Date of Completion

Summer 2026

Document Type

DNP Scholarly Project

Academic Department

School of Nursing

Degree Type

Doctoral

Degree Name

Doctor of Nursing Practice

First Advisor

Dr. Lydia Forsythe

Second Advisor

Dr. Corrine Cochran

Third Advisor

Dr. Jeanine Maine

Abstract

Problem: Delayed medication administration in an adult inpatient mental health facility exceeded organizational benchmarks and posed risks to patient safety, treatment effectiveness, and continuity of care. Baseline electronic health record (EHR) audits showed that about 30% of scheduled medications were administered outside the organization's acceptable timeframe, and inconsistent nurse shift handoffs contributed to the delays.

Aim of the Project: The aim of the quality improvement project was to improve patient outcomes by implementing the I-PASS standardized handoff communication tool to reduce late medication administration from 30% to 15% within 12 weeks.

Review of the Evidence: Evidence supports structured handoff frameworks to improve information transfer, reduce communication-related errors, and strengthen patient safety. Standardized handoff frameworks, such as I-PASS, improve care coordination and medication timeliness, supporting better quality outcomes.

Project Design: The quality improvement project design included the Plan-Do-Study-Act (PDSA) framework and the OhioHealth Change Management Model to guide baseline data collection, stakeholder engagement, staff education, implementation, and iterative evaluation throughout the project.

Intervention: The I-PASS handoff tool was implemented during nurse shift reports and supported by staff education, competency validation, leadership rounding, direct observation, real-time coaching, performance feedback, and workflow modifications to promote adherence and sustainability.

Significant Findings/Outcomes: Weekly EHR audits showed late medication administration decreased from 30% at baseline to 12% after implementation, exceeding the project goal of 15%. I-PASS compliance remained above 90%, and balancing measures showed no significant workflow disruptions or adverse effects. High implementation fidelity and improved medication timeliness suggest that the standardized handoff process supported more reliable communication and enhanced care delivery.

Implications for Nursing: Findings support integrating structured handoff communication as an evidence-based nursing practice to improve medication timeliness, patient safety, accountability, and interdisciplinary collaboration. The project demonstrates the effectiveness of nurse-led quality improvement initiatives in driving system-level change and highlights standardized communication as a sustainable strategy for improving behavioral health outcomes by supporting more timely medication administration.

Rights

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