NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Introduction

Good day, and thank you all for attending this important in-service presentation. My name is ________, and today, we will address a crucial issue impacting patient safety in the Intensive Care Unit (ICU): Diagnostic Errors (DE) arising from communication breakdowns during nursing shift changes. A recent sentinel event involving a ventilated patient whose pulmonary embolism diagnosis was delayed due to miscommunication highlights the critical nature of this problem. This presentation will outline the implications of DE and introduce evidence-based strategies to optimize handoff communication, foster interdisciplinary collaboration, and improve patient outcomes.

Part 1: Agenda and Outcomes

Session Overview

This in-service session aims to address diagnostic errors that arise from ineffective handoffs in the ICU. The high-stakes nature of the ICU demands precise communication; even small lapses during transitions can lead to life-threatening conditions, increased length of stay, and heightened healthcare costs (Atinga et al., 2024). A prominent case involved a missed diagnosis of a pulmonary embolism due to unreported changes in patient condition during handoff, emphasizing the need for structured practices. Therefore, this session centers on integrating tools like SBAR and bedside protocols to promote clearer, standardized communication.

Goals

The primary goal is to identify and mitigate root causes of communication failures contributing to diagnostic errors. Facility data and literature review reveal factors such as:

Contributing Factor	Description
Insufficient Training	Limited instruction on standardized handoff methods
Time Constraints	Short transition periods reducing communication quality
Lack of Protocols	Absence of formalized handoff procedures
Staffing Shortages	Inadequate staff coverage increases burnout and errors
Systemic Inefficiencies	Fragmented technology and manual reporting delaying care decisions

Research shows communication failures are responsible for nearly 80% of serious diagnostic errors (Lazzari, 2024). The implementation of protocols like SBAR and EHR templates ensures that critical patient data is transferred accurately and consistently.

Anticipated Outcomes

Upon completing this training, participants are expected to:

• Identify Communication Risks: Nurses will recognize vulnerabilities in handoff practices, such as overlooked clinical signs or incomplete documentation.
• Apply Structured Tools: Staff will be trained in SBAR, bedside reports, and EHR documentation to support accurate transitions (Browning et al., 2025).
• Enhance Handoff Efficiency: By addressing gaps, the session will improve handoff reliability and reduce DE rates in ICU settings (Zimolzak et al., 2021).

These outcomes collectively aim to fortify patient safety and professional accountability while reducing the burden of diagnostic inaccuracy.

Part 2: Safety Improvement Plan

Overview of Diagnostic Errors

Diagnostic errors in the ICU often stem from communication disruptions during handoffs. According to Lazzari (2024), between 26% and 40% of adverse events arise from verbal and written handoff failures. A review of 23,000 malpractice claims attributed 7,000 incidents to handoff miscommunication, contributing to an estimated 2,000 preventable deaths. In the U.S., these lapses cost approximately \$12.1 billion annually (Janagama et al., 2020). Such staggering figures reflect the urgent need for structured, technological, and educational interventions to improve ICU transitions.

Safety Improvement Process

Step	Initiative	Purpose
1	SBAR Standardization	Implement standardized SBAR templates for consistent verbal communication
2	Monitoring and Alarm Management	Create quiet zones and enhance alert responsiveness for high-risk patients
3	EHR-Integrated Templates	Utilize digital templates to ensure accuracy and prevent reliance on memory
4	Training and Certification	Conduct continual staff education and introduce shift-length policies

These strategies aim to mitigate communication lapses, increase staff vigilance, and ensure the accurate transfer of clinical data.

Organizational Implications

Failure to address DE can damage both patient safety and institutional credibility. Ineffective handoffs result in escalated interventions, prolonged stays, and increased costs (Janagama et al., 2020). Moreover, unclear protocols reduce staff morale and contribute to workflow inefficiencies. Structured communication tools such as SBAR, combined with EHR integration, foster interprofessional collaboration, reduce litigation risks, and ensure compliance with safety standards (Singh et al., 2022). By institutionalizing these improvements, healthcare organizations strengthen diagnostic reliability and operational resilience.

