Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Professor Name

Submission Date

Enhancing Quality and Safety

Improving the quality and safety is a key goal of healthcare, with a particular focus on patient safety & quality in nursing. One such effort to accomplish this goal – and promote the health and safety of military veteran – is the prevention of suicide. Military veterans with post-traumatic stress disorder (PTSD), depression, substance abuse, and social isolation are at higher risk of suicidal behavior and require rapid, comprehensive coordinated care due to evidence of their significant impact on suicide risk among military veterans (Hoffmire et al., 2024). In this paper, this paper will examine the role nurses can play in assisting patients in identifying their risks and then implementing effective intervention strategies and coordinating multidisciplinary care will be examined with the case study of Mr. James Carter, who is a patient at an outpatient mental health clinic for Veterans Affairs (VA).

• Scenario

Mr. James Carter is a 42-year-old veteran who is being treated at a VA outpatient mental health clinic. Mr. Carter has had several deployments overseas and was medically discharged due to physical injuries, as well as developing signs of PTSD. Mr. Carter indicates he’s struggling with insomnia, withdrawal from friends and family, hopelessness, and an increasing consumption of alcohol at a follow-up visit. Mr. Carter has seen some counseling previously, but has had a lack of regular follow-up visits and appointments. At the time of the nursing assessment, other factors suggest that Mr. Carter has a greater risk of self-harm, such as his recently losing his job, distancing himself from family members, and uncertainty about his future.

Factors Leading to the Patient Safety Risk in Healthcare Setting

Numerous factors related to veteran suicidal risk could be potentially hazardous if the patient’s time is not spent in prevention and treatment. In this case, multiple and easily identifiable risk factors are evident within the client, Mr. James Carter, that put him at greater risk of suicidal ideation and behavior. These risk factors encompass his PTSD, depression symptoms, alcohol use, unemployment, and disconnection from his civilian community in his post-service life. The stress of this interconnection is compounded and places a greater strain on his resources to cope, with the potential for suicide. Study evidence suggests that veterans with comorbid mental illness, co-occurring mental illness, and adverse life events are at higher risk for suicide compared to veterans with only a single or none of these factors (Hoffmire et al., 2024). Mr. Carter’s sporadic and brief visits make it more likely that his psychological condition will deteriorate without his parents even noticing. It can be impossible to overemphasize the significance of routine monitoring of suicide risk in all veterans, continuity of comprehensive and consistent treatment, and regular follow-up of veterans (Saulnier et al., 2025); these should be the pillars of treatment for veterans. If one of these comprehensive and complex evaluations is not conducted, there is a risk of missing suicide warning signs.

Evidence-Based Practice Solutions to Improve Patient Safety and Reduce Costs

The most effective way to reduce veteran suicide is to implement evidence-based interventions that facilitate better identification, engagement and maintenance of veterans in care within health care settings. One of the first interventions is to implement universal suicide risk screening to identify at-risk veterans before they engage in suicidal behaviours, and allow the health care team to be notified of mental status changes before self-harm occurs (Powsner et al., 2023). For Mr. James Carter, the same nurses who conducted suicide risk assessments at each outpatient encounter would be used to detect early signs of distress and make mental health referrals to specialists before the crisis, avoiding the event. It will also save costs linked to suicidal activities, which include crisis avoidance, an absence of visits to the emergency department, and hospitalization. Intervention two was personalized safety planning (PSI), in which a veteran discussed with them practical strategies, emergency contacts, and resources to help them manage and mitigate acute suicidal ideation.

Regarding Mr. James Carter, if he is experiencing symptoms of depression, he can use his personal safety plan, list the people available to him and/or his health care team, and call on one of those people to avoid a situation leading to crisis. This will lessen the need for costly emergency services and treatment associated with an acute psychiatric emergency. The third intervention is the use of cognitive behavioural therapy (CBT). Besides bolstering coping behaviors, CBT addresses patients’ thinking patterns and the connection between the thinking patterns and maintenance and development of negative behaviors (Nakao et al., 2021). CBT will help Mr. James Carter to replace thoughts of hopelessness due to unemployment and his experience of trauma during his time of service. Avoidable hospitalization and costs of treatment will be reduced by effective treatment, which will prevent future recurrences. Fourth is the prompt follow-up of any missed appointments or after patient discharge from the hospital, where veterans face a greater risk of suicide (Ee et al., 2023).

A quick follow-up with Mr James Carter will provide good information about why he is not in the appointment and will thereby help to maintain continuity of his treatment, thus minimizing unnecessary emergency care and hospitalizations. Fifth is the collaboration of multidisciplinary healthcare where nurses would be part of a collaborative care team consisting of a psychologist, primary care provider, addiction counselor, social worker, and a psychiatrist (Isaacs & Mitchell, 2024). The nurse will collaborate with the multidisciplinary health team that cares for Mr. James Carter to help him with his PTSD, alcohol abuse, lack of employment, and family problems. Better coordination will help with treatment outcomes and lower the costs of duplication of services, prevent complications, reduce unnecessary emergency department visits, psychiatric hospitalization, and suicidal behavior.

Role of Nurses in Improving Patient Safety

The combined efforts of a nurse at different levels of the health system can have a significant impact on Mr. James Carter’s mental health. Nurses help with ongoing assessments for suicidal risk, monitor and track his emotional status, remind Mr. James Carter of his individual safety plan, and arrange for prompt transfer to an urgent care clinic to psychiatrist and psychologist. Research has shown that sustained monitoring and engagement by a multi-disciplinary care team support in reducing the risk of suicide among our veterans (Edwards et al, 2025). The nurse also educates the veteran’s family about warning signs of suicide and what to do if he’s thinking about suicide. The nurse supports and is in regular communication with Mr. James Carter and his family, as he implements his individualized treatment plan.

