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 feedback will strengthen safety and speed up the improvements.

Implications of Diagnostic Errors and Their Importance for Healthcare Organizations

Slide 7:

Solving the ongoing error of misdiagnoses plays a big role in boosting both the care and the results of organizations. Errors in diagnosing a condition often result in patients getting delayed help, getting hurt, and experiencing increased costs. Incorrect diagnoses can lead to increased hospital visits, a greater chance of problems following treatment, and higher costs. Such errors can bring legal action against the facility, reduce its safety evaluation, and lower its reputation (Toker et al., 2022). In addition, when the way patients are diagnosed is not consistent, it can make workflow disruptions, upset staff, and lead to greater burnout, which can worsen patient care.

When SBAR communication is required, staff are regularly trained with scenarios and schedules are adjusted to lessen staff fatigue, the organization could see a big drop in errors when making diagnoses (Shinta & Bunga, 2024). By following these instructions, teams will become stronger, patients will have better assessments and safety and responsibility will be promoted in the organization. By following this strategy, patients receive better treatment and staff experience feel supported.

Part 3: Audience’s Role and Importance

Slide 8:

For the plan to reduce diagnostic errors to work, nurses, clinicians, and hospital leaders must all participate actively. Adequate nursing staff increases both the quality of care and patient safety. SBAR should be used whenever healthcare workers are explaining or discussing a patient’s health to make sure they do not omit any key aspect (Fernández et al., 2022). Regular staff training, giving input on obstacles in the workflow and joining multidisciplinary talks can help support the best ways of doing things. If these steps are made routine in work, the people responsible will ensure the improvements continue in accuracy and patient safety. The Role of hospital administrators includes supporting the use of standard communication methods and giving resources such as training programs and technology for use. Backing from department heads allows staff to invest sufficient time in assessments and avoid diagnosis mistakes.

Key Stakeholder Requirements for Plan Success

Slide 9:

Nurses are responsible for keeping watch and making sure errors in patient diagnosis do not happen, mainly while transferring shifts and checking each patient. Being active helps them avoid errors caused by people not receiving all the necessary details. Good leadership from clinical staff and hospital administrators is just as important (Elendu et al., 2024). If staff members had no commitment, using SBAR, EHR, and other digital tools would not be feasible. Properly using these tools allows accurate, simple-to-read, and easy-to-find patient information, aiding communication and saving health professionals both time and money. Collecting staff feedback about matters like overcrowded days, distractions in workflow, or system problems is useful for coming up with changes that matter. Having all healthcare providers work together and take responsibility encourages care that is safe for patients and practical, which helps to reduce mistakes and make results better.

Value of the Audience’s Contribution

Slide 10:

Getting involved with the diagnostic error reduction measures helps nurses deal with stress better and reduce errors while talking to and evaluating their patients. Using SBAR and suitable documenting tools helps nurses hand over important patient details effectively. It helps both health providers and patients understand what is happening by clearly discussing all the details. Adopting these methods helps doctors choose better diagnoses, means fewer requests for additional information from staff, and reduces frustration among team members.

Continued training helps nurses grow their abilities in detecting problems and talking about them with others. According to Elendu et al. (2024), being educated all the time improves doctors’ communication and reduces the chance of mistakes in passing along a diagnosis. Over the years, these improvements cut down on stress at work, raise job satisfaction, help teams unite, and make the workplace safer and more positive for everyone.

Part 4: New Process and Skills Practice

Slide 11:

On this slide, the plan is introduced, showing how it aims to reduce wrong diagnoses and make care procedures more accurate. Staff in charge must use SBAR whenever they communicate about urgent situations. It makes it easier for healthcare providers to explain important details, limit mistakes, and make it smoother to switch care for patients. By following SBAR, nurses ensure they give all important details to the person coming on shift during handoff time (Fernández et al., 2022). Ongoing training, which includes learning from scenarios and simulations, is also an important step.

