Improvement Plan Tool Kit
Capella University
NURS-FPX4020: Improving Quality Care and Patient Safety
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Dr. Tom Dalesandro
January 2024
Improvement Plan Tool Kit
This improvement plan toolkit is designed to help nurses and other healthcare practitioners in
organizations implement and maintain safety enhancement measures in the healthcare
environment in the clinical department. The presented tool kit has been structured into four
categories each with three annotated sources. The categories include best practices for
patient safety in healthcare organizations, technological solutions and patient identity,
regulatory compliance and standards, and lastly interdisciplinary collaboration as a solution
to patient identity errors.
Best Practices for Patient Safety in Healthcare Organizations
Chellam Singh, B., & Arulappan, J. (2023). Operating Room Nurses’ Understanding of
Their Roles and Responsibilities for Patient Care and Safety Measures in Intraoperative
Practice. SAGE Open Nursing, 9, 23779608231186247. Retrieved from
https://journals.sagepub.com/doi/full/10.1177/23779608231186247
This resource offers an outline of the roles and responsibilities of nurses in the operating room in
patient care and safety following a qualitative study. The research pointed out seven factors that
facilitate a conducive operating room. They include the safety of the patient, physician readiness
during operation, practice standardization, proper staffing, management of time, patient support,
effective communication, and education to staff. The source can enable nurses to understand the
issues and possibilities about patient safety in the operating room environment. It gives
information about certain things such as proper identification of patients that operating room
nurses can adopt to enhance patient safety. This resource can help nurses have an increased grasp
of their responsibilities concerning patient safety. It can be relevant when nurses engage in
quality enhancement processes aimed at resolving problems of patient safety.
Farmanova, E., Bonneville, L., & Bouchard, L. (2018). Organizational health literacy: review of
theories, frameworks, guides, and implementation issues. INQUIRY: The Journal of
Health Care Organization, Provision, and Financing, 55, 0046958018757848.
Retrieved from https://journals.sagepub.com/doi/full/10.1177/0046958018757848
This journal explores organizational health literacy including its significance to medical practitioners
such as nurses. The article tries to help readers understand how they can comprehend, use, and
control health information for the improvement of patient welfare. The authors examined different
theories, principles, guidelines, and challenges concerning organizational health literacy, features,
and their combination with cultural understanding and
patient participation. The journal can help nurses gain an understanding of the organizational
dimensions of health literacy and establish proper ways to practice recommendations that can
improve patient identification. Nurses can use this resource for quality improvement. The source
identifies 9 quality improvement features for health literary direction. This information can be
used to determine effective communication and quality delivery of care services that enhance
patient identity safety and general safety.
Gandhi, T. K., Kaplan, G. S., Leape, L., Berwick, D. M., Edgman-Levitan, S., Edmondson, A.,
... & Wachter, R. (2018). Transforming concepts in patient safety: a progress report. BMJ
Quality & Safety. Retrieved from
https://qualitysafety.bmj.com/content/qhc/early/2018/07/17/bmjqs-2017-007756.full.pdf
This resource offers an extensive explanation of the achievements in the implementation of
principles to boost the safety of patients. It focuses on the huge accomplishments in the
utilization of technology and procedures in healthcare settings. It also identifies different
technological developments that have been used like patient monitoring and staff systems and,
the use of artificial intelligence to improve disease diagnosis and treatment among other
technologies that lead to effective collaboration and communication. Using this resource, nurses
can have a better understanding of how patient identity strategies can be implemented using the
ideas availed in the article concerning the importance of technology in improving patient safety.
It will also help them know the various technologies that can be used to facilitate patient safety
and identification. Moreover, nurses can utilize this source to get ideas about the dynamics of
patient safety technology within the organization. Nurses who want to know and use innovative
strategies to enhance patient safety, in technological intervention during diagnosis, medication,
and communication can benefit.
Technological Solutions and Patient Identity
Houtan, B., Hafid, A. S., & Makrakis, D. (2020). A survey on blockchain-based self-sovereign
patient identity in healthcare. IEEE Access, 8, 90478-90494. Retrieved from
https://ieeexplore.ieee.org/abstract/document/9091543
Houtan et al. (2020) is a survey about the possible utilization of blockchain technology to
manage the data of patients and their identity in the healthcare setting. The article talks about the
opportunities and challenges of blockchain technology, specifically in Electronic Health Records
(EHR) as well as Patient Health Records (PHR) including the obstacles and the possible tradeoffs involved in creating the given technological systems. Moreover, the survey provides
different examples and designs like hybrid and decentralized architectures for patient identity
management and interactivity in the healthcare setting.
