Capella FPX 4035 Assessment 3

Capella FPX 4035 Assessment 3

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name:

Date

Improvement Plan In-Service Presentation

Slide 1: Hi, and welcome to all! I am _______. Today, I will discuss a serious safety issue in medical care: patient handoff failures. This in-service session aims to provide staff with practical resources and strategies for effective patient handovers. The objective is to strengthen interactions among medical staff to ensure safer patient care and achieve better health results.

Part 1: Agenda and Outcomes

Agenda

Slide 2: This session aims to tackle the issue of patients being handed off from one healthcare provider to another ineffectively. This training is meant to strengthen nurses’ skills in communicating and passing information about patients to other team members, to ensure patients are safe. If handoffs between healthcare teams are not done well, patients may face harm, a lower level of care, longer hospitalization, higher medical costs, and, in serious cases, death (Le et al., 2023). Through this training, nurses will learn the necessary steps and techniques to ensure that patients move from one area to another smoothly and safely. For example, they will discover ways to reduce errors during shift changes by using SBAR and bedside reporting. A recent case of a 56-year-old woman demonstrated how much we need handoffs to be improved. The nurse had not been told about the patient’s changed state because important details and some documentation were missing. Therefore, patients with sepsis did not get timely treatment, which might have been prevented if there were a better system for handing over care.

Goals

Slide 3: Three specific goals are established to address the patient safety issue and to conduct the safety initiative. These goals are:

Goal 1: Understand the significance of accurate patient handoffs and develop practical skills for improving safety practices

This session will begin by emphasizing the importance of effective patient handovers in ensuring continuity of care and patient well-being. Errors during shift changes can lead to serious consequences such as patient harm, reduced quality of treatment, extended hospital stays, increased costs, and even mortality. Staff will be introduced to practical competencies and strategies that support a safety culture and allow them to implement improved handoff procedures in their daily routines (Ma et al., 2024). Attendees will learn to recognize potential risks and apply corrective actions during care transitions. 

Goal 2: Identify common causes of patient handoff failures within healthcare settings

We will explore the core challenges that contribute to flawed patient handoffs. Based on institutional insights and recent studies, leading issues include insufficient training, limited time allocation for transitions, interruptions during shift reports, absence of standardized communication frameworks, systemic inefficiencies, and workforce shortages. Poor communication is linked to roughly 29% of nurse-related adverse outcomes, highlighting the urgent need for improvement (Desmedt et al., 2021). 

Goal 3: Explore evidence-based solutions to enhance handoff effectiveness and reduce communication errors

The final part of the session will examine proven strategies for improving handover processes. This includes implementing structured tools like SBAR (Situation, Background, Assessment, Recommendation), using bedside shift reporting, and integrating the Electronic Health Record (EHR) for consistent and accurate information sharing. Establishing clear protocols, promoting standardized communication formats, and ensuring accuracy and consistency are key components in reducing handoff-related mistakes and enhancing care coordination (Ma et al., 2024).

Outcomes 

Slide 4: The anticipated outcomes of this in-service session are: 

1. Improved Awareness and Understanding

Attendees will develop a solid grasp of how essential precise patient handoffs are for ensuring safety and consistent care, as well as the risks that poor communication during shift transitions can pose.

1. Identification of Contributing Factors

Attendees will be able to recognize the common causes of ineffective patient handovers—such as lack of standardization, time constraints, and communication barriers—and understand how these issues impact clinical outcomes.

1. Application of Evidence-Based Strategies

Nursing staff will demonstrate the ability to apply practical, evidence-based tools such as the SBAR technique, bedside handoff practices, and EHR utilization to ensure consistent and effective communication during patient transitions.

Part 2: Safety Improvement Plan

Slide 5: Ineffective and inaccurate patient handoffs remain a pressing issue within healthcare settings, posing serious risks to patient safety and overall organizational performance. When handoff procedures fail, the consequences can be severe, ranging from patient harm and compromised quality of care to extended hospital stays, higher treatment costs, and even loss of life (Ma et al., 2024). These breakdowns are often linked to preventable factors such as miscommunication, staffing shortages, inconsistent handoff procedures, and limitations within healthcare systems.

Research indicates that approximately half of negative patient outcomes, including clinical errors and fatalities, are directly tied to poor handoff practices. Specifically, ineffective communication during nurse-to-nurse handoffs contributes to about 29% of adverse incidents in nursing care (Desmedt et al., 2021). Communication failures during patient transfers are estimated to cause up to 80.1% of all medical errors. In the United States alone, such communication lapses incur an estimated $12.1 billion annually in associated costs (Janagama et al., 2020). These findings underscore the urgent need to improve handoff practices, as they are crucial for ensuring patient safety and maintaining high standards of care across healthcare environments.

Safety Improvement Process

Slide 6: A formal and thorough safety enhancement strategy is crucial to increase patient handoff effectiveness and dependability and improve health outcomes. The initial part of the strategy is implementing the SBAR technique as a formalized communication system. This system assists in tackling communication failures by providing a concise and reliable system for exchanging critical patient information, minimizing the likelihood of errors and missing data (Eun, 2024). The second phase entails putting in place active safety interventions like bolstering monitoring systems and streamlining alert systems, which assist in spotting potential problems early and reducing risks. In the third phase, electronic tools such as the Electronic Health Record (EHR) with embedded handoff templates will enable smooth data transition.

