NURS FPX 4035 Assessment 1 Enhancing Quality and Safety

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Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

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Enhancing Quality and Safety

Transitions of care in emergency departments (EDs) represent pivotal points that can heavily impact patient outcomes. The nature of emergency care, with its urgency and complexity, increases the likelihood of errors during patient handoffs. In this high-intensity environment, critical details can be lost or miscommunicated, leading to treatment delays, medical mistakes, and heightened risks to patient safety. This discussion focuses on identifying the root causes of these communication failures, presents practical strategies for improvement, and emphasizes the critical role nurses and interprofessional collaboration play in promoting safety and cost-efficiency in care delivery.

Factors Leading to Patient Safety Risk

Numerous interrelated factors contribute to the risk of adverse events during ED handoffs. Chief among them is communication inconsistency, often intensified by the time-sensitive nature of emergency care. Research shows that nearly 80% of severe errors in healthcare can be traced back to breakdowns in communication during transitions (Kinney-Sandefur, 2024). The unpredictable pace and patient acuity in EDs create an environment where vital information may be hurriedly or incompletely transferred.

Another prominent issue is the absence of a standardized handoff framework. Without a unified protocol, providers rely on variable, often informal methods of transferring responsibility, resulting in fragmented care. According to Atinga et al. (2024), time pressure and the demand for quick decision-making further exacerbate the problem, with up to 70% of treatment failures and 50% of preventable events attributed to flawed handover practices. These conditions underline the importance of systematic communication and teamwork among providers to minimize risks and maintain care quality.

Solutions to Improve Patient Safety and Reduce Costs

To address these issues, the use of structured communication methods has gained prominence. Tools like SBAR (Situation, Background, Assessment, Recommendation) provide a concise and consistent way to relay information, which has been shown to reduce misunderstandings and improve workflow. Ghosh et al. (2021) highlight that SBAR protocols contribute to better documentation, increased accuracy in billing, and overall improved patient experiences.

Incorporating technology into the handoff process also supports safer transitions. Electronic Health Records (EHRs) featuring standardized templates allow for up-to-date, accessible patient data that reduces reliance on memory and minimizes omissions. Tataei et al. (2023) found that bedside shift reporting, which includes the patient and family, enhances communication accuracy and fosters trust in care providers. These innovations help lower healthcare costs by decreasing the frequency of avoidable complications such as medication errors, delayed diagnoses, or prolonged hospital stays.

The table below outlines the key issues, risk factors, and solutions:

Enhancing Quality and Safety	Factors Leading to Patient Safety Risk	Solutions to Improve Patient Safety and Reduce Costs
ED handoffs are critical and high-stakes processes.	Miscommunication accounts for 80% of serious errors during transitions (Kinney-Sandefur, 2024).	SBAR tool enhances the clarity of handoffs and boosts documentation accuracy (Ghosh et al., 2021).
Lack of consistency in handoff practices causes harm.	High-pressure decisions lead to oversight and incomplete reporting (Atinga et al., 2024).	EHR-integrated handoff templates support real-time updates and reduce information loss (Tataei et al., 2023).
Nurses are central to effective transition management.	Multidisciplinary care coordination is disrupted by unstructured handoffs.	Bedside reporting involving families promotes transparency and reduces readmissions.

Nursing Coordination for Patient Safety and Reducing Costs

Nurses serve as pivotal agents in ensuring seamless care transitions within emergency departments. Their responsibilities extend beyond clinical care to include validating the accuracy of information both before and after handoffs. By actively participating in interdisciplinary rounds, nurses can detect potential issues early and correct inconsistencies, leading to improved outcomes and fewer medical errors (Shirley et al., 2024). Their efforts directly contribute to reducing redundant tests and treatments, lowering overall costs for both patients and institutions.

Closed-loop communication, a method that confirms message receipt and comprehension, is one of the most effective tools employed by nurses. This approach helps prevent scenarios such as delayed medication administration or failure to follow up on lab results. For example, if a nurse ensures that a physician is aware of a patient’s scheduled antibiotics, costly complications like ICU transfers can often be avoided. Additionally, using electronic handoff systems increases the reliability and efficiency of communication.

Moreover, nurses are instrumental in involving patients and families during transitions. Their role in these conversations fosters patient trust and contributes to accurate information sharing. Bucknall et al. (2020) affirm that patient engagement during handoffs leads to fewer hospital readmissions and better continuity of care. Through these strategies, nurses promote both safety and fiscal responsibility in healthcare delivery.

Stakeholders’ Involvement in Nursing Coordination

Effective handoffs in emergency departments require coordinated efforts from a range of stakeholders. Physicians depend heavily on accurate, timely updates to make appropriate decisions. However, communication breakdowns between nurses and physicians remain a prevalent barrier to effective care delivery, often resulting in adverse patient outcomes (Jemal et al., 2021). Likewise, pharmacists contribute by reviewing medications for accuracy and safety during transitions, ensuring drug interactions or duplications are avoided.

Healthcare administrators play a vital role in supporting structured handoff systems. Their responsibilities include policy development, staff training, and investing in digital infrastructure that enables standardized practices. By equipping staff with the tools and education necessary for smooth transitions, administrators help minimize variability and risk in patient care.

Additionally, the role of patient safety officers and quality assurance teams cannot be overstated. These professionals monitor handoff data, identify trends in adverse events, and recommend process improvements based on evidence. Importantly, patients and their families are essential yet often overlooked stakeholders. When they are included in bedside shift reports, their participation fosters a more personalized and thorough transition. Nurses remain at the center of this collaborative model, ensuring that every voice is heard and that patient care remains comprehensive and cost-effective.

Conclusion

Patient handoffs in emergency departments are critical to patient safety and operational efficiency. Without structured processes, miscommunication during these transitions can result in preventable harm and increased healthcare costs. Implementing tools like SBAR and EHR templates can substantially mitigate these risks. Nurses play a leading role in executing these strategies, guiding coordination efforts, and promoting engagement among all stakeholders. Their collaboration with physicians, pharmacists, administrators, and families ensures a system of care that is both safe and economically sound.

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

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

Jemal, M., Kure, M. A., Gobena, T., & Geda, B. (2021). Nurse–physician communication in patient care and associated factors in public hospitals of Harari regional state and Dire-Dawa city administration, Eastern Ethiopia: A multicenter-mixed methods study. Journal of Multidisciplinary Healthcare, 14(1), 2315–2331. https://doi.org/10.2147/jmdh.s320721

Kinney-Sandefur, A. V. (2024). Improving patient handoff in the emergency department microsystem. University of New Hampshire Scholars’ Repository. https://scholars.unh.edu/thesis/1799

Shirley, S. G. A., Abdullah, B. F., & Dioso, R. I. (2024). Enhancing teamwork through effective handover practices among nurses in elder care setting. The Malaysian Journal of Nursing, 15(04), 100–108. https://doi.org/10.31674/mjn.2024.v15i04.0012