NURS FPX 4035 Assessment 1 Enhancing Quality and Safety

Enhancing Quality and Safety

Student Name

Capella University

NURS FPX 4035

Professor’s Name

Submission Date

Enhancing Quality and Safety

Patient safety belongs to the basic dimensions of quality healthcare, and it is more interconnected with effective communication between health workers. One of the highest safety risks in healthcare organizations is ineffective handoffs of patients (Howick et al., 2024). Patient handoff is the transfer of responsibility and accountability of patient care among health care providers, and this may be intra- or inter-shift, between units, or departments.

Being the reasons that lead to the omission or misunderstanding of valuable information, poorly planned orrushed handoffs cause the negative patient outcomes, excessive spending on healthcare, and the decline in the quality of care (McCarthy et al., 2025). The given paper is dedicated to the topic of patient handoff as a safety quality issue in an acute care hospital setting, with a real-life scenario of an adverse event of falls. Evidence-based and best-practice resolutions are outlined, and the contribution of nurses and interprofessional stakeholders to improving patient safety and reducing the expenses of organizations is considered.

Scenario

A 62-year-old female patient with CHF and pneumonia presented to the hospital. She was administered her regular sleep and pain medication, and the first consideration was that she was at low risk of falls. One night, when the unit was already operational, and there was extra furniture in her room and long oxygen tubing, she was found lying on the floor, and she had a broken hip. Factors of the same were sedation, environmental risk, lack of fall risk assessment, and complete staff-to-staff communication. The next day, she had surgery in which she experienced intraoperative AMI and passed away. The fall is a reportable incidence of serious injuries, which implies that there is a discontinuity in the system of fall prevention and fall monitoring of the patient.

Factors Leading to Patient Safety Risk in a Healthcare Setting

One of the areas where patient safety risks have been adequately reported in the acute care settings is patient handoffs. Communication failures during handoffs have been estimated to be the cause of a significant percentage of sentinel events in hospitals, and particularly, those events involving falls, medication errors, and delayed treatments.

It is estimated to occur in handoffs, in cases where providers change their responsibilities over the patient, and approximately 67 percent of the communication errors occur. Moreover, it is found that more than 60 percent of sentinel events reported to The Joint Commission were caused by miscommunication, which indicates the relationship between bad handoff communication and extremely serious adverse outcomes, such as falls, medication errors, and delays in treatment (Joint Commission, 2024). Various factors that are interrelated revealed the risk of the patient being harmed in this situation. 

One, there was a lack of standard handoff communication, and hence some essential patient information was not delivered. Despite the fact that the general verbal report was presented, the attention to the required information regarding the recent medication administration, the development of confusion, environmental hazards, and new oxygen equipment was not specific (Ryan and McNamara, 2025). The evidence-based criteria of safe handoffs point to the need to use the structured resources that ensure the regularity and comprehensive nature of the information exchange.

Second, no reassessment of the risk of falls has been done, and this is a nonconformance to the best-practice safety standards. Falls are dynamic, and they depend on medications, time of day, surroundings, as well as acute illness. Sedatives and opioid analgesics are deemed as one of the significant contributors to the risk of falls, particularly among the aged patients. In this case, the patient received a sleeping pill and some pain medication shortly prior to the fall; however, this risk was identified as high, and the patient was not reported to doctors, nor were precautionary steps taken.

Third, other risk factors that contributed to the threat of a safety risk were the environmental factors and the workload. The unit was in a postoperative admission, and the patient had extra furniture in the room that could not be moved or accessed. Other risks included inadequate lighting, an unknotted oxygen hose, and an IV pump (Boyle et al., 2025). These points show that emergency handoff and a workload may lead to the loss of the possibility to identify and eliminate safety risks.

One of the primary causes of adverse outcomes that are severe in healthcare institutions is always the failure in the process of patient handoff. According to the Joint Commission reports, communications failures in approximately 60-70 percent of sentinel events involve a patient-to-patient handoff, and patient-to-patient communication failure is among the primary areas of care transition failure (Nawawi & Ibrahim, 2024). These malfunctions are particularly risky in acute care units where the factors of patients can vary rapidly, and the level of care is high.

Evidence-Based Practice Solutions to Improve Patient Safety and Reduce Costs

The evidence in using standardized handoff protocols to improve patient safety outcomes and reduce healthcare costs is strong. Survivable communication tools are available that are known to minimize communication errors and adverse events, in addition to improving continuity of care. The following tools are going to be used to ensure that the changes in the patient condition, medications, and risks posed by the environment are reported adequately during each handoff (McCarthy et al., 2025).

Periodic and circumstantial re-assessment of the risks of falls is another best-practice intervention. The fall prevention programs are evidence-based and aimed at reassessment after a change in medication, clinical deterioration, and environmental changes. The identification of the risk of falls at an early stage provides a timely response, such as bed alarms, heightened vigilance, clearing up of the rooms occupied by the patient, and scheduled toileting, which is associated with a lower rate of falls and reduced cost of treatment.

The interdisciplinary communication protocols are also very important. To facilitate the recording and communication orally of changes in modes of oxygen delivery or the length of tubing, closed-loop communication between the respiratory therapy, nursing, and medical staff should be applied (Weekley & Bland, 2025). This reduction of the organizational spending can significantly lower the longer hospitalization, surgery, lawsuits, and penalties associated with the low quality indicators and accreditation requirements. SBAR (Situation, Background, Assessment, Recommendation) was identified as an instrument of organised communication with the potential to reduce the number of communication errors, negative events, and continuous care (Kaliraman & Watson, 2025). Such tools will ensure that the change in patient status, drug reactions, and environmental hazards are sufficiently reported during any particular handoff. 

