Enhancing Quality and Safety
FPX4020: Improving Quality of Care and Patient Safety
Proper identification of patients is a very crucial aspect of safe healthcare delivery. Misidentification of patients is one of the major risks to patient safety and may lead to such terrible consequences as medication errors, wrong-site surgery, or other inappropriate treatments which result in serious complications, extended recovery time, or even death. Apart from the direct consequence of patient health, identification errors have a lot of trust loss from the healthcare system, professional reputation damage of healthcare providers, and huge legal, financial, and operational implications. This paper discusses a critical challenge in healthcare settings regarding patient identification errors, followed by an analysis of the consequences and some potential evidence-based and best-practice solutions. It also highlights the integral role of nurses and stakeholders in addressing and mitigating these errors to ensure a safer healthcare environment.
Factors Leading to a Specific Patient Safety Risk
Various factors contribute to the risk of misidentification in a patient’s identity. One major factor is the reliance on manual processes and human intervention in identifying patients. This could result in misidentification in cases whereby healthcare professionals might accidentally misidentify patients because of similar names, miscommunication, or high-pressure environments. For instance, during multitasking or change-of-shift, the nurse can possibly misapply an identification band or fail to appropriately compare the identity of a patient. In addition, handwritten records and labels mostly bring about errors from hard-to-read handwriting and transcription errors. Manual processes like these can lead to errors that may turn out to be fatal (Higgins & Herpy, 2021).
Other key factors contributing to this error include the lack of standardized protocols for patient identification and a lack of training in patient identification procedures. Various practices
in different departments or healthcare institutions could encourage different standards of checking and recording patient information. In addition, lack of training on the purpose of accurate patient identification and on the proper application of identification technologies may inadequately prepare members of the healthcare team to prevent errors. Technology-related issues, such as malfunctioning barcode scanners or EHR systems that are poorly integrated, also result in identification errors. In case such systems are unable to work, that would disrupt the workflow and result in mistakes in patient identification (Dorothy et al., 2021). All these factors should be measured in the light of proper training, standardization of protocols, and strong technology solutions that will help reduce the risk associated with patient identification errors.
Literature provides evidence from studies regarding critical impact of patient identification errors on patient safety. According to a research article Journal of Patient Safety, misidentification of patients accounts for about 13% of all medical errors (Ensaldo-Carrasco et al., 2021). Another study reported in Yearbook of Medical Informatics found nearly 18% of all the adverse events that occur in a healthcare set-up resulting in severe harm or delays in care relate to patient misidentification (Riplinger et al., 2020). The statistics indicate the need for rapid embracing of advanced technologies and standardized protocols with a view to ensuring the safety of patients and minimizing errors related to identification.
Best Practice Solutions to Improve Patient Safety and Reduce Costs
Healthcare providers must utilize best practice strategies in order to improve patient safety and reduce costs. One of the best practice strategies in enhancing patient safety is through identity protocols, like barcoded wristbands and biological identifiers. Identification errors can be significantly reduced by barcoded wristbands, which are scanned when a patient enters and before and after any procedure. Also, fingerprints and facial identification methods bring the result to
almost 100% as they are unique for each person and difficult to be copied or forged (Hutton et al., 2021).
Another important approach is the implementation of patients’ safety by means of health information technology, particularly integrated electronic health records. Advanced EHRs can match the information of the patient with other records, list the discrepancies, and prompt a healthcare professional to verify the critical details before commencing treatment or surgical procedure (Zayas-Cabán et al., 2021). Furthermore, encouraging a safety culture by implementing and following up on staff education and training may help enhance the understanding of the significance of the accurate patient identification and the compliance with existing guidelines among the healthcare. For example, according to a Pennsylvania Patient Safety Authority study, In United States healthcare BCMA technology cut medication errors by 54% and prevented some 95,000 potential adverse drug events annually at very little cost (Hutton et al., 2021).
Nurses Help Coordinate Care to Increase Patient Safety
Nurses play pivotal role in care coordination and patient safety along the continuum of healthcare services. Since nurses are, in most cases, the first point of contact between patients and health providers, they are usually involved in confirming the identity of patients at various instances of care. Nurses apply standardized strategies and use available technology, such as barcoded wristbands and EHRs, to improve the accuracy of patient identification in a bid to reduce the incidence of wrong patient errors. By advocating and implementing such practices, nurses reduce the risk of misidentification and therefore assure appropriate care to the patient. (LoBiondo-Wood & Haber, 2021).
Besides the direct role of nurses in the process of patient identification, nurses facilitate safety by participating in interdisciplinary collaboration. It is through nurses that communication
and teamwork with physicians and other healthcare professionals maintain correct and current patient information. The collaborative effort it allows ensures that all team members are updated in case of any critical change in a patient’s data, reducing potential errors and improving quality of care and patient outcomes. By promoting a teamwork approach to their work, nurses enhance not only patient safety but also improves the quality of care and outcomes, which lead to healthcare cost savings due to reduction in errors (Wei et al., 2022).