Nurses can achieve a lot from the use of this source. They can acquire increased comprehension
of the way blockchain technology can lead to patient safety enhancement programs. By
understanding the possible utilization of this technology in the management of data, nurses can
identify strategies to improve the safety, privacy, and interactivity of patient information. The
understanding will possibly help them recognize chances to apply blockchain technology to
enhance patient treatment, care, and general healthcare services.
To improve patient safety through proper identity, nurses can often apply proper data
management using blockchain by referring to this resource. This resource can be useful during
projects targeted at improving patient identity and management of data.
Memon, Z., Noran, O., & Bernus, P. (2019). A Framework to Evaluate Architectural Solutions
for Ubiquitous Patient Identification in Health Information Systems. In ICEIS (2) (pp.
580-587). Retrieved from
https://www.scitepress.org/PublishedPapers/2019/76963/76963.pdf
The source by Memon et al. (2019) provides important ideas and an organized evaluation
framework for resolving patient safety problems in healthcare settings, specifically concerning
patient identification and avoidance of errors. By discussing the best approaches for patient
identification, this resource can ensure that nurses are informed about safety enhancement
strategies and how they can be properly implemented to achieve effective patient identification.
Through this resource, nurses can carry out rigorous evaluation of the problems and specific
causes of patient identification errors in healthcare facilities. Additionally, they can utilize the
suggested health information system (HIS) architectures to know the technical as well as
structural factors that influence patient identification. The resource is suitable for nurses
engaging in healthcare data management, coordination of patient care, and quality improvement.
It can boost better decision-making on the use of technologies for patient identification.
Piera-Jiménez, J., Dooling, J., Ranade-Kharkar, P., Pollock, S., Mann, D., Thornton, S., ... &
Rai, A. (2020). Patient identification techniques–approaches, implications, and
findings. Yearbook of medical informatics, 29(01), 081-086.Retrieved from
https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1701984
This resource provides modern patient identification methods and strategies commonly applied
across the world including a study of different identification techniques, problems, suggestions,
and their effects on patient safety, financial losses, and sharing of data in healthcare settings.
Nurses can use this source to improve their understanding of patient identification techniques
and problems associated with wrong patient identification. Through a better understanding of
patient identification strategies and the impact of patient identification errors, nurses can gain
valuable knowledge of how they can prevent patient identification errors. It can also help them
recognize possible opportunities for improvement and create ways to reduce patient
identification errors in the facility.
This resource can be used by nurses to determine patient identification approaches that are used
today in the healthcare sector and determine their relevance and ways that can facilitate
improvement. It can also be appropriate for resolving patient identification errors when nurses
are involved in interdisciplinary collaborations like using new technologies for identification,
improvement of patient matching, and associated algorithms.
Regulatory Compliance and Standards
Haddara, M., & Staaby, A. (2018). RFID applications and adoptions in healthcare: a review on
patient safety. Procedia computer science, 138, 80-88. Retrieved from
https://www.sciencedirect.com/science/article/pii/S1877050918316430
Haddara & Staaby (2018) gives extensive details about radio frequency identification (RFID) in
healthcare organizations. It discusses issues about patient safety, obstacles to RFID
implementation, modern changes in RFID, the 6-layer model, and solutions for electronic health.
The varied assortment of data can highly help nurses comprehend and exercise safety
enhancement strategies concerning patient identification errors.
This source can help them follow regulations and standards founded on the RFID technology for
patient safety, monitoring, and management of treatment through proper identification.
Moreover, it can offer information about the problems and issues about new technology
implementation, modern developments in security, and privacy enhancement issues as outlined
in the organizational rules and regulations as well as guidelines. Nurses can use this resource
whenever they are engaging in patient identification procedures and implementation of patient
safety to help them comply with healthcare safety regulations and standards. The use of
technology in patient identification reduces errors. This source can prove invaluable to nurses
looking for reliable technology-based solutions that improve patient identification and
compliance with regulations and high standards of patient safety.
Lawati, M. H. A., Dennis, S., Short, S. D., & Abdulhadi, N. N. (2018). Patient safety and safety
culture in primary health care: a systematic review. BMC family practice, 19(1), 1-12.