Because of these sessions, staff can catch problems early and improve their skill in clinical judgement. Training often helps experts remember what to look for and grow confident in their health decisions. The goal is to ensure staffing can be changed to help nurses and doctors stay alert and have enough time to understand the health of every patient. Shifting schedules better will reduce personnel fatigue and assist with in-depth patient care. All of these efforts result in improved speaking with patients, better ability to diagnose, and safer overall care (Elendu et al., 2024).

Hands-On Exercise

Slide 12:

A simulation-based training session will be held to improve staff skills in preventing diagnostic errors and to support the safety improvement plan. Practice through simulation boosts confidence and communication among healthcare providers during patient assessments and information sharing. Participants will work in small groups, role-playing scenarios involving a patient with complex symptoms needing an accurate diagnosis (Elendu et al., 2024).

Using the SBAR model, each team will have two minutes to clearly communicate the patient’s condition, relevant history, current findings, and next steps in diagnosis and care. Realistic distractions will be added to mimic busy clinical settings. Afterward, facilitators will provide constructive feedback on communication strengths and areas to improve. A group discussion will follow, focusing on reducing mistakes and improving clarity in real diagnostic handoffs. This activity highlights how structured tools like SBAR improve accuracy, reduce errors, and promote patient safety.

Collaborative Q/A Session

The exercise will include a question-and-answer time where nurses and clinicians discuss strategies to avoid diagnostic errors. Attendees will be invited to share their experiences and reflect on challenges. For example, one question could be: “When handing off a patient with unclear symptoms, what key details must you always include?” Participants will learn to communicate updated findings, test results, and diagnostic concerns clearly using SBAR. Another question might be: “How can you ensure diagnostic information is accurate during handoffs?” This will encourage discussion about using electronic tools like EHR templates to standardize information and avoid missing critical details. The Q&A session encourages active participation and critical thinking. This interactive learning helps healthcare staff remember and apply best practices daily, ultimately improving diagnostic accuracy and patient outcomes.

Part 5: Soliciting Feedback

Slide 13:

Nursing and clinical staff will be encouraged to share their feedback on the diagnostic safety improvement plan and training sessions through both spoken comments and written responses. After the training, participants will complete an anonymous survey with multiple-choice and open-ended questions to evaluate what they learned. A brief group discussion will also take place to invite staff to share their thoughts and experiences.

This approach collects both quantitative data and personal insights. Feedback from participants will help identify common challenges, misunderstandings, new topics to address, and ways to improve the training exercises. Valuable suggestions from mentors and staff will help refine the diagnostic handoff process, enhance future training sessions, and better tailor classes to meet staff needs. This collaborative approach fosters teamwork, accountability, and ongoing improvement, making diagnostic practices safer and helpful for patients (Elendu et al., 2024).

Conlusion

In conclusion, reducing diagnostic errors is not only essential for patient safety, but it is also a shared responsibility that begins with clear communication, the use of structured tools like SBAR, and strong teamwork. By improving how we share information, supporting ongoing training, and adjusting staffing to prevent fatigue, we can create a safer, more reliable care environment. Each of us plays a vital role in making this improvement plan a success. Through collaboration, awareness, and commitment, we can prevent avoidable mistakes, strengthen diagnostic accuracy, and ensure the best outcomes for our patients. Thank you for your attention and dedication to safer care.

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://www.sciencedirect.com/science/article/pii/S266732152400091X

Elendu, C., Amaechi, D. C., Okatta, A. U., Amaechi, E. C., Elendu, T. C., Ezeh, C. P., & Elendu, I. D. (2024). The impact of simulation-based training in medical education: A review. Medicine, 103(27), 1–14. https://doi.org/10.1097/MD.0000000000038813

Fernández, M. C. M., Martín, S. C., Presa, C. L., Martínez, E. F., Gomes, L., & Sanchez, P. M. (2022). SBAR method for improving well-being in the internal medicine unit: Quasi-Experimental research. International Journal of Environmental Research and Public Health, 19(24), 1–13. https://doi.org/10.3390/ijerph192416813

Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/