WGU D221 NGM2
TASK 1 LATEST
UPDATE WITH
COMPLETE
SOLUTIONS
Haylie Stwalley
NGM2 Task 1
1. Describe a healthcare-related situation (S) prompting a systems-level patient safety
concern that has the potential to impact multiple patients.
A recurring issue in labor and delivery, with the potential to affect multiple patients, is
inconsistent handoff communication during shift change. L&D units often use mixes of
verbal reports and handwritten notes instead of SBAR. By doing so, we are missing
critical information during shift change on busy shifts, such as GBS status, induction
indications, or fetal concerns. Sometimes these are inaccurately communicated when the
floors are busy. Incoming nurses have noticed discrepancies in medications,
documentation of high-risk events, or unclear provider plans. These gaps create delays in
treatment, medications, and missed fetal or maternal deterioration. Shift changes occur
multiple times a day and affect the care every patient receives; the lack of standardized
SBAR-style reports creates a system-wide patient safety concern.
2. Analyze background (B) information about the concern by doing the following:
A. Several sources of data support the need to improve shift change reports for L&D
units. Internal incident reports over the last 12 months show multiple near-miss
events related to incomplete handoffs. Some of these, to name a few, are delayed
ABX treatment for GBS-positive patients and missed magnesium rate changes.
Another source of data is chart audits conducted by clinical management teams,
which identify discrepancies in the documentation of these high-risk conditions
and the provider's plan of care.
B. Inconsistent handoff communication aligns with The Joint Commission’s patient
safety goal to improve the effectiveness of communication among caregivers. The
Joint Commission says that communication failures are a leading contributor to
sentinel events and that standardized approaches to shift handoffs are required.
The lack of a structured shift change report fails to meet this expectation because
reports are inconsistent and incomplete, increasing the risk that nurses will miss
important information.
3. Assess (A) the impact of the safety concern on the patient(s), staff, and the organization
as situated in the identified healthcare setting.
A. For patients, inconsistent shift change reports increase the risk of delayed
interventions, medication errors, and missed deterioration or status changes. In
labor and delivery specifically, this could result in maternal or fetal
complications, prolonged labor, or unnecessary interventions that all could have
been avoided. This also creates a lack of trust among patients due to poor
communication and staff repeatedly asking the same questions. This, in turn,
TASK 1 LATEST
UPDATE WITH
COMPLETE
SOLUTIONS
Haylie Stwalley
NGM2 Task 1
1. Describe a healthcare-related situation (S) prompting a systems-level patient safety
concern that has the potential to impact multiple patients.
A recurring issue in labor and delivery, with the potential to affect multiple patients, is
inconsistent handoff communication during shift change. L&D units often use mixes of
verbal reports and handwritten notes instead of SBAR. By doing so, we are missing
critical information during shift change on busy shifts, such as GBS status, induction
indications, or fetal concerns. Sometimes these are inaccurately communicated when the
floors are busy. Incoming nurses have noticed discrepancies in medications,
documentation of high-risk events, or unclear provider plans. These gaps create delays in
treatment, medications, and missed fetal or maternal deterioration. Shift changes occur
multiple times a day and affect the care every patient receives; the lack of standardized
SBAR-style reports creates a system-wide patient safety concern.
2. Analyze background (B) information about the concern by doing the following:
A. Several sources of data support the need to improve shift change reports for L&D
units. Internal incident reports over the last 12 months show multiple near-miss
events related to incomplete handoffs. Some of these, to name a few, are delayed
ABX treatment for GBS-positive patients and missed magnesium rate changes.
Another source of data is chart audits conducted by clinical management teams,
which identify discrepancies in the documentation of these high-risk conditions
and the provider's plan of care.
B. Inconsistent handoff communication aligns with The Joint Commission’s patient
safety goal to improve the effectiveness of communication among caregivers. The
Joint Commission says that communication failures are a leading contributor to
sentinel events and that standardized approaches to shift handoffs are required.
The lack of a structured shift change report fails to meet this expectation because
reports are inconsistent and incomplete, increasing the risk that nurses will miss
important information.
3. Assess (A) the impact of the safety concern on the patient(s), staff, and the organization
as situated in the identified healthcare setting.
A. For patients, inconsistent shift change reports increase the risk of delayed
interventions, medication errors, and missed deterioration or status changes. In
labor and delivery specifically, this could result in maternal or fetal
complications, prolonged labor, or unnecessary interventions that all could have
been avoided. This also creates a lack of trust among patients due to poor
communication and staff repeatedly asking the same questions. This, in turn,
