NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan In-Service Presentation

Hi, and welcome to all! I am _______. Today, I will be discussing a serious patient safety concern: medication errors during the discharge process. This in-service session focuses on a recent sentinel event involving a 70-year-old patient who was discharged with the wrong dosage of a high-risk anticoagulant, warfarin. Our goal today is to equip nursing staff with actionable strategies to enhance discharge education, improve medication reconciliation accuracy, and promote patient understanding through evidence-based practices, such as the TBM. By addressing communication gaps, time pressures, and cultural barriers, we aim to enhance discharge safety, minimize preventable harm, and promote improved patient outcomes through collaborative teamwork and accountability.

Part 1: Agenda and Outcomes

Agenda

The in-service program will aim to inform nursing personnel about how they can improve patient safety upon discharge, especially those on high-risk medications such as warfarin. We will investigate the underlying causes, including communication breakdowns, documentation lapses, employee burnout, cultural obstacles, and non-adherence to policies.

Nurses will participate in a simulation process in an interactive form, revisit the teach-back approaches, and examine the handoff between the nursing and pharmacy teams. The session will present a uniform discharge checklist, EHR documentation prompts, and guidelines for engaging the pharmacy in discharge education. The attendees will leave with the skills and information needed to deliver safer, clearer discharge instructions and improved patient comprehension. The future patient education processes will be improved based on staff feedback.

Goals

To strengthen discharge safety by improving communication, enhancing medication education, and promoting patient-centered care strategies.

• Goal 1: Participants will learn how system-level issues—such as rushed discharges, poor interdisciplinary collaboration, inadequate patient education, and unclear policies—can lead to dangerous medication errors. Through root cause analysis, nurses will gain insight into how these vulnerabilities contribute to increased patient harm and reduced trust in care (Hawkins & Morse, 2022).
• Goal 2: Nurses will practice applying the TBM through role-playing exercises and scenarios involving high-risk medications like warfarin. This will help them confirm patient understanding and adapt instructions based on health literacy and cultural needs, reducing the likelihood of post-discharge errors (Eloi, 2021).
• Goal 3: Participants will review new protocols requiring pharmacy involvement in counseling for high-risk medications and learn to use EHR prompts to verify that education steps are completed. The goal is to support interdisciplinary teamwork and prevent omission of critical safety checks during patient transitions (O’Mahony et al., 2023).

Outcomes

•  Staff will consistently use the Teach-Back Method (TBM) to confirm patient understanding during discharge education.
  • Discharge instructions for high-risk medications will be complete, accurate, and documented in the EHR using standardized checklists.
  • The pharmacy will be actively involved in reviewing and counseling patients on anticoagulant therapy before discharge.
  • Patients will demonstrate improved understanding of their medication regimen, reducing post-discharge adverse events.
  • Staff will report increased confidence in delivering culturally sensitive, patient-centered education.
  • Incidents of warfarin-related medication errors and readmissions will be significantly reduced through structured follow-up and surveillance.

Part 2: Safety Improvement Plan

The sentinel event that took place in a busy medical-surgical unit involved a 70-year-old postoperative patient being discharged with a wrong dose of a high-alert anticoagulant warfarin. The mistake was a transcription error between the Electronic Health Record (EHR) and the discharge summary, which was exacerbated by the failure to include a pharmacy verification process and the lack of implementation of a TBM. The nurse conducting the discharge was under time constraints and short-staffed, and did not provide proper education to ensure the patient understood.

The patient, a solo living patient with low health literacy, overdosed twice, causing internal bleeding and readmission to the ICU. Several factors were identified during the root-cause analysis, including staff fatigue, communication failure, lack of interdisciplinary coordination, unclear protocols, and the inability to individualize patient education according to literacy and cultural needs (Hawkins & Morse, 2022; Keller & Carrascoza-Bolanos, 2022). Such lapses not only put the patient at risk but also expose failures within the system regarding the discharge process and team responsibility.

Proposed Plan Overview

This safety improvement plan focuses on the process of discharging patients who are prescribed high-risk medications. It focuses on standardized communication with organized education with the TBM, enhanced pharmacy-nurse collaboration, and EHR improvements. The most important interventions are the compulsory TBM training of nursing employees, the introduction of a medication education checklist into the EHR, and the appointment of pharmacists to perform the final medication reconciliation and counseling before discharge. Discharge teaching will be conducted in quiet, private settings to minimize distractions and ensure a calm environment.

The staff schedules will be reviewed to ensure sufficient time is provided for discharge education, and a 48-hour post-discharge follow-up call system will be introduced to identify early complications. Patient education materials will be disseminated that are culturally sensitive, multilingual, and written at a low literacy level to increase understanding. Such measures align with evidence-based practices suggested by the Agency for Healthcare Research and Quality (2024), which promote health literacy-based interventions, multidisciplinary teamwork, and the application of technology to minimize medication errors and enhance patient safety.

