Capella FPX 4035 Assessment 4

Improvement Plan In-Service Presentation

Slide 1: Hi, and welcome to all! I am Nolly. Today, I will discuss an important patient safety issue: diagnostic errors. This in-service session aims to give staff with practical tools and strategies to recognize, prevent, and respond to potential diagnostic delays or mistakes. The objective is to enhance interdisciplinary communication, promote timely and accurate diagnoses, and ensure safer patient outcomes through improved nursing vigilance and collaboration.

Part 1: Agenda and Outcomes

Agenda

Slide 2: This in-service training session aims to enhance nurses’ understanding of diagnostic errors, with a particular focus on delayed cancer diagnosis resulting from communication breakdowns and system inefficiencies. Throughout the session, participants will be introduced to real-world examples of missed or delayed cancer diagnosis. They will examine how poor communication during patient handoffs, inadequate use of electronic health records (EHR), and lack of escalation protocols contribute to these failures. Nurses will explore the use of structured communication tools, such as SBAR (Situation, Background, Assessment, and Recommendation), and handoff checklists to mitigate these risks.

Interactive components, including a short role-play and simulation, will provide staff with an opportunity to practice new strategies in a safe and nonjudgmental environment. Staff will also be introduced to the revised communication protocols outlined in the safety improvement plan and will discuss their role in implementing and sustaining these changes. Time will be allocated for Q&A and feedback. By the end, participants should feel empowered to advocate for patient safety through effective communication and collaboration.

Goals

Slide 3: Three specific goals are established to address the diagnostic delayed errors. 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 critical role of effective patient handoffs in preventing diagnostic delays, particularly in the context of cancer care. Communication breakdowns during transitions of care can result in missed or delayed test results, failure to escalate concerns, and overlooked follow-ups—contributing significantly to diagnostic errors (Baurasien et al., 2023). Nurses will explore real-world scenarios where inadequate handoffs led to delayed cancer diagnoses. The session will introduce structured tools such as SBAR and handoff checklists to promote consistency and clarity in communication. Attendees will develop practical competencies and strategies to minimize handoff-related risks and ensure continuity of care. 

Goal 2: Identify system-based and human factors contributing to diagnostic delays and explore interventions to mitigate them

This segment will guide participants in recognizing both organizational and individual-level contributors to diagnostic errors, including EHR mismanagement, unclear responsibilities, cognitive biases, and inadequate escalation protocols. Nurses will examine how these factors affect the timeliness and accuracy of cancer diagnoses. Evidence-based interventions such as escalation pathways for abnormal results, improved documentation workflows, and enhanced interdisciplinary communication will be discussed (Jawad et al., 2024). Participants will learn how to proactively identify vulnerabilities within their practice environment and contribute to system-level solutions. 

Goal 3: Demonstrate the application of structured communication tools to improve patient outcomes and reduce diagnostic errors

Participants will engage in interactive role-play and simulation exercises to practice using tools such as SBAR, the I-PASS handoff tool, and communication checklists. These structured frameworks improve clarity, reduce emissions, and ensure critical information is effectively communicated during transitions and interdisciplinary discussions. Nurses will be coached on how to tailor communication strategies to different clinical settings, advocate for escalation when diagnostic delays are suspected, and apply these tools confidently in real-world situations. These hands-on activities will reinforce learning and support skill retention.

Outcomes 

Slide 4: By the end of this session, participants will be able to:

• Recognize how diagnostic errors negatively impact patient safety and outcomes.
• Understand the system-based and communication-related causes of delayed diagnoses.
• Accurately apply SBAR in simulated patient handoff scenarios.
• Utilize a standardized checklist to improve clinical handoffs.
• Commit to using new communication protocols in daily practice.
• Collaborate more effectively with interdisciplinary teams to ensure timely diagnosis and follow-up care.

Part 2: Safety Improvement Plan

Slide 5: Diagnostic mistakes are still a major patient safety concern in contemporary healthcare, with cancer diagnoses delayed to the detriment of patient outcomes. Auerbach et al. (2024) reports that diagnostic mistakes are responsible for approximately 23% of patient fatalities and 6–17% of hospital adverse events annually. Cancer diagnostic delays can lead to loss of treatment opportunities, more advanced disease, and lower survival. The most frequently reported causes include poor handoff communication, loss of follow-up for abnormal test results, and breakdowns in coordination. In most healthcare systems, these delays are then exacerbated by system-level issues, such as fragmented electronic health records and unclear responsibility for diagnostic follow-up.

Proposed Plan Overview

Slide 6: The proposed safety improvement strategy will help decrease diagnostic delays in cancer cases through improved communication handovers, standardization of communication tools such as SBAR and I-PASS, and the development of proper follow-up procedures for abnormal results. The strategy also involves training nurses to identify early manifestations of diagnostic delays, escalate issues through designated pathways, and promptly document and communicate with multidisciplinary teams (Stenquist et al., 2022). By delivering these interventions through in-service training targeted to specific areas and simulation-based learning, the intention is to engender a culture of vigilance and accountability in which every team member actively participates in the timely and accurate diagnosis.

