NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit

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Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

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Date

Improvement Plan Toolkit

Medication errors (MEs) remain one of the most pressing safety issues in healthcare settings, often leading to adverse events and compromised patient outcomes. This improvement plan is built upon a robust annotated bibliography composed of twelve evidence-based academic and professional studies. These resources are structured across four primary themes: technology-enabled medication safety, effective communication and handoff practices, education and competency development, and effective team collaboration. This toolkit is designed to support frontline staff nurses—who are at the center of medication administration—by offering actionable insights and interventions. Each source was chosen for its practical application, capacity to support implementation, and ability to foster a culture of safety.

Technology-Enabled Medication Safety

The integration of technology into medication processes plays a vital role in minimizing errors and enhancing clinical decision-making. Azadi and García-Peñalvo (2025) emphasize the synergy between human–computer interaction (HCI) and Clinical Decision Support Systems (CDSS), advocating for systems designed with usability in mind. Such integration reduces cognitive workload and increases the accuracy of medication administration. This is particularly critical in high-pressure settings like emergency departments and intensive care units.

Expanding upon this, Jung et al. (2020) identify barriers and facilitators to implementing Medication Decision Support Systems (MDSS) within electronic health records. Alert fatigue, non-intuitive interfaces, and lack of customization are highlighted as significant obstacles. However, ease of use and perceived performance benefits promote system adoption. This highlights the need for targeted interface enhancements and tailored alerts to improve engagement and effectiveness.

Yu et al. (2024) present real-world evidence from a longitudinal study examining the use of barcode scanning, automated dispensing cabinets, and smart counters. Their data show a substantial error reduction (up to 77.78%) over six years, validating the impact of phased technology deployment. The findings advocate for strategic rollouts in high-volume units and underscore the need for scalable, evidence-driven digital tools to improve both efficiency and safety.

Table 1: Summary of Technology-Enabled Medication Safety Resources

Study	Focus Area	Key Insights	Application in Nursing
Azadi & García-Peñalvo (2025)	CDSS & HCI Integration	User-centered systems reduce input errors	Design insights for ICU/ED medication safety
Jung et al. (2020)	MDSS Implementation in EHR	Alert fatigue and UI design influence use	Guides MDSS optimization and training
Yu et al. (2024)	Medication Tech Efficiency	Error reduction through technology	Workflow improvement in acute settings

Effective Communication and Handoff Practices

Clear and structured communication is foundational to preventing medication-related errors during transitions of care. Alizadeh-Risani et al. (2024) compare the SBAR method with a modified handover model, finding that structured communication enhances information clarity and mutual understanding, especially in emergency departments. The study supports incorporating standardized checklists for medication tracking during patient handovers.

Felipe et al. (2022) validate an SBAR-based tool for shift changes in surgical units, noting its high usability and effectiveness in preventing medication miscommunication. The tool supports nursing staff by providing consistency in relaying crucial medication-related information, ensuring that no detail is missed or duplicated.

McCarthy et al. (2025) conduct a systematic review on handoff protocols, emphasizing the reliability of I-PASS and SBAR in reducing medical errors. I-PASS shows moderate evidence in improving outcomes, reinforcing the necessity for structured communication tools as part of routine clinical practice.

Table 2: Communication Models and Tools for Safe Handoffs

Study	Tool/Model Evaluated	Outcome	Recommended Use
Alizadeh-Risani et al. (2024)	Modified Handover	Enhanced nurse perception and clarity	ED and fast-paced environments
Felipe et al. (2022)	SBAR Tool	Improved consistency during shift changes	Surgical and inpatient settings
McCarthy et al. (2025)	SBAR & I-PASS	Reduced medical errors and better outcomes	Cross-unit handoffs, ICUs, acute care units

Education and Competency Development

Competency-based education is key to reducing MEs by equipping nurses with up-to-date skills and knowledge. Ahmed and Tamim (2025) advocate for comprehensive educational programs, such as workshops and technology-assisted training, that bolster medication literacy. These efforts foster critical thinking and empower nurses in high-risk specialties like oncology and critical care.

Jung and Park (2025) explore medication safety education across various stages of a nurse’s clinical career using a ladder model. Their findings support individualized training modules, with new nurses focusing on fundamentals and experienced nurses engaging in advanced error prevention and peer training. This tailored approach enhances decision-making and builds long-term safety competencies.

Komal et al. (2023) show that structured workshops significantly improve nurses’ drug dosage calculation skills, particularly in high-stakes units like pediatrics or emergency departments. These workshops offer long-term value by institutionalizing skill development and reducing high-risk errors in clinical environments.

Table 3: Competency-Based Educational Tools for Nurses

Study	Educational Method	Key Takeaway	Best Application
Ahmed & Tamim (2025)	Health promotion, HIT	Supports critical thinking and literacy	Critical care, oncology
Jung & Park (2025)	Clinical ladder education	Stage-based learning improves safety	Career-long development
Komal et al. (2023)	Structured workshops	Reduces dosage calculation errors	Pediatric, emergency care

Effective Team Collaboration in Medication Safety

Team-based strategies are central to enhancing medication safety. Alhur et al. (2024) highlight how interprofessional communication lowers error rates by encouraging open dialogue and shared responsibility. For staff nurses, this translates into better coordination with pharmacists and physicians, particularly in settings where quick and accurate decisions are vital.

