Capella 4035 Assessment 4
Student Name
Capella University
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Improvement Plan Toolkit
Riverside Community Hospital implemented an Improvement Plan Toolkit following a critical diagnostic failure involving a 67-year-old sepsis patient. This event highlighted the urgent need for reform in early diagnosis and interprofessional communication. The toolkit is structured around four central components: Understanding and Preventing Diagnostic Errors, Analyzing the Reasons for Missed Diagnoses, Strategies That Enhance Patient Safety, and Improving Communication and Handover Practices. These components are grounded in scientific evidence and aim to create a structured pathway toward safer patient outcomes (Marshall et al., 2022).
To address diagnostic inaccuracies, Auerbach et al. (2024) emphasized the prevalence of diagnostic errors in ICU transfers or deaths, primarily resulting from flawed clinical evaluation and test interpretation. Similarly, Morgan et al. (2023) introduced the concept of diagnostic stewardship, suggesting that test usage should be controlled and evidence-based to reduce misdiagnosis. Newman-Toker et al. (2023) quantified the national burden, showing that diagnostic errors contribute to nearly 795,000 serious harms annually, especially in cases involving vascular conditions, infections, and cancer.
| Study | Focus Area | Key Recommendations |
|---|---|---|
| Auerbach et al. (2024) | Diagnostic errors in ICU/deceased patients | Improve evaluation and diagnostic testing accuracy |
| Morgan et al. (2023) | Diagnostic stewardship | Control and tailor diagnostic test usage |
| Newman-Toker et al. (2023) | National impact of diagnostic errors | Focus on “Big Three” high-risk conditions |
These resources collectively advocate for a systemic approach to diagnostics, supporting training initiatives for nurses in recognizing red flags, refining test interpretation, and collaborating with multidisciplinary teams.
Analyzing the Reasons for Missed Diagnosis
Understanding the underlying causes of diagnostic delays is crucial to implementing corrective action. Barwise et al. (2021) conducted a qualitative analysis revealing five core barriers to timely diagnoses: systemic flaws, poor coordination, inadequate communication, clinician variability, and patient factors. This broad view helps hospitals pinpoint and eliminate root causes within their structures.
Electronic Health Record (EHR) systems also play a significant role. Dixit et al. (2023) presented a framework explaining how EHR usability issues—such as non-intuitive interfaces and data inaccuracy—can lead to delayed or missed diagnoses. The study provides a roadmap for improving system design to support safe diagnosis. Complementarily, Politi et al. (2022) reviewed root cause analysis (RCA) reports from the Veterans Health Administration, identifying formal process gaps and policy non-compliance as major contributors to treatment delays.
| Study | Diagnostic Barrier | Clinical Implication |
|---|---|---|
| Barwise et al. (2021) | Organizational and communication failures | Address information flow and team coordination |
| Dixit et al. (2023) | EHR usability and system design flaws | Redesign EHR for accuracy and clinician usability |
| Politi et al. (2022) | Delay in diagnosis and treatment | Reinforce policies and interdepartmental communication |
These findings encourage nurses to advocate for system-level improvements, enhance documentation accuracy, and refine communication protocols to prevent lapses in care delivery.
Strategies That Enhance Patient Safety and Communication
A strong safety culture and effective communication are pivotal in healthcare settings. Al-Dossary (2022) examined how nursing work environments impact safety outcomes in Saudi Arabian hospitals. The presence of leadership support, resources, and teamwork was directly linked to reduced clinical errors and increased reporting of safety incidents. In parallel, Labrague (2024) demonstrated how protocol adherence—especially in fall prevention and pressure ulcer monitoring—was inversely related to adverse events.
McHugh et al. (2021) expanded this scope by investigating how nurse-to-patient ratio laws in Australia influenced patient outcomes. The findings indicated that more favorable ratios led to lower mortality and readmission rates, validating calls for legislative support in staffing practices.
Improving communication during shift changes is also vital. Scolari et al. (2022) evaluated the SBAR communication model among ICU nurses and discovered that factors like training and ICU experience affected how effectively SBAR was implemented. Labrague (2025) explored nurse-physician collaboration and its positive effects on job satisfaction and reduced turnover. Furthermore, Toren et al. (2022) assessed ISBAR use in Israeli hospitals, finding that structured handoffs contributed to fewer errors and improved teamwork satisfaction.
| Author | Area | Key Takeaways |
|---|---|---|
| Al-Dossary (2022) | Work environment | Supportive leadership improves safety culture |
| Labrague (2024, 2025) | Protocol adherence & collaboration | Fewer adverse events and increased workforce satisfaction |
| McHugh et al. (2021) | Staffing legislation | Safer ratios improve patient outcomes |
| Scolari et al. (2022) | SBAR effectiveness | Training enhances communication accuracy |
| Toren et al. (2022) | ISBAR handoff structure | Fewer errors and better staff morale |
These insights empower nurses to engage in initiatives promoting effective communication, supportive work environments, and team-based care models. Structured handoffs such as SBAR and ISBAR are vital in reducing errors during transitions and should be standardized across departments.