He makes an effort to ask for follow-up visits in case patients miss their appointments, thus lowering his disengagement with the care team. With effective nursing care, there will be improved adherence to treatment, reduced psychiatric hospitalization, better outcomes, enhanced long-term wellness and safety, and reduction in expenses. However, poor nursing coordination could result in more severe episodes of depression or despair, increasing risk of medication and appointment compliance failures, and delayed mental health interventions, which would lead to a rise in suicidal ideation, suicide risk, and subsequent medical costs of emergency psychiatric evaluations and hospital admissions.

• Stakeholders with Whom Nurses Coordinate to Drive Safety Enhancements

Veterans’ suicide prevention is complex and requires a multi-disciplinary approach, where a team of professionals is comprised of individuals with different skill sets, who work together toward the patient’s safety and continuity of care. Within the context of Mr. James Carter’s treatment, the registered nurse acts as the healthcare team’s lead and acts as a liaison between psychiatrists, psychologists, primary care, social workers, and the veteran’s family members to tackle all the veteran’s mental health concerns. Psychiatrists are the ones that would be responsible for giving a mental health disorder diagnosis and for developing and delivering a medication treatment plan, and a psychologist would be responsible for providing services that would decrease the frequency of suicidal ideation, monitor existing chronic health conditions, and social workers would help with successful re-entry into the community and stable housing. Social workers would help with unemployment.

Successful suicide prevention is built on collaborative and interdependent practices across professional disciplines, where healthcare professionals work as a team and jointly communicate and make clinical decisions to deliver optimal patient care (Edward et al., 2025). This team’s leader, the registered nurse, shares current assessment data with team members, initiates referrals as needed, monitors how the veteran is following treatment plans, and implements the safety plan for Mr. James Carter. One key factor in a veteran’s prevention of suicide is their family – they know how to identify signs and symptoms, encourage treatment, and offer emotional support beyond the scope of formal treatment. Family support has been proven to enhance patient engagement, provide continuity in mental health services, and minimize the risk of a crisis occurring involving veterans and suicide (Levine & Sher, 2025). Without a constant coordination of the above-mentioned disciplines, valuable clinical data is often omitted, due to which the care is poorly coordinated and the risk to patient safety is increased.

Conclusion

Early suicide risk screening, evidence-based care, and collaborative, interdisciplinary team care will be key in preventing suicide for this veteran population. Mr. James Carter’s case is a reminder of the way PTSD, depression, loss of work, and a lack of social support can lead to an increase in suicidal risk, and why continuous suicide risk monitoring and continuous collaborative care by the interdisciplinary team are so important. The main responsibilities for nurses are conducting suicide assessment, developing an individualized safety plan, educating the patient and/or families about safety, and follow-up and monitoring throughout the treatment process.

References

Edwards, E. R., Anderson, G. N., Fonseca, E. M., Reed, A. L., Chan, C., Hazlett, E. A., Geraci, J. C., & Goodman, M. (2025). Suicide risk assessment and management protocol for research within the Department of Veterans Affairs. Journal of Psychopathology and Clinical Science, 134(4). https://doi.org/10.1037/abn0000968

Ee, S., Gwon, Y. G., & Kim, K.-H. (2023). Follow-Up timing after discharge and suicide risk among patients hospitalized with psychiatric illness. JAMA Network Open, 6(10), https://doi.org/10.1001/jamanetworkopen.2023.36767

Hoffmire, C. A., Barnes, S. M., Holliday, R., Kittel, J. A., Schneider, A. L., Brenner, L. A., Tock, J. L., & Monteith, L. L. (2024). The assessing social and community environments with national data (ascend) for veteran suicide prevention study. American Journal of Epidemiology. https://doi.org/10.1093/aje/kwae461

Isaacs, A. N., & Mitchell, E. (2024). Mental health integrated care models in primary care and factors that contribute to their effective implementation: A scoping review. International Journal of Mental Health Systems, 18(1). https://doi.org/10.1186/s13033-024-00625-x

Levine, J., & Sher, L. (2025). The prevention of suicide in older military veterans. Behavioral Sciences, 15(3), 379. https://doi.org/10.3390/bs15030379

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial medicine, 15(1), 16. https://doi.org/10.1186/s13030-021-00219-w

Powsner, S., Goebert, D., Richmond, J. S., & Takeshita, J. (2023). Suicide risk assessment, management, and mitigation in the emergency setting. FOCUS, 21(1), 8–17. https://doi.org/10.1176/appi.focus.20220072

Saulnier, K. G., Bagge, C. L., Ganoczy, D., Bahraini, N. H., Jagusch, J., Hosanagar, A., Ilgen, M. A., & Pfeiffer, P. N. (2025). Suicide risk evaluations and suicide in the veterans health administration. JAMA Network Open, 8(2), e2461559. https://doi.org/10.1001/jamanetworkopen.2024.61559

Wen, J., Li, M.-Y., Song, P.-P., & Teng, F. (2025). Effectiveness of evidence-based nursing interventions in the management of patients with schizophrenia. Frontiers in Psychiatry, 16. https://doi.org/10.3389/fpsyt.2025.1610260