine simulation training and refresher courses. These sessions reinforce proper handoff procedures, ensure knowledge of updated protocols, and provide staff with hands-on experience in managing complex cases. Encouraging a culture of open reporting, supported by leadership, can transform adverse events into opportunities for learning and systemic improvement. References Cvach, M. (2012). Monitor alarm fatigue: An integrative review. Biomedical Instrumentation & Technology, 46(4), 268–277. https://doi.org/10.2345/0899-8205-46.4.268 Putra, A. A., Wardani, E. Y., & Sari, K. (2022). Implementation of SBAR communication

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NURS FPX 4035 Assessment 1

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

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