Part 3: Audience’s Role and Importance

Role in Plan Implementation

The success of this initiative hinges on active engagement by frontline staff, including nurses, physicians, and administrators. Clinical staff must consistently use tools like SBAR during handoffs to ensure seamless communication. Additionally, staff participation in ongoing training and interdisciplinary rounds is vital to sustaining improvements. Leadership should facilitate this process by allocating time for education, updating policy, and integrating digital tools into practice (Russo et al., 2024). This combined effort reinforces accountability and empowers staff to deliver safe, error-free care.

Critical Role of the Audience

Nursing staff, who perform frequent ICU transitions, are central to this plan’s success. Their familiarity with real-time patient data makes them best positioned to identify potential communication gaps. Using tools like SBAR and EHR reports significantly reduces the likelihood of oversights that could lead to diagnostic errors (Lazzari, 2024). Engagement from all levels—clinical and administrative—is essential to foster sustainable change and cultivate a culture of safety.

Benefits of Participation

By embracing their roles, ICU staff will experience reduced workplace stress, improved communication efficiency, and fewer diagnostic oversights. Structured handoff protocols provide clarity, improve collaboration, and reduce burnout by minimizing redundant clarifications. Training sessions enhance competence and build confidence, particularly in high-pressure situations (Atinga et al., 2024). These efforts collectively support better patient care, improved staff morale, and lower adverse event rates.

Part 4: New Process and Skills Practice

Introduction of New Skills and Tools

The plan introduces several new practices to minimize DE, including:

• SBAR Framework: Promotes structured, precise communication during shift transitions (Russo et al., 2024).
• EHR Integration: Digital templates reduce errors by ensuring complete and real-time data capture.
• Bedside Reporting: Involves direct interaction during patient evaluation to promote mutual understanding.

These tools collectively ensure more reliable information transfer and greater care continuity during handoffs.

Simulation-Based Practice

To support these skills, participants will engage in simulation exercises. Groups will role-play ICU handoffs using SBAR, simulating a pulmonary embolism case. Each team will provide a two-minute structured handoff, incorporating assessment findings and care plans. Distractions will be introduced to mimic real-world interruptions. Facilitators will offer feedback, reinforcing correct practices and addressing communication weaknesses (Richters et al., 2023). This hands-on method strengthens decision-making and reduces DE risk.

Collaborative Q\&A Activity

A question-and-answer session will encourage critical thinking and reflection. Key prompts include:

Question	Purpose
“How will you ensure proper patient handoff during shift change?”	Reinforces use of SBAR and complete condition reporting
“How can you validate patient details during transition?”	Emphasizes the role of EHR integration and confirmation checks

This interactive segment will allow staff to share insights and further refine handoff strategies collaboratively.

Part 5: Soliciting Feedback

Feedback Collection Methods

To ensure continuous improvement, feedback will be gathered using:

Method	Description
Anonymous Surveys	Evaluate tool effectiveness and session content
Open-Ended Feedback	Allow staff to share experiences and suggestions for process improvement
Post-Session Analysis	Identify recurring themes and areas for refinement based on feedback trends

These methods will guide the iterative development of handoff protocols. According to Meyer et al. (2021), such feedback loops are essential for aligning safety measures with frontline challenges and ensuring staff ownership of new practices.

Conclusion

This in-service presentation has explored the persistent issue of diagnostic errors in the ICU, emphasizing the consequences of communication breakdowns during nursing shift changes. The session has introduced evidence-based interventions—including SBAR, bedside reporting, and EHR-integrated templates—to improve communication and prevent clinical oversights. These tools, combined with staff training and institutional support, create a robust foundation for safer, more effective patient care. The collaborative efforts of nurses, physicians, and administrators are critical to sustaining these changes and promoting a strong culture of diagnostic safety.

References

(APA style references retained as per your original formatting) 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

NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

Janagama, S. R., Strehlow, M., Gimkala, A., Rao, G. V. R., Matheson, L., Mahadevan, S., & Newberry, J. A. (2020). Critical communication: A cross-sectional study of signout at the prehospital and hospital interface. Cureus, 12(2), e7114. https://doi.org/10.7759/cureus.7114

Lazzari, C. (2024). Implementing the verbal and electronic handover in general and psychiatric nursing using the introduction, situation, background, assessment, and recommendation framework: A systematic review. Iranian Journal of Nursing and Midwifery Research, 29(1), 23. https://doi.org/10.4103/ijnmr.ijnmr_24_23

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

NURS FPX 4035 Assignment 3 Improvement Plan In-Service Presentation

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