Retrieved from https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-018-
0793-7
The resource gives critical information about the culture of patient safety in healthcare settings,
including safety evaluation tools, incident reporting, the effect of risk control measures, and
research questions. This source can be used by nurses to improve an understanding of the
healthcare culture on patient safety and the certain programs applied across the world to
determine the relevance of safety regulatory compliance and standards. Moreover, it explains the
relevance of patient safety including communication problems, safety of medication, and
interdisciplinary collaboration standards in the healthcare setting. The resource evaluates the
impact of incident reporting standards and regulations.
Nurses can get useful information about the systems relevant to safety culture adherence in
healthcare. They can learn from the common ideas used globally to determine a better safety
culture and its relevance in the healthcare setting for proper patient identification. The resource
can be appropriate during the evaluation of safety regulations and standards, their
implementation, and application in patient identification processes. It is also appropriate when
nurses are looking for evidence-based practices to improve a culture of patient safety including
regulations and standards to be met.
Oikonomou, E., Carthey, J., Macrae, C., & Vincent, C. (2019). Patient safety regulation in the
NHS: mapping the regulatory landscape of healthcare. BMJ Open, 9(7). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615819/
Oikonomou et al. (2019) offer insights into the regulatory environment of the National Health
Service (NHS). The authors study organizations that have regulatory control over healthcare
organizations that provide NHS-based services. It identifies the coinciding activities and roles
within the regulatory environment.
Nurses can utilize this source to achieve a meaningful understanding of the regulatory
frameworks and organizations that shape patient safety and the quality of healthcare services.
Through a keen study of this article, nurses stand a chance to understand different regulatory
systems, responsibilities, and the management of patient safety programs and patient
identification standards and regulations.
It can be appropriate for enabling nurses to understand the different organizations such as NHS
that regulate healthcare services and practitioners including patient identification and safety. It
can also prove relevant to nurses engaging in patient safety enhancement programs because it
facilitates appreciation of the general regulatory frameworks and standards.
Interdisciplinary Collaboration as a Solution to Patient Identity Errors.
Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an
integrative review. Expert Opinion on Drug Safety, 17(3), 259-275. Retrieved from
https://www.tandfonline.com/doi/abs/10.1080/14740338.2018.1424830
Manias (2018) gives a detailed analysis of the impact of interdisciplinary collaboration on errors
experienced during medication processes, stressing the need to deal with communication issues
in the healthcare setting. The article recognizes five major categories of interdisciplinary
collaboration relating to medication errors. It discusses patient identification errors and identifies
possibilities for improved collaboration that can lead to medication safety through a high
collaboration between various healthcare teams.
This resource is a useful tool for nurses in various ways. It can help them appreciate and understand
the importance of interdisciplinary collaboration in the reduction or outright avoidance of medication
errors. Moreover, they can learn from this resource about how effective
communication and cooperation among various healthcare workers help in enhancing patient
identification safety and general medication errors.
Nurses can also use this source to sensitize others within the healthcare system about the
influence of interdisciplinary collaboration on accurate patient identification which will
culminate in reduced medication errors. It has been found that most medication errors are caused
by patient identification errors, usually by nurses. This resource is appropriate for training
programs in healthcare because it can help the practitioners understand how patient
identification errors can be avoided and lead to overall patient safety.
Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls.
Treasure Island (FL): StatPearls Publishing. Retrieved from
http://www.saludinfantil.org/Postgrado_Pediatria/Pediatria_Integral/papers/Medical%20
Error%20Prevention%20-%20StatPearls%20-%20NCBI%20Bookshelf.pdf
Through detailed discussion of medical errors and their prevention in healthcare settings, this
resource offers various suggestions including interdisciplinary collaboration among different
teams to prevent medical errors and specifically stop patient identity errors. The article talks
about the goals of patient safety and the explanation of specific medical errors such as patient
identity errors that cause other related errors like surgical and diagnostic errors including
accountability of medical practitioners during patient interaction. By studying this resource,
nurses can get a valuable understanding of medical errors and the way they affect the safety of
patients, especially when collaboration is ineffective. It highlights the essence of collaboration
for effective patient safety and recommends the importance of engaging various healthcare
workers in patient care.
The source can offer better ways of exercising effective communication among teams and
collaborating to reduce patient identification errors. It can be important during meetings
involving different healthcare teams and a review of patient identification protocols. It can also
be appropriate and relevant during the training of staff to understand proper patient
identification.
