NURS FPX 4035 Assessment 1

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Enhancing Quality and Safety

Effective communication during patient handoffs in emergency departments (EDs) is vital for maintaining healthcare quality and patient safety. The dynamic and fast-paced nature of emergency care intensifies the potential for miscommunication, making transitions particularly vulnerable. When vital clinical details are omitted or misunderstood, it often results in treatment delays, patient harm, or unnecessary costs. This discussion explores common handoff communication issues, evaluates structured, evidence-based practices for improvement, and highlights the crucial role nurses and stakeholders play in optimizing handoff quality to ensure cost-effective care.

The high-pressure environment of EDs, combined with time-sensitive cases and often nonstandardized procedures, magnifies the potential for error. This creates significant safety gaps that hinder quality care delivery. The challenge is not just about speed but also accuracy and consistency in information transfer. This paper underscores how implementing structured communication tools and engaging interdisciplinary teams can significantly improve both safety outcomes and cost-efficiency in emergency healthcare settings.

Through analysis of current research and best practices, it becomes clear that standardizing patient handoffs is no longer optional but necessary. Effective handoff strategies have proven benefits, including enhanced workflow, reduced legal risks, and improved patient satisfaction. Nurses are not only facilitators but leaders in this transition, coordinating closely with physicians, pharmacists, and administrators to support seamless continuity of care.

Contributing Factors to Patient Safety Risks

Poor communication practices combined with limited response time pose critical risks during ED patient transfers. Studies report that nearly 80% of serious medical errors during ED handoffs stem from miscommunications or failure to follow standardized protocols (Kinney-Sandefur, 2024). These issues are compounded when handoffs are rushed, incomplete, or lack essential documentation, causing misinterpretation of clinical status and jeopardizing patient safety.

Time-sensitive decisions and complex treatments require rapid yet precise communication, something that can falter under ED stress. Literature also attributes 24% of medical malpractice cases in emergency care settings to inefficient handover methods (Kinney-Sandefur, 2024). When verbal briefings are disorganized or inadequately supported by documentation, providers may miss key updates that affect diagnosis or treatment planning.

Compounding the situation, the absence of standardized handoff practices leads to fragmented care, particularly in patients requiring multidisciplinary interventions. Without a reliable system to ensure comprehensive updates, the potential for medical errors, extended stays, and redundant tests escalates—factors that drive up healthcare costs and compromise patient outcomes (Atinga et al., 2024).

Strategies for Improving Safety and Reducing Costs

Structured communication methods such as SBAR (Situation, Background, Assessment, Recommendation) have demonstrated success in strengthening patient safety during handoffs. SBAR promotes a clear and concise exchange of information, ensuring no vital details are overlooked. Research has shown that SBAR not only improves satisfaction and communication among providers but also streamlines billing and reduces documentation errors, thus lowering institutional costs (Ghosh et al., 2021).

Technology integration further supports safe and cost-efficient transitions. For example, electronic health record (EHR) handoff templates provide real-time updates that reduce reliance on memory and verbal cues. Tools like bedside shift reports also promote patient and family engagement, leading to improved understanding and fewer readmission cases. These methods mitigate costly errors and unnecessary treatments that often result from communication breakdowns (Tataei et al., 2023).

Involving nurses in multidisciplinary communication, reinforcing closed-loop handoff strategies, and utilizing digital tools are critical in ensuring accurate transitions. Nurses are instrumental in confirming that recipients fully understand patient status, medication needs, and required interventions. These efforts prevent care delays and reduce adverse events that often inflate operational and legal costs (Shirley et al., 2024).

NURS FPX 4035 Assessment 1 Enhancing Quality and Safety

Enhancing Quality and Safety	Contributing Factors to Patient Safety Risks	Strategies for Improving Safety and Reducing Costs
Emergency department handoffs are pivotal to patient safety and cost management. Breakdown in communication can lead to preventable errors and complications during transitions.	Poor communication, lack of standardized procedures, and time constraints contribute to 80% of serious handoff errors. Malpractice claims often involve poor transitions, particularly in emergency settings.	SBAR is a validated tool that standardizes handoff communication. EHR systems with real-time updates and bedside reporting foster accuracy, reduce redundancy, and lower costs.
High-pressure settings in EDs challenge effective information exchange. Misunderstandings and incomplete reports raise risks to quality care.	Incomplete verbal handoffs and poor documentation hinder accurate diagnosis and treatment. Up to 50% of poor outcomes stem from faulty handoffs.	Nurses reinforce closed-loop communication, ensuring understanding and accountability. This reduces test repetition, improves response times, and enhances patient outcomes.
The role of nurses in care coordination and collaboration with other professionals is essential to enhancing transitions and ensuring safety.	Fragmented coordination among teams without defined handoff policies leads to care delays, longer hospital stays, and increased patient risk.	Bedside involvement of patients and families during handoffs reduces readmissions and improves satisfaction. Consistent training and administrative support ensure long-term improvements.

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

Tataei, A., Rahimi, B., Afshar, H. L., Alinejad, V., Jafarizadeh, H., & Parizad, N. (2023). The effects of electronic nursing handover on patient safety in general (non-COVID-19) and COVID-19 intensive care units: A quasi-experimental study. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09502-8