Why This Matters to the Organization

Slide 7: Diagnostic delays must be addressed not only to enhance patient safety and outcomes but also to fulfill the healthcare organization’s legal and ethical obligations. Misdiagnosis or delayed diagnoses are the most frequent and expensive root causes of malpractice claims, representing about 35% of all claims in the United States (Toker et al., 2024). Additionally, healthcare organizations that fail to address these issues risk reputational harm, patient mortality, and patient dissatisfaction. This safety improvement plan goes with The Joint Commission’s National Patient Care Goals, which prioritize effective communication and clinical decision support as top priorities (Toker et al., 2024). Addressing diagnostic errors directly demonstrates the organization’s promise to the quality, equitable care and helps construct a safer, more responsive healthcare system. 

Part 3: Audience’s Role and Importance

 Slide 8: As frontline providers, nurses have a critical role in the implementation of the safety improvement plan to mitigate diagnostic delays. Nurses will be required to utilize improved communication tools, such as SBAR and I-PASS, during shift-to-shift reports, patient handoffs, and interdisciplinary updates. This entails proper documentation of abnormal results, timely follow-up, and reporting concerns when diagnostic actions are dubious or delayed. Nurses can also take charge by monitoring lab and imaging tests, facilitating communication between primary care and specialty groups, and ensuring patients are aware of their next steps (Stenquist et al., 2022). Nurse’s attention and timely actions can act as a safety net that catches any oversights before they cause harm. 

Why Nurse’s Role Is Critical to the Plan’s Success

Slide 9: Nurses’ engagement is essential, as they are both the initial point of contact and the constant presence throughout a patient’s care journey. While physicians may rotate, nurses often provide continuity across shifts and are uniquely positioned to observe subtle changes, identify early warning signs, and question delayed or missing diagnostic actions. Evidence has shown that when nurses are empowered to raise concerns and escalate care, diagnostic safety improves significantly (Jawad et al., 2024). Without their involvement, even the most well-designed plans can fail since successful implementation relies heavily on real-time awareness, clinical judgment, and team collaboration—strengths in which nurses consistently excel.

How Nurses Will Benefit by Embracing This Role

Slide 10: By actively implementing the safety improvement plan, nurses not only help protect patients but also promote their own professional growth and job satisfaction. They will gain increased confidence in recognizing clinical red flags, improve interdisciplinary communication, and support a culture rooted in accountability and patient advocacy. This initiative also reinforces evidence-based nursing practice, which can reduce the emotional burden and professional liability associated with diagnostic errors (Aljabari & Kadhim, 2021). Ultimately, by embracing this role, nurses are empowered to make meaningful impacts on patient outcomes, affirm their vital role as patient advocates, and contribute to the overall improvement of care quality within the organization.

Part 4: New Process and Skills Practice

 Slide 11: To address diagnostic errors effectively, a structured escalation and communication process will be introduced, focusing on three core improvements: (1) standardized handoff tools such as SBAR, (2) use of diagnostic timeouts during patient assessments, and (3) implementation of a “red flag” checklist that helps nurses identify signs of diagnostic delay or mismatch. Nurses will be trained to flag unusual symptoms, unconfirmed diagnoses, or delays in testing or results and communicate these to providers using assertive and clear language. Additionally, the plan encourages the use of an internal escalation chain, allowing nurses to bypass traditional hierarchies if serious concerns are not addressed promptly.

Practical Activity 

Slide 12: In this session, staff will participate in a case-based simulation centered on the patient discussed in Assessment 2—an elderly male patient presenting with generalized fatigue, shortness of breath, and intermittent chest discomfort. Despite these red flag symptoms, he experienced a delayed diagnosis of myocardial infarction due to fragmented communication and an initial focus on non-cardiac causes. This real-world-inspired case will serve as the basis for a role-play exercise. Participants will be divided into small teams, each acting as the primary nurse during the patient’s early assessment.

They will use the “Red Flag Symptom Checklist” to identify diagnostic concerns and will complete an SBAR communication role-play with a provider. The goal is to practice assertive and structured communication when raising diagnostic concerns and to identify when to escalate concerns using the newly introduced diagnostic escalation algorithm (Stenquist et al., 2022). After the role-play, each group will reflect on their approach and receive constructive feedback. The exercise is designed to foster clinical reasoning, clarity of communication, and team collaboration in real-time diagnostic decision-making.

Collaborative Q/A Activity

To help nurses engage critically with the new diagnostic safety protocols, we have included a brief Q&A segment that addresses likely concerns and provides practical clarifications. A common question might be, “What if the provider dismisses our concern during handoff or escalation?” In such cases, nurses need to remain firm yet respectful, utilizing the structured escalation pathway. Nurses are not challenging authority—they are advocating for patient safety, and the plan supports them with a non-punitive process to elevate concerns when needed. Another typical question may be, “How do we differentiate between a diagnostic red flag and normal patient variation?” Nurses are not expected to diagnose but to observe patterns.