Routine and condition-based fall risk assessment is also another best-practice intervention. The fall prevention programs are evidence-based as they concentrate on reassessment after a change in the drug or deterioration in the clinical process or environmental change (Miura and Kanaya, 2025). Some of the fall-preventive measures, such as bed alarms, closer monitoring, removal of clutter in patient rooms, and timely toileting, have been found to decrease the number of falls experienced by patients and the costs of treatment among patients with high fall risk because the augmentation of fall risks is realized early.

Two-way communication between respiratory care, nursing, and medical staff must be adopted so that any changes, such as oxygen delivery systems or even tube lengths, can be documented in addition to the communication. The prevention of unnecessary falls will significantly lower the organizational costs, as it will help to avoid long-term hospitalization, surgeries, lawsuits, and fines calculated according to the inappropriate quality indicators and accreditation rules. 

Using the standardized tools of handoff is one of the evidence-based practices that can contribute to reducing the number of adverse events connected to communication. The structured handoff interventions can help reduce the adverse events by 30 percent and increase the satisfaction and trust of the staff in the procedure of care transition. The role that nurses could play in improving patient safety and reducing costs (Le et al., 2023).

Nurses are supposed to be essential in the safe handoff of patients and in mitigating falls to improve outcomes. The nurses, as the front-line caregivers, have the responsibility to ensure that they comprehensively examine the patients, detect a change in condition, and communicate the same efficiently during a handoff. In this instance, nurses play a significant role in re-assessing the risk of falls following the administration of the drugs and reporting the assessment of increased risks to subsequent staff.

Role of Nurses in Increasing Patient Safety and Reducing Cost

Nurses are the key to patient safety and reduction of healthcare expenses, as they can be directly related to patients at any moment and eliminate the mistakes and complications at the initial stage before they can become critical. To illustrate the above, the nurse-led interventions, including educational programs, workflow engineering, and electronic medication management, are very effective in minimizing medication errors, thus enhancing safety and lowering treatment costs associated with adverse drug events (Eze et al., 2025). It is also known that the growth of responsibilities of advanced practice nurses (APNs) can help to reduce the overall healthcare spending, the cost of hospitalization, the readmission rates, patient satisfaction, and well-being, which evidences that the enlarged responsibilities of nurses can have a positive influence on the quality and cost outcomes. 

Also, nurses can be considered the facilitators of environmental safety since nurses make sure that the patients do not have to encounter dangers in the rooms, the equipment is not thrown off, and the assistive devices are available to them. In addition to this, the nurses assist in reducing the costs through early intervention and prevention (Ghasemi et al., 2025). Prevention of severe injuries resulting in inpatient falls will save the medical facilities a lot on operations, extended hospitalization, and even lawsuits. Handoff communication should be under the control of nurses in order to enhance patient safety and financial sustainability.

Additionally, sufficient investment in nurse staffing has been observed as a cost-effective patient safety intervention, and statistics indicate that the reduction of readmission and prolonged stay in the hospital saves lives and is a cost-effective intervention. The nurses can also facilitate safety through improvement of communication, risk assessment, and informatics and decision support systems that may contribute to the prevention of adverse events and, in general, enhance quality and efficiency (Lasater, 2025). Nursing can play a part in safer care and unnecessary expenditure across the entire healthcare framework by promoting early interventions, averting errors before they arise, and improving the coordination of care.

Coordination of Nurses with Stakeholders for Safety Enhancement

In order to improve patient handoffs, a number of stakeholders should work closely together. Nurses must collaborate with the physicians to report patient changes, medication response, and mobility limitations. It should also be forced to work with respiratory therapists to ensure that the changes in the oxygen therapy are provided and informed in a safe manner. The additional stakeholders include the hospital leaders and quality improvement teams. 

Frontline intelligence is a great source of information obtained through nurses, and it can be utilized to influence policy making, fall prevention guidelines, and handoff education. The presence of nursing personnel in the RCA and the formulation of the corrective action plans will promote the alteration at the system rather than the individual level (Aiss et al., 2025). The other stakeholders of the safety improvement are the patients and their families. The ability of patients to make a call in the event of an obstacle, comprehending the risk of falls, and the role of a nurse in the safety plan can be significantly improved by the nurses. The success of the sharing among the stakeholders enhances the safety and accountability culture within the organization.

Conclusion

The major safety quality problem in healthcare facilities is poor patient transfer, which can result in significant negative outcomes, as was the case in this fall. The lack of completeness of communication, the inability to examine the danger and hazards in the setting, contribute to causing harm that could have been prevented.

The necessary interventions will be evidence-based interventions, such as the use of standardized handoff paperwork, regular evaluation of the risk of falls, interdisciplinary communication, etc., which will help to enhance patient safety and reduce the expenses. The nurses are central in coordinating care, safety, and collaborating with key stakeholders. The positive outcomes of the enhancement of the practice of handoff are the quality outcomes, patient protection against injuries, and the improvement of the overall effectiveness of the healthcare delivery systems.

For the next assessment of this class visit: Nurs FPX 4035 Assessment 1