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NGM2 — NGM2 TASK 1: Practice Improvement Plan Proposal
Mandeep Kaur
Western Governors University
D221
Molly Hall
06/7/2025
, 2
Organizational Systems and Healthcare Transformation
A1: Safety Concern
In a busy urban hospital, a systems-level patient safety concern has been identified
involving medication errors during patient handoffs between nursing shifts. These errors occur
when essential drug information isn't accurately communicated or is left out when shifts change,
resulting in incorrect dosing, missed medications, or administration of contraindicated drugs.
This issue has the potential to impact multiple patients, as handoffs occur multiple times daily
across various units, increasing the risk of adverse drug events (ADEs) that can lead to prolonged
hospital stays, severe patient harm, or even mortality (Rodziewicz et al., 2024).
A2A: Data
Medication errors are a major concern issue in healthcare and are estimated to result in
around 250,000 deaths in the United States each year, consequently becoming a leading cause of
preventable harm (Tariq et al., 2024). At the selected hospital, over the last year, there were 47
internal incident report records of a medication error that was attributable to poor handoff
communication, resulting in a treatment-related ADE for 15 of these incidents (Vega et al.,
2023). These errors were common in high-acuity areas such as intensive care units (ICUs) and
medical-surgical units where complex prescription schedules are the norm. The findings describe
a pattern of inadequate or ambiguous verbal and written reports in the form of handoffs, usually
compounded by time constraints and high nurse-to-patient ratios.
A2B: National Safety Standards
The Joint Commission’s National Patient Safety Goals (NPSG) focus on communication
to prevent errors. Specifically, NPSG. 02. 03. 01, requires healthcare institutions to strive
NGM2 — NGM2 TASK 1: Practice Improvement Plan Proposal
Mandeep Kaur
Western Governors University
D221
Molly Hall
06/7/2025
, 2
Organizational Systems and Healthcare Transformation
A1: Safety Concern
In a busy urban hospital, a systems-level patient safety concern has been identified
involving medication errors during patient handoffs between nursing shifts. These errors occur
when essential drug information isn't accurately communicated or is left out when shifts change,
resulting in incorrect dosing, missed medications, or administration of contraindicated drugs.
This issue has the potential to impact multiple patients, as handoffs occur multiple times daily
across various units, increasing the risk of adverse drug events (ADEs) that can lead to prolonged
hospital stays, severe patient harm, or even mortality (Rodziewicz et al., 2024).
A2A: Data
Medication errors are a major concern issue in healthcare and are estimated to result in
around 250,000 deaths in the United States each year, consequently becoming a leading cause of
preventable harm (Tariq et al., 2024). At the selected hospital, over the last year, there were 47
internal incident report records of a medication error that was attributable to poor handoff
communication, resulting in a treatment-related ADE for 15 of these incidents (Vega et al.,
2023). These errors were common in high-acuity areas such as intensive care units (ICUs) and
medical-surgical units where complex prescription schedules are the norm. The findings describe
a pattern of inadequate or ambiguous verbal and written reports in the form of handoffs, usually
compounded by time constraints and high nurse-to-patient ratios.
A2B: National Safety Standards
The Joint Commission’s National Patient Safety Goals (NPSG) focus on communication
to prevent errors. Specifically, NPSG. 02. 03. 01, requires healthcare institutions to strive
