633 Discussion VI

In the Institute for Healthcare Improvement case An Extended Stay (Hilliard, 2013), a patient’s hospitalization was unnecessarily prolonged because of communication failures, missed orders, and delayed follow-up. This situation demonstrates how fragmented care processes can compromise patient safety and increase costs. To reduce the likelihood of similar errors, I would implement a structured quality improvement process that emphasizes standardized communication, proactive clinical decision support, and continuous feedback loops.

The first step would involve developing a standardized handoff protocol using the SBAR (Situation, Background, Assessment, Recommendation) framework. This method ensures that each provider communicates essential information consistently so that important details such as pending orders or abnormal lab results are not overlooked. Integrating electronic health record alerts would further strengthen the process by automatically flagging missing prophylaxis orders, abnormal findings, or care delays (Basso et al., 2023). When an alert occurs, the nurse would follow a defined escalation pathway to notify the responsible provider within a specific timeframe.

Implementation would follow the Plan Do Study Act model to test, refine, and expand the process. Pilot testing the protocol on one hospital unit would allow the team to identify workflow challenges and make improvements. Success would depend on collaboration among nurses, physicians, and pharmacists to promote accountability and ownership of patient outcomes.

Evaluation would include both process and outcome measures such as compliance with handoff documentation, resolution of alerts within time limits, and reductions in extended length of stay or preventable adverse events. Staff surveys could also measure perceptions of communication and safety culture improvements. As Cowdell et al. (2025) note, sustainable quality improvement requires cultivating a learning environment where every error becomes an opportunity for system redesign and professional growth.

References

Basso, I., Mariani, C., & Palese, A. (2023). Quality improvement interventions to reduce errors in clinical practice: A systematic review. International Journal for Quality in Health Care, 35(1), mzad024.

Cowdell, F., Wright, K., & Traynor, V. (2025). Implementing and sustaining quality improvement initiatives in nursing practice. Journal of Nursing Management, 33(2), e30421.

Hilliard, R. (2013). An extended stay. Institute for Healthcare Improvement.