Taylor, A., Lee, H. R., Kubota, A., & Riek, L. D. (2019). Coordinating clinical teams: Using
robots to empower nurses to stop the line. Proceedings of the ACM on Human-Computer
Interaction, 3(CSCW), 1-30. Retrieved from https://dl.acm.org/doi/abs/10.1145/3359323
Taylor et al. (2019) is an article that evaluates problems and issues concerning participatory
systems in Computer Supported Cooperative Work (CSCW). It discusses interdisciplinary
collaboration and the use of computing approaches to improve medical service provision in
healthcare. It gives insights on effective ways that various healthcare personnel can
collaboratively implement including technologies like computer-supported cooperative work to
reduce patient identification errors.
With this resource, nurses can comprehend and use safety enhancement strategies, mainly those
focused on reducing patient identification errors. It can enable them to understand the relevance
of collaboration with IT specialists, physicians, and pharmacists in the creation and
implementation of strategies and architectures that can enhance patient identification procedures.
The nurses can utilize this resource by integrating interdisciplinary collaboration aspects into
their work when dealing with patient identification errors in the organization. Nurses can use the
information from this source to engage appropriate personnel from different departments and
achieve proper patient identification and error reduction.
References
Chellam Singh, B., & Arulappan, J. (2023). Operating Room Nurses’ Understanding of
Their Roles and Responsibilities for Patient Care and Safety Measures in Intraoperative
Practice. SAGE Open Nursing, 9, 23779608231186247. Retrieved
from https://journals.sagepub.com/doi/full/10.1177/23779608231186247
Farmanova, E., Bonneville, L., & Bouchard, L. (2018). Organizational health literacy: review of
theories, frameworks, guides, and implementation issues. INQUIRY: The Journal of
Health Care Organization, Provision, and Financing, 55, 0046958018757848. Retrieved
from https://journals.sagepub.com/doi/full/10.1177/0046958018757848
Gandhi, T. K., Kaplan, G. S., Leape, L., Berwick, D. M., Edgman-Levitan, S., Edmondson, A.,
... & Wachter, R. (2018). Transforming concepts in patient safety: a progress report. BMJ
Quality & Safety. Retrieved
from https://qualitysafety.bmj.com/content/qhc/early/2018/07/17/bmjqs2017-007756.full.pdf
Haddara, M., & Staaby, A. (2018). RFID applications and adoptions in healthcare: a review on
patient safety. Procedia computer science, 138, 80-88. Retrieved from
https://www.sciencedirect.com/science/article/pii/S1877050918316430
Houtan, B., Hafid, A. S., & Makrakis, D. (2020). A survey on blockchain-based selfsovereign patient identity in healthcare. IEEE Access, 8, 90478-90494. Retrieved from
https://ieeexplore.ieee.org/abstract/document/9091543
Lawati, M. H. A., Dennis, S., Short, S. D., & Abdulhadi, N. N. (2018). Patient safety and safety
culture in primary health care: a systematic review. BMC family practice, 19(1), 1-12.
Retrieved from https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-0180793-7
Manias, E. (2018). Effects of interdisciplinary collaboration in hospitals on medication errors: an
integrative review. Expert Opinion on Drug Safety, 17(3), 259-275. Retrieved
from https://www.tandfonline.com/doi/abs/10.1080/14740338.2018.1424830
Memon, Z., Noran, O., & Bernus, P. (2019). A Framework to Evaluate Architectural Solutions
for Ubiquitous Patient Identification in Health Information Systems. In ICEIS (2) (pp.
580-587). Retrieved from
https://www.scitepress.org/PublishedPapers/2019/76963/76963.pdf
Oikonomou, E., Carthey, J., Macrae, C., & Vincent, C. (2019). Patient safety regulation in the
NHS: mapping the regulatory landscape of healthcare. BMJ Open, 9(7). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615819/
Piera-Jiménez, J., Dooling, J., Ranade-Kharkar, P., Pollock, S., Mann, D., Thornton, S., ... & Rai,
A. (2020). Patient identification techniques–approaches, implications, and findings. Yearbook of
medical informatics, 29(01), 081-086. Retrieved from https://www.thiemeconnect.com/products/ejournals/html/10.1055/s-0040-1701984
Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls. Treasure
Island (FL): StatPearls Publishing. Retrieved
from http://www.saludinfantil.org/Postgrado_Pediatria/Pediatria_Integral/papers/Medical
%20Error%20Prevention%20-%20StatPearls%20-%20NCBI%20Bookshelf.pdf
Taylor, A., Lee, H. R., Kubota, A., & Riek, L. D. (2019). Coordinating clinical teams: Using
robots to empower nurses to stop the line. Proceedings of the ACM on Human-Computer
Interaction, 3(CSCW), 1-30. Retrieved from https://dl.acm.org/doi/abs/10.1145/3359323