They facilitate handoff procedures by presenting correct, structured clinical data, minimizing handover time, and enhancing communication quality and patient satisfaction (Browning et al., 2025). Lastly, training personnel must enhance handoff quality and guarantee adherence to validated communication procedures. Training medical staff on standardized handoff techniques instills confidence, raises skill levels, and lowers communication-related errors (Ma et al., 2024). Decreasing avoidable adverse events due to incomplete or incorrect patient information at times of transition is central to sustaining patient safety and high-quality care.

Poor Patient Handoff Implications and Importance for the Medical Organization

Slide 7: Resolving the chronic issue of poor patient handoffs is paramount to enhancing overall healthcare quality and organizational productivity. Communication failure across patient transitions is a top cause of avoidable medical mistakes, treatment delays, and rising healthcare costs. Poor communication is responsible for an estimated $12.1 billion in annual costs in the U.S. healthcare system (Janagama et al., 2020). Ineffective handoffs not only result in patient injury and longer hospitalization, but also put the facility at risk for legal liability, harm its safety scores, and erode its reputation.

Additionally, unclear or inconsistent handoff practices can interfere with workflow, breed staff discontent, and lead to burnout, ultimately compromising the quality of care provided. By adopting standardized handoff protocols, the organization can diminish preventable errors significantly, enhance coordination between healthcare teams, and ensure continued compliance with accreditation requirements. Such enhancements will contribute to patient safety and staff development, encourage teamwork, and improve morale, giving rise to a culture of accountability and producing better outcomes for patients and providers. 

Part 3: Audience’s Role and Importance

 Slide 8: The Success of the improvement plan of effective patient handoff relies on the involvement of all health stakeholders, particularly nurses, clinicians, and hospital administrators. According to Gungor and Tosun (2025), adequate nursing staffing is vital for improving quality and increasing the care standard. During patient transfers and shift changes, nurses, doctors, and other health professionals need to continue using structured communication tools to avoid leaving out vital information. In addition, they undergo training, offer feedback on workflow problems, and engage in multidisciplinary rounds to support standardized practices.

By integrating the processes into daily operations, providers who adopt ownership of these changes will ensure effective and lasting handoff accuracy and patient safety enhancements. Hospital administrators are crucial in implementing standard handoff techniques and offering resources like electronic handoff devices and staff training sessions. Their support allows nurses to spend time and have the facilities to provide safe and effective handoffs. 

Audience Needs for Plan’s Success

Slide 9: The nursing team, being key players in morning and afternoon patient handoff processes, is pivotal in any plan to improve patient safety. Direct participation in care transitions makes their involvement critical to reduce errors caused by poor communication. The active support and coordination of clinical and management staff are just as important. Without their backing, even the best tools and guidelines, including SBAR, Electronic Health Records (EHR), and Electronic Nursing Handover Systems (ENHS), can be inadequate in practice.

When used to full capacity, such systems facilitate handover by ensuring patient information is clear, accurate, and accessible, ultimately enhancing the quality of communication, cutting handoff time, and enhancing patient satisfaction (Browning et al., 2025). In addition, staff feedback on practical issues—such as time limitations, disruption of workflow, or operational inefficiencies—can inform useful improvement and ensure new procedures are realistic and sustainable. Fostering input and ownership from healthcare teams enhances a shared accountability culture for patient safety and facilitates incorporating evidence-based practices to improve care results.

Benefits of the Audience’s Role

Slide 10: Contributing to the initiative allows nursing staff to manage their stress better, reduce mistakes when passing duties, and make their work routine more efficient. Using SBAR and EHR templates improves the speed and accuracy of handing over patient information. When using SBAR, nurses can discuss patient details in a way that helps prevent confusion and missed information. Using these practices results in better patient care, fewer calls for clarification, and less confusion that can exhaust staff. Moreover, continued training improves nurses’ ability and confidence when moving patients between different health care settings. According to the Eun (2024), ongoing education helps doctors improve communication and decreases errors when handing over patients. As time passes, the efforts help decrease negativity at work, improve people’s feelings about their jobs, encourage teamwork, and create a safer and better environment for all.

Part 4: New Process and Skills Practice

 Slide 11: This patient safety improvement initiative includes innovative practices to improve the accuracy and efficacy of patient handoffs. One such practice is the use of the SBAR communication model. Through this approach, healthcare providers can communicate vital details about a patient’s condition clearly and effectively, reducing miscommunication and facilitating a seamless handoff of care (Eun, 2024). By breaking down handoff communication into four structured elements, nurses can ensure that essential information is always communicated during shift changes.