The red flag checklist is based on evidence-based indicators, such as unexplained chest pain or incongruent test results, making it easier to identify when further evaluation is necessary. Some may also ask, “Will this new process add to our workload?” While it might feel like an extra step at first, these tools are streamlined and will ultimately reduce workload by catching issues earlier and avoiding emergencies or readmissions. Lastly, a crucial question could be, “Will we get further training after today?” Absolutely. This in-service is part of a larger quality initiative, which includes ongoing support, follow-up training, and opportunities to provide feedback, allowing the process to become second nature over time.

Part 5: Soliciting Feedback

Slide 13: To ensure the efficacy and relevance of the enhancement plan and the in-service session, feedback will be sought from all participants actively through both anonymous written assessments and a brief open discussion at the end of the session. The written feedback will comprise questions regarding the clarity of the material, the usefulness of the skills practice, and suggestions for improvement. Nurses will be asked in the open discussion to express their first impressions, thoughts, and suggestions on how to improve the process.

The use of a dual strategy helps provide candid input while fostering a sense of being part of a team effort (Aljabari & Kadhim, 2021). The gathered feedback will then be analyzed systematically and sorted by themes. Substantial recommendations, such as increasing the usability of red flag checklists or refining training schedules, will be incorporated into subsequent sessions or used to revise implementation tools. Ongoing refinement, informed by frontline staff feedback, ensures that the plan remains realistic, accepted, and effective in preventing diagnostic errors. 

Conclusion

Slide 14: Diagnostic errors, especially in cancer care, pose serious risks to patient safety. This in-service session empowers nurses to use structured communication tools and escalation protocols to prevent delays. By enhancing real-time collaboration and situational awareness, nurses can play a pivotal role in improving outcomes. Ongoing training and feedback ensure the plan remains effective and sustainable.

References

Aljabari, S., & Kadhim, Z. (2021). Common barriers to reporting medical errors. The Scientific World Journal, 21(1), 1–8. https://doi.org/10.1155/2021/6494889 

Auerbach, A. D., Lee, T. M., Hubbard, C. C., Ranji, S. R., Raffel, K., Valdes, G., Boscardin, J., Dalal, A. K., Harris, A., Flynn, E., Schnipper, J. L., UPSIDE Research Group, Feinbloom, D., Roy, B. N., Herzig, S. J., Wazir, M., Gershanik, E. F., Goyal, A., Chitneni, P. R., & Burney, S. (2024). Diagnostic errors in hospitalized adults who died or were transferred to intensive care. Journal of American Medical Association Internal Medicine, 184(2). https://doi.org/10.1001/jamainternmed.2023.7347 

Capella FPX 4035 Assessment 4

Baurasien, B. K., Alareefi, H. S., Almutairi, D. B., Alanazi, M. M., Alhasson, A. H., & Alshahrani, A. D. (2023). Medical errors and patient safety: Strategies for reducing errors using artificial intelligence. International Journal of Health Sciences, 7(S1), 3471–3487. https://doi.org/10.53730/ijhs.v7ns1.15143 

Cummings, C. O., Krucik, D. D. R., Carroll, J. P., & Eisenbarth, J. M. (2022a). Improving within-team communication to reduce the risk of medical errors. Journal of the American Veterinary Medical Association, 22, 1–3. https://doi.org/10.2460/javma.21.09.0407 

Cummings, C. O., Krucik, D. D. R., Carroll, J. P., & Eisenbarth, J. M. (2022b). Improving within-team communication to reduce the risk of medical errors. Journal of the American Veterinary Medical Association, 22, 1–3. https://doi.org/10.2460/javma.21.09.0407 

Jawad, B., Pedersen, K. Z., Andersen, O., & Meier, N. (2024). Minimizing the risk of diagnostic errors in acute care for older adults: An interdisciplinary patient safety challenge. Healthcare, 12(18). https://doi.org/10.3390/healthcare12181842 

Stenquist, D. S., Yeung, C. M., Szapary, H. J., Rossi, L., Chen, A. F., & Harris, M. B. (2022). Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. Global Research and Reviews, 6(9). https://doi.org/10.5435/jaaosglobal-d-22-00079 

Capella FPX 4035 Assessment 4

Toker, D. E., Nassery, N., Schaffer, A. C., Yu-Moe, C. W., Clemens, G. D., Wang, Z., Zhu, Y., Tehrani, A. S. S., Fanai, M., Hassoon, A., & Siegal, D. (2024). Burden of serious harms from diagnostic error in the USA. British Medical Journal Quality & Safety, 33(2). https://doi.org/10.1136/bmjqs-2021-014130