Importance of Addressing the Issue

The failures in the communication of discharge are a critical issue that needs to be addressed since medication-related errors are one of the main causes of preventable harm among hospitalized patients (particularly those receiving anticoagulants). The Joint Commission regularly establishes the lack of proper discharge activities and patient education as one of the key sources of adverse events (Ibrahim et al., 2022). In the given case, the absence of verification of dosage, participation of the pharmacy, and evaluation of the patient’s knowledge undermined the safety and resulted in a life-threatening outcome.

In addition to the patient volume, these incidents create an emotional burden for staff, lower patient trust, and overburden healthcare assets. Through the adoption of this safety improvement plan, the organization will facilitate safer care transitions and enhance interprofessional accountability and patient-centered education. Moreover, enhanced discharge procedures and documentation will minimize readmission rates, increase compliance with regulatory standards, and foster a culture of transparency and continuous learning. As mentioned by Eloi (2021), the regular application of TBM to the process of patient education provides a high level of understanding among patients, particularly when used in combination with interdisciplinary support and health literacy awareness. 

Part 3: Audience’s Role and Importance

Nurses are the key frontline caregivers to the success of this safety improvement plan that focuses on discharge. One of the tasks nurses will be assigned is to consistently utilize the TBM during patient education on high-risk medications such as warfarin. They will ensure that patients are aware of important information, such as dosage, timing, potential dietary interactions, and signs of complications. During discharge, nurses will also work closely with pharmacy personnel to ensure that the medication reconciliation process is accurate and complete.

To develop communication skills and cultural competence, participation in TBM simulation exercises and health literacy workshops is expected. During discharges, nurses will assist in a calm and confidential environment to facilitate focused teaching and learning. Those are not mere compliance, but rather direct harm reduction and better patient outcomes (Hawkins & Morse, 2022).

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

This safety plan is also fully dependent on the active participation and responsibility of the nursing personnel. The last barrier between hospital care and home self-management is nurses, who can make or break a patient by what they say (or do not say) at discharge. The protocols, education checklists, and EHR updates are useless without implementation by the nurses who should use them regularly, individualize the teaching, and record patient comprehension. No one can replace their capacity to identify a confused patient, a culturally reluctant patient, or a patient who is at risk because of his or her low health literacy.

Moreover, nurses’ ideas about actual discharge interactions will influence the improvement of EHR prompts, TBM processes, and subsequent training materials. Through their adoption of this role, nurses drive change towards safer and more equitable patient transitions, contributing to the creation of a culture of precision and compassion in discharge practices (Subih et al., 2025).

How Nurses Will Benefit by Embracing This Role

Adopting this improvement plan will result in improved, structured, and gratifying patient discharges. Nurses will have access to fewer medication-related errors, better communication with the pharmacy, and fewer last-minute complications or readmissions. Having quiet teaching areas and standardized equipment, such as TBM and discharge checklists, allows nurses to concentrate on the patient without being distracted.

This helps to enhance a safer working process, reduce stress, and increase confidence in providing culturally appropriate care. Acquiring the skill of health literacy communication, medication safety, and interdisciplinary collaboration also qualifies nurses to take leadership positions in patient education and quality improvement (Stucky et al., 2022). Above all, in claiming this role, nurses will also reinforce the most important value of nursing: patients leave the hospital enlightened, safe, and empowered.

Part 4: New Process and Skills Practice

New processes included in this safety improvement plan aim to enhance consistency, clarity, and safety in the discharge of patients, particularly those prescribed high-risk medications such as warfarin. All instructions given to patients upon discharge will require nurses to apply the TBM to ensure patients comprehend. The checklist on the TBM will be standardized and added to the EHR, ensuring that core issues such as medication dose, timing, diet, and side effects are discussed and documented. The other necessary change would be to have quiet and secluded areas where patients can be educated without distractions, facilitating one-on-one conversations.

The nurses will be trained on health literacy communication, cultural sensitivity, and collaboration with the pharmacists in a structured manner. The staff in the pharmacy will now be required to conduct a final medication reconciliation and provide patient counseling on high-alert drugs (O’Mahony et al., 2023). The rationales behind these evidence-based processes are to minimize the medication errors that occur due to hasty discharges, poor communication, and poor health literacy. 

Practical Activity 

The in-service session will also include a simulation-based practice of discharge education to help nurses implement these new practices. Nurses will work in pairs and take turns being the nurse and the patient to practice providing medication instructions through the TBM. In both situations, issues of poor health literacy, language barriers, and time constraints are likely to arise. The communicators will be observed and given feedback on communication clarity, completeness, and use of the TBM checklist by the facilitators.