Further key developments include the incorporation of EHR with embedded handoff templates and the use of ENHS. These promote standardization of documentation, avoidance of omissions, and preservation of accuracy of patient data. Regularly employing an electronic handoff structure facilitates more structured, timely, and applicable information sharing among staff, minimizing the likelihood of errors and optimizing communication effectiveness. Uniform handoff protocols ensure high-quality, safe care (Appelbaum et al., 2021). By embracing these practices, the facility seeks to address age-old problems related to inconsistent handovers, to properly convey critical information during shift changes, and improve patient outcomes.

Practical Activity 

Slide 12: There will be a simulation-based training exercise that will enhance the handoff skills of nurses and support the effective implementation of revised practices. Based on Ma et al. (2024), simulation-based instruction greatly enhances communication skills and nurses’ confidence in handling patient transitions. For this exercise, participants will be grouped into small teams to partake in role-playing exercises on patient handoffs. Each group will practice a handoff for a 56-year-old woman with acute heart failure (AHF) receiving treatment.

With the SBAR model, each team will have two minutes to share the patient’s clinical presentation, pertinent history, assessment findings at present, and follow-up needed. Environmental distractions will be introduced during practice, as in real clinical environments. Then, facilitators will offer positive feedback regarding communication strengths and areas for improvement. Following that, there will be a group discussion on minimizing misunderstandings and increasing clarity in real-world handoffs. The activity emphasizes the importance of structured tools such as SBAR in increasing accuracy, minimizing errors, and ensuring patient safety during shift transfers.

Collaborative Q/A Activity

As part of the exercise, there will be a question-and-answer session with nursing staff to explain and discuss important strategies for handling patient care. Those attending will be prompted to reflect on the topic and share what they have been through. One example of a question could be: “When giving care to someone with acute heart failure, what details should you always include when handing it off?” As a result, nurses have to ensure they always share current symptoms, update medications, and highlight the most important care points using tools such as SBAR.

Another consideration is: “Which approaches can you take to check data accuracy during a handover?” It leads to discussing options that make data exchange dependable, standardized, and prompt, such as electronic handoff templates and the ENHS. This makes it less likely that important details and instructions will be missed during shifts. During the Q&A session, staff are encouraged to share ideas and use analytical skills. The interactive coursework helps nurses remember important practices and apply them each day, thus ensuring patients receive quality care.

Part 5: Soliciting Feedback

Slide 13: Nursing staff will be invited to share their input on the enhancement plan and training session through both spoken and written responses. After the session, participants will fill out an anonymous form with multiple-choice and open-ended questions to evaluate what was taught. A quick discussion will also take place to invite students to share their thoughts and impressions. This way of doing things allows for collecting both numbers and experiences. Gathering feedback from learners will help identify similar challenges, such as misconceptions, new topics to cover, and how to improve the simulation. Helpful ideas from mentors will improve the handoff process, update training delivery, and customize future classes for the staff (Appelbaum et al., 2021). Because of this, employees work together, are responsible, and continue to improve, making patient care safer and more effective. 

Conclusion

Slide 14: This in-service aims to lower risks from patient handoff failures using SBAR and new electronic systems such as EHR and ENHS. Nurses ensure that handoffs are effective so that patient safety and care are sustained. Practicing in simulated activities and discussing answers will give learners a chance to reflect on their learning. For these practices to continue to improve and stay successful, staff should be involved and give feedback. All of these efforts combine to improve safety and efficiency for those receiving and providing healthcare.

References

Appelbaum, R., Martin, S., Tinkoff, G., Pascual, J. L., & Gandhi, R. R. (2021). Eastern association for the surgery of trauma – quality, patient safety, and outcomes committee – transitions of care: Healthcare handoffs in trauma. The American Journal of Surgery, 222(3). https://doi.org/10.1016/j.amjsurg.2021.01.034 

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, 25(1). https://doi.org/10.1155/jonm/5585723 

Desmedt, M., Ulenaers, D., Grosemans, J., Hellings, J., & Bergs, J. (2021). Clinical Handover and Handoff in healthcare: a Systematic Review of Systematic Reviews. International Journal for Quality in Health Care, 33(1). https://doi.org/10.1093/intqhc/mzaa170

Capella FPX 4035 Assessment 3

Eun, J. (2024). Development of SBAR simulation training to improve patient handoff communication among nursing students. Journal of East-West Nursing Research, 30(2), 71–78. https://doi.org/10.14370/jewnr.2024.30.2.71 

Gungor, S., & Tosun, B. (2025). The impact of improving clinical patient handover interventions on patient outcomes and handover practices: A complex nursing intervention study. Journal of Evaluation in Clinical Practice, 31(4). https://doi.org/10.1111/jep.70087 

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

Le, A., Lee, M. A., & Wilson, J. (2023). Nursing handoff education: An integrative literature review. Nurse Education in Practice, 68(8). https://doi.org/10.1016/j.nepr.2023.103570 

Ma, L., Yan, R., Wang, X., Gao, X., Fan, N., Liu, L., & Kang, H. (2024). Enhancing surgical nursing student performance: Comparative study of simulation-based learning and problem-based learning. Journal of Multidisciplinary Healthcare, 17, 991–1005. https://doi.org/10.2147/jmdh.s440333