Conclusion
The Improvement Plan Toolkit at Riverside Community Hospital represents a comprehensive, evidence-based strategy to improve diagnostic accuracy and communication, particularly in response to a sentinel event involving undiagnosed sepsis. By addressing diagnostic processes, communication failures, environmental factors, and staff collaboration, the toolkit provides a practical path forward. Nurses are central to this improvement, acting as change agents in policy implementation, patient advocacy, and safety culture reinforcement. The collective application of these strategies fosters safer, more efficient, and more responsive healthcare environments.
References
Al-Dossary, R. N. (2022). The effects of nursing work environment on patient safety in Saudi Arabian hospitals. Frontiers in Medicine, 9, 872091. https://doi.org/10.3389/fmed.2022.872091
Auerbach, A. D., Lee, T. M., Hubbard, C. C., Ranji, S. R., Raffel, K., Valdes, G., Boscardin, J., Dalal, A. K., Harris, A., Flynn, E., Schnipper, J. L., UPSIDE Research Group, Feinbloom, D., Roy, B. N., Herzig, S. J., Wazir, M., Gershanik, E. F., Goyal, A., Chitneni, P. R., & Burney, S. (2024). Diagnostic errors in hospitalized adults who died or were transferred to intensive care. JAMA Internal Medicine. https://doi.org/10.1001/jamainternmed.2023.7347
Barwise, A., Leppin, A., Dong, Y., Huang, C., Pinevich, Y., Herasevich, S., Soleimani, J., Gajic, O., Pickering, B., & Kumbamu, A. (2021). What contributes to diagnostic error or delay? A qualitative exploration across diverse acute care settings in the US. Journal of Patient Safety, 17(4), 239–248. https://doi.org/10.1097/PTS.0000000000000817
Capella 4035 Assessment 4
Dixit, R. A., Boxley, C. L., Samuel, S., Mohan, V., Ratwani, R. M., & Gold, J. A. (2023). Electronic health record use issues and diagnostic error: A scoping review and framework. Journal of Patient Safety, 19(1), e25. https://doi.org/10.1097/PTS.0000000000001081
Labrague, L. J. (2025). A systematic review on nurse-physician collaboration and its relationship with nursing workforce outcomes. JONA: The Journal of Nursing Administration, 55(3), 157–164. https://doi.org/10.1097/nna.0000000000001549
Labrague, L. J. (2024). Nurses’ adherence to patient safety protocols and its relationship with adverse patient events. Journal of Nursing Scholarship, 56(2), 282–290. https://doi.org/10.1111/jnu.12942
Marshall, T. L., Rinke, M. L., Olson, A. P. J., & Brady, P. W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149(Supplement 3). https://doi.org/10.1542/peds.2020-045948d
McHugh, M., Aiken, L., Sloane, D., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. The Lancet, 397(10288), 1905–1913. https://doi.org/10.1016/S0140-6736(21)00768-6
Morgan, D. J., Malani, P. N., & Diekema, D. J. (2023). Diagnostic stewardship to prevent diagnostic error. JAMA, 329(15). https://doi.org/10.1001/jama.2023.1678
Capella 4035 Assessment 4
Newman-Toker, D. E., Nassery, N., Schaffer, A. C., Yu-Moe, C. W., Clemens, G. D., Wang, Z., Zhu, Y., Tehrani, A. S. S., Fanai, M., Hassoon, A., & Siegal, D. (2023). Burden of serious harms from diagnostic error in the USA. BMJ Quality & Safety, 33(2). https://doi.org/10.1136/bmjqs-2021-014130
Politi, R. E., Mills, P. D., Zubkoff, L., & Neily, J. (2022). Delays in diagnosis, treatment, and surgery: Root causes, actions taken, and recommendations for healthcare improvement. Journal of Patient Safety, 18(7). https://doi.org/10.1097/pts.0000000000001016
Scolari, E., Soncini, L., Ramelet, A., & Schneider, A. G. (2022). Quality of the Situation‐Background‐Assessment‐Recommendation tool during nurse‐physician calls in the ICU: An observational study. Nursing in Critical Care, 27(6). https://doi.org/10.1111/nicc.12743
Toren, O., Lipschuetz, M., Lehmann, A., Regev, G., & Arad, D. (2022). Improving patient safety in general hospitals using structured handoffs: Outcomes from a national project. Frontiers in Public Health, 10, 777678. https://doi.org/10.3389/fpubh.2022.777678