Ravi et al. (2022) explore nurse-pharmacist collaboration in community care, showing that joint reviews, patient education, and adherence strategies significantly improve medication outcomes. This model is especially effective for nurses in home care, allowing proactive identification of problems and tailored interventions.

Weller et al. (2024) focus on situational awareness in teams. Their narrative review emphasizes that shared mental models and real-time communication support cohesive decision-making in high-risk units. Nurses benefit by participating actively in clinical discussions and becoming vigilant in detecting potential errors before they reach the patient.

Table 4: Team Collaboration Strategies to Reduce MEs

Study	Team Strategy Focus	Outcome	Nursing Relevance
Alhur et al. (2024)	Interprofessional communication	Fewer medication errors, open dialogue	ICUs, surgical wards
Ravi et al. (2022)	Nurse-pharmacist partnership	Improved adherence, reduced events	Home/community care
Weller et al. (2024)	Team situation awareness	Better coordination and prevention	Perioperative, critical care

Conclusion

In summary, this improvement plan toolkit illustrates that a combination of digital solutions, structured communication protocols, tailored educational programs, and collaborative teamwork is essential to reducing medication errors. Each thematic area supports the empowerment of staff nurses by offering practical, scalable, and evidence-informed strategies. By integrating these findings into clinical workflows, healthcare organizations can nurture a proactive safety culture, enhance nurse competency, and ultimately improve patient outcomes across various care settings.

References

Ahmed, R., & Tamim, T. R. (2025). Enhancing medication safety: The role of community and hospital pharmacists in modern healthcare systems. Radinka Journal of Health Science (RJHS), 2(3), 328–355. https://doi.org/10.56778/rjhs.v2i3.418

Alhur, A., Alhur, A. A., Al-Rowais, D., Asiri, S., Muslim, H., Alotaibi, D., Al-Rowais, B., Alotaibi, F., Al-Hussayein, S., Alamri, A., Faya, B., Rashoud, W., Alshahrani, R., Alsumait, N., & Alqhtani, H. (2024). Enhancing patient safety through effective interprofessional communication: A focus on medication error prevention. Cureus, 16(4). https://doi.org/10.7759/cureus.57991

NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit

Alizadeh-Risani, A., Mohammadkhah, F., Pourhabib, A., Fotokian, Z., & Khatooni, M. (2024). Comparison of the SBAR method and modified handover model on handover quality and nurse perception in the emergency department: A quasi-experimental study. BMC Nursing, 23(1). https://doi.org/10.1186/s12912-024-02266-4

Azadi, A., & García-Peñalvo, F. J. (2025). A synergistic bridge between human–computer interaction and data management within CDSS. Data, 10(5), 60. https://doi.org/10.3390/data10050060

Felipe, T. R. L., Spiri, W. C., Juliani, C. M. C. M., & Mutro, M. E. G. (2022). Nursing staff’s instrument for change-of-shift reporting – SBAR (Situation-Background-Assessment-Recommendation): Validation and application. Revista Brasileira de Enfermagem, 75(6), e20210608. https://doi.org/10.1590/0034-7167-2021-0608

Jung, S., & Park, J. (2025). Educational needs for medication safety competence among nurses by clinical ladder stage. PLOS ONE, 20(4), e0319483. https://doi.org/10.1371/journal.pone.0319483

Jung, S. Y., Hwang, H., Lee, K., Lee, H.-Y., Kim, E., Kim, M., & Cho, I. Y. (2020). Barriers and facilitators to implementation of medication decision support systems in electronic medical records: Mixed methods approach based on structural equation modeling and qualitative analysis. JMIR Medical Informatics, 8(7), e18758. https://doi.org/10.2196/18758

Komal, M., Javed, H. S., & Namra. (2023). Effect of structured training workshop on nurses’ drug dosage calculation competence at tertiary care hospitals of Faisalabad. Pakistan Journal of Medical and Health Sciences, 17(3), 185–188. https://doi.org/10.53350/pjmhs2023173185

McCarthy, S., Motala, A., Lawson, E., & Shekelle, P. G. (2025). Use of structured handoff protocols for within-hospital unit transitions: A systematic review from Making Healthcare Safer IV. BMJ Quality & Safety. https://doi.org/10.1136/bmjqs-2024-018385

NURS FPX 4035 Assignment 4 Improvement Plan Tool Kit

Ravi, P., Pfaff, K., Ralph, J., Cruz, E., Bellaire, M., & Fontanin, G. (2022). Nurse-pharmacist collaborations for promoting medication safety among community-dwelling adults: A scoping review. International Journal of Nursing Studies Advances, 4(4), 100079. https://doi.org/10.1016/j.ijnsa.2022.100079

Weller, J. M., Mahajan, R., Fahey-Williams, K., & Webster, C. S. (2024). Teamwork matters: Team situation awareness to build high-performing healthcare teams, a narrative review. British Journal of Anaesthesia, 132(4), 771–778. https://doi.org/10.1016/j.bja.2023.12.035

Yu, W.-N., Cheng, Y.-D., Hou, Y.-C., & Hsieh, Y.-W. (2024). Implementation of medication-related technology and its impact on pharmacy workflow: A real-world evidence study from 2017 to 2023 (preprint). Journal of Medical Internet Research, 27. https://doi.org/10.2196/59220