A second station will feature an interdisciplinary discharge coordination simulator, where nurses will role-play discharge coordination with pharmacists to clarify warfarin protocols (Smith et al., 2024). Nurses will be asked to discuss how to adjust their teaching to meet the various needs of patients. The session encourages practical learning and problem-solving, and staff will be equipped with skills they can apply immediately in clinical practice.

Question/Answer Session

During the in-service, nurses will be encouraged to ask questions and express concerns regarding the implementation of the new discharge protocols. The typical fear can be as follows: What will happen if I cannot find time to follow all the TBM steps? The answer is that, in fact, with TBM, confusion and callbacks are avoided, which saves time and eliminates readmissions. The second issue may be, what should be done if the patient fails to understand the instructions despite being repeated? In this situation, nurses will learn to adjust their language, apply visual aids, and seek assistance from the pharmacist or an interpreter.

A question that some staff members may ask is, what happens in a case where the EHR checklist is not easy to use or consumes too much time? This will be handled through an EHR walkthrough and continued IT assistance. Employees can also ask whether such changes are optional or temporary. The solution: These alterations are long-term, endorsed by national safety recommendations, and required to avoid severe medication mistakes. Nevertheless, the hospital is committed to providing continuous feedback and modifying workflows as necessary. Such discussions will help clarify expectations, boost nurses’ confidence, and ensure that new practices are adopted.

Part 5: Soliciting Feedback

A story-sharing wall will be incorporated in the in-service session to record the experience of frontline nurses. Nurses will be prompted to write and post brief reflections on their experiences with the problem of discharging patients, including instances of confusion, missed instructions, or ineffective communication strategies. The purpose of this interactive activity is to encourage a discussion, empathetic understanding, and the human aspect of discharge planning. Additionally, a digital suggestion box will remain open for 48 hours after the session, allowing participants time to reflect and provide thoughtful feedback at their convenience.

The quality improvement team will review all submissions, and themes will be noted. In cases where multiple stories arise regarding confusion over EHR documentation or opportunities missed due to a lack of pharmacy involvement, the group will address these issues through the creation of specific skill-building sessions or by streamlining system prompts to enhance clarity and efficiency. This participatory approach not only facilitates ongoing learning but also highlights the crucial role of nurses in the development of safer and more effective discharge practices.

Conclusion

In conclusion, improving discharge safety for high-risk medications, such as warfarin, requires consistent communication, interdisciplinary collaboration, and patient-centered education. By embracing tools like the TBM and supporting workflow improvements, nurses can significantly reduce preventable harm. This initiative empowers both patients and providers through clarity, compassion, and accountability. Together, we can ensure safer transitions from hospital to home.

References

Agency for Healthcare Research and Quality. (2024). Medication errors and adverse drug events. PSNet. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events

Eloi, H. (2021). Implementing teach‐back during patient discharge education. Nursing Forum, 56(3). https://doi.org/10.1111/nuf.12585

Hawkins, S. F., & Morse, J. M. (2022). Unattainable expectations: Nurses’ work in the context of medication administration, error, and the organization. Global Qualitative Nursing Research, 9(2). https://doi.org/10.1177/23333936221131779

Ibrahim, S. A., Reynolds, K. A., Poon, E., & Alam, M. (2022). The evidence base for US Joint Commission hospital accreditation standards: A cross-sectional study. BMJ, 377, 1–11. https://doi.org/10.1136/bmj-2020-063064 

NURS FPX 4035 Assessment 3 Improvement Plan In-Service Presentation

Keller, M. S., & Carrascoza-Bolanos, J. (2022). Pharmacists’, nurses’, and physicians’ perspectives on and use of formal and informal interpreters during medication management in the inpatient setting. Patient Education and Counseling, 105(4), 107607. https://doi.org/10.1016/j.pec.2022.107607

O’Mahony, E., Kenny, J., Hayde, J., & Dalton, K. (2023). Development and evaluation of pharmacist-provided teach-back medication counselling at hospital discharge. International Journal of Clinical Pharmacy, 45(3), 698–711. https://doi.org/10.1007/s11096-023-01558-0

Smith, L. M., Jacob, J., Prush, N., Groden, S., Yost, E., Gilkey, S., Turkelson, C., & Keiser, M. (2024). Virtual interprofessional education. Professional Case Management. https://doi.org/10.1097/ncm.0000000000000717 

Subih, M., Rababa, M., Aryan, F. S., Alnaeem, M., AlRahahleh, M. H., Niarat, A., Saleh, Z. T., Alsulami, G. S., Almagharbeh, W. T., & Elshatarat, R. A. (2025). Factors influencing nurses’ knowledge and competence in warfarin–drug and nutrient interactions and patient counseling practices. BioMed Central Medical Education, 25(1), Article 70. https://doi.org/10.1186/s12909-025-07074-1