Assessment 1: Enhancing Quality and Safety

Unit / Course

NURS4035 / NURS-FPX4035: Improving Quality of Care and Patient Safety (BSN level)

Assessment Overview

This assessment requires you to develop a focused academic paper examining one clearly defined quality and patient safety issue within a healthcare setting. You will analyse the factors that contribute to or exacerbate the safety risk, evaluate evidence-based and best-practice solutions from current literature, and explain how nurses and other stakeholders collaborate to improve patient safety while reducing healthcare costs. The paper should demonstrate a sound understanding of contemporary quality and safety frameworks and the role of the BSN-prepared nurse in system-level improvement.

Assessment Type, Level, Length, and Weighting

• Type: Individual written paper (academic essay or report style)

• Level: RN–BSN core quality and safety subject

• Length: 3–5 pages (approximately 1,000–1,400 words), excluding title and reference pages, double-spaced

• Weighting: Typically 20–25% of the final grade for NURS4035 (confirm in your subject outline)

Assessment Instructions

1. Select a Specific Safety–Quality Issue

Choose one clearly defined patient safety or quality issue that occurs in a real healthcare setting such as acute care, primary care, community health, aged care, or mental health.

Examples include:

• Patient falls

• Medication administration errors

• Delayed response to clinical deterioration

• Failures in handoff communication

• Diagnostic delays

• Hospital-acquired infections

• Inadequate patient education leading to readmissions

The issue should be narrow enough to allow in-depth analysis within the 3–5 page limit. You may draw on practice experience, course case studies, or de-identified published incidents.

2. Explain Factors Leading to the Patient Safety Risk

Provide a clear explanation of the factors that contribute to or sustain the selected safety risk.

• Describe the clinical context and workflow in which the risk commonly occurs

• Analyse contributing factors at multiple levels, including:

  • Individual staff (knowledge, skill mix, fatigue)

  • Team communication and collaboration

  • Processes and protocols

  • Environment and equipment

  • Organisational culture

  • Patient-related factors such as complexity, language, or health literacy

• Support your analysis with current evidence, safety frameworks, or incident data where possible

3. Explain Evidence-Based and Best-Practice Solutions

Identify and explain evidence-based and best-practice interventions that reduce the chosen safety risk and associated costs.

• Discuss at least two to three relevant interventions (for example, SBAR communication, fall prevention bundles, barcode medication administration, early warning scores, checklists, or structured patient education programs)

• Explain how these strategies improve patient safety and reduce costs through fewer adverse events, shorter length of stay, or reduced readmissions

• Support discussion with recent peer-reviewed research or authoritative guidelines (generally within the last five years)

4. Explain the Nurse’s Role in Coordinating Care

Describe how BSN-prepared nurses coordinate care to improve safety and reduce costs related to the selected issue.

• Discuss actions such as leading safety huddles, coordinating interdisciplinary communication, educating patients and families, monitoring protocol compliance, escalating concerns, and participating in quality improvement initiatives

• Explain how nurses act as a central link between patients, families, physicians, allied health professionals, and support services

• Link nursing actions to relevant professional competencies such as leadership, teamwork, safety, informatics, and quality improvement

5. Identify Stakeholders for Safety Enhancements

Identify key stakeholders with whom nurses collaborate to implement and sustain safety improvements.

• Include internal stakeholders such as bedside nurses, nurse managers, physicians, pharmacists, allied health professionals, quality and safety teams, informatics staff, and executives

• Identify patients and family carers as essential stakeholders

• Briefly explain how each group contributes to safety improvement through decision-making, education, data provision, policy support, or resource allocation

6. Structure, Style, and Referencing

• Use clear headings aligned with marking criteria

• Write in a formal, professional academic style with logical structure

• Follow formatting requirements (double spacing, standard font, title page)

• Use current APA style (or institutional equivalent)

• Cite a minimum of four recent scholarly or professional sources

Marking / Grading Criteria (Scoring Guide)

Criterion 1: Factors Leading to a Specific Patient-Safety Risk (20%)

Assesses depth of analysis, systems thinking, and use of evidence.

Criterion 2: Evidence-Based and Best-Practice Solutions (25%)

Evaluates relevance, quality, and application of evidence-based strategies.

Criterion 3: Nurse’s Role in Coordinating Care (25%)

Assesses clarity, specificity, and linkage to safety and cost outcomes.

Criterion 4: Stakeholders for Driving Safety Enhancements (20%)

Evaluates identification of stakeholders and explanation of collaboration.

Criterion 5: Academic Writing and Referencing (10%)

Assesses clarity, organisation, academic tone, and referencing accuracy.

Patient falls in acute care units frequently reflect system-level gaps in risk assessment, targeted interventions, and consistent team communication rather than isolated lapses by individual nurses. Evidence shows that multifactorial fall prevention programs combining validated risk assessment tools, tailored care plans, environmental modifications, and active patient and family engagement significantly reduce fall-related harm. Nurses play a central role by coordinating assessments, leading interdisciplinary discussions, educating patients, and monitoring adherence to prevention strategies across shifts.

Effective quality and safety improvement depends on embedding evidence-based interventions within routine clinical workflows and fostering a culture of shared accountability. Studies demonstrate that when nurses are empowered to lead safety initiatives and collaborate closely with interdisciplinary teams, organisations experience measurable reductions in preventable harm and associated costs. Structured quality improvement frameworks help translate evidence into practice and support sustained safety gains across healthcare settings (Melnyk & Fineout-Overholt, 2019).

References

1. LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalised patients: State of the science. Clinics in Geriatric Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007

2. Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2024). Medical error reduction and prevention. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499956/

3. Mitchell, P. H. (2018). Defining patient safety and quality care. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK2681/

4. Pronovost, P. J., & Freischlag, J. A. (2019). Improving teamwork to reduce surgical mortality. JAMA, 321(7), 603–604. https://doi.org/10.1001/jama.2019.0769

5. Agency for Healthcare Research and Quality. (2020). Patient Safety Network: Patient Safety Primers. https://psnet.ahrq.gov/primers

6. Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer. https://doi.org/10.1097/00006205-201908000-00002