Identifying Stakeholders with whom Nurses would need to coordinate
In order to minimize patient identification errors and improve patient safety, nurses must identify and engage other key stakeholders in the healthcare institution. Other stakeholders include healthcare administrators who are in charge of applying standard identification procedures or attaining the required technologies. It is therefore important to involve IT professionals since they help in implementing and maintaining EHR systems and other technology that enhances patient identification (Blijleven et al., 2021). Nurses have to collaborate with quality improvement teams and patient’s family for implementing and evaluating patient safety interventions. These stakeholders can help in finding patterns of identification errors and in assessing the impact of the utilized measures (Rotteau et al., 2022). Furthermore, communication with the training and education departments guarantees that all the healthcare staff is trained on the patient identification procedures and on the handling of relevant technologies to support this process and promote safety culture.
Potential Importance of the Stakeholders
The potential importance of the stakeholders lies in their critical roles toward enhancing patient safety and improving health outcomes. Healthcare administrators create a safe environment for patients by making policies and providing resources necessary for the implementation of
protocols related to standardized procedures and technologies, like those using barcoded wristbands and EHRs. The healthcare provider is responsible for managing accurate patient data through interdisciplinary collaboration and following set safety guidelines. This will entail regular training and education to minimize error occurrences as much as possible (McGonigle & Mastrian, 2024). Finally, involvement of patients and families during the verification process and in the provision of feedback also enhance safety improvements (Campbell et al., 2021). All these stakeholders come together for an integrated approach toward better safety for patient’s treatment and cost reduction in healthcare.
Conclusion
Patient identification is the base of safe management and delivery of care, misidentification has serious implications with loss of trust and considerably huge in financial and legal terms. Standardization of the processes for identification and leveraging technologies like barcoded wristbands and electronic health records can significantly reduce these errors for healthcare providers. This requires collaborative efforts from health administrators, nurses, physicians, patients, and families in maintaining data accuracy and advancing the culture of safety. Through collaborative efforts, continuous education, and the presence of an engaged patient, it becomes very easy to improve safety for healthcare systems; hence, this will reduce costs and improve patient outcomes.
References
Blijleven, V., Hoxha, F., & Jaspers, M. (2021). Workarounds in Electronic Health Record Systems: A Scoping Review and Revised SEWA Framework (Preprint). Journal of Medical Internet Research, 24(3). https://doi.org/10.2196/33046
Campbell, A. R., Kennerly, S., Swanson, M., Forbes, T., & Scott, E. S. (2021). Manager’s influence on the registered nurse and nursing assistant relational quality and patient safety culture. Journal of Nursing Management. https://doi.org/10.1111/jonm.13426
Dorothy, A., Yadesa, T. M., & Atukunda, E. (2021). Prevalence of Medication Errors and the Associated Factors: A Prospective Observational Study among Cancer Patients at Mbarara Regional Referral Hospital. Cancer Management and Research, Volume 13, 3739–3748. https://doi.org/10.2147/cmar.s307001
Higgins, M. C. S. S., & Herpy, J. P. (2021). Medical Error, Adverse Events, and Complications in Interventional Radiology: Liability or Opportunity? Radiology, 298(2), 275–283. https://doi.org/10.1148/radiol.202020234 1
Hutton, K., Ding, Q., & Wellman, G. (2021). The Effects of Bar-coding Technology on Medication Errors. Journal of Patient Safety, 17(3), 192–206.
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LoBiondo-Wood, G., & Haber, J. (2021). Nursing Research E-Book: Methods and Critical Appraisal for Evidence-Based Practice. In Google Books. Elsevier Health Sciences.
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McGonigle, D., & Mastrian, K. (2024). Nursing Informatics and the Foundation of Knowledge. In Google Books. Jones & Bartlett Learning.
Rotteau, L., Goldman, J., Shojania, K. G., Vogus, T. J., Christianson, M., Baker, G. R., Rowland, P., & Coffey, M. (2022). Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. BMJ Quality & Safety, 31(12), bmjqs-2021-013938. https://doi.org/10.1136/bmjqs-2021-013938
Wei, H., Horns, P., Sears, S. F., Huang, K., Smith, C. M., & Wei, T. L. (2022). A systematic meta-review of systematic reviews about interprofessional collaboration: facilitators, barriers, and outcomes. Journal of Interprofessional Care, 36(5), 735–749. https://doi.org/10.1080/13561820.2021.1973975
Zayas-Cabán, T., Chaney, K. J., Rogers, C. C., Denny, J. C., & White, P. J. (2021). Meeting the challenge: Health information technology’s essential role in achieving precision medicine. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocab032
Ensaldo-Carrasco, E., Suarez-Ortegon, M. F., Carson-Stevens, A., Cresswell, K., Bedi, R., & Sheikh, A. (2021). Patient Safety Incidents and Adverse Events in Ambulatory Dental Care. Journal of Patient Safety, 1.
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Riplinger, L., Jiménez, J. P., & Dooling, J. P. (2020). Patient identification techniques – approaches, implications, and findings. Yearbook of Medical Informatics, 29(1), 81–86. https://doi.org/10.1055/s-0040-1701984
NURS FPX 4020 Assessment 1
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