Root Cause Analysis and Safety Improvement Plan are the most important approaches toward ensuring patient safety in a health facility. This paper highlights the important issue of misidentification at St. Joseph Hospital, which affects the safety and quality of care delivered to the patient. Deeper explanations will be given for root causes of such errors through an explanation of problems resulting from poor identification protocols, poor communication among health professionals, and poor implementation of technology. It will also propose evidence-based methods through which these errors can be mitigated by using available resources from the organization which promote safety. A systemic improvement strategy will be imparted in St. Joseph Hospital with the purpose of decreasing identification errors, promoting better patient outcomes and implementing a culture of safety. This paper will cover the discussion on the process of introducing the RCA, analysis of the root causes, applying evidenced-based strategies, and developing a detailed improvement plan.
This is Root Cause analysis on the misidentification of patient at St. Joseph Hospital relates an event that led to a serious and critical outcome. The described event involves a patient who was administered wrong medication due to an admission error in patient identification. The event was identified by a nurse performing routine check for medication administration. This error negatively impacted the patient, who had an adverse drug reaction, and substantially troubled the healthcare team, who intervened in the complications caused due to this error. The patient suffered from adverse reactions that required additional medical intervention and monitoring. The health care team had to use extra resources to handle these complications, thus the apparent impact on general workflow and patient care.
While conducting the RCA, the event and relevant findings need to be critically analyzed in search of the root causes. Upon reviewing the case study, several factors that led to the current incident were identified. The policy of the hospital dictates proper identification of the patient by bar-coded wristbands on admission; this was not implemented as intended.
The high levels of pressure in an emergency department most likely contributed to lapses in protocol adherence to environmental factors. The equipment factors were also involved, as malfunctioning bar-code scanners failed to ensure proper identification. Human factors were notable, with staff members not following carefully with procedures for identification. Communication factors were very relatable, with poor handoff communication between shifts overlooking discrepancies in patient identification.
The RCA identified some of these root causes such as non-adherence to standardized protocols of identification, malfunctioning equipment, poor training of staff, and poor communication during handoffs. Each of the identified root causes is of immense relevance and has to be worked on to prevent a similar incident in the future.
These factors can, in turn, be minimized with appropriate strategies once they have been identified. The literature suggests that strong identification systems, and strong training programs are required. For instance, Highfill (2019) pointed out in a study that electronic health records and barcode wristbands have decreased cases of patient misidentification. Another study by Alsabri et al. (2020) discusses for ongoing training and education regarding overall safety protocol compliance.
There are several evidence-based strategies that could be incorporated to reduce the root causes of patient identification errors in St. Joseph Hospital. Literature highlights various best
practices that could be implemented in order to reduce the occurrence of these errors in general and hence improve patient safety. One of the major factors is interruption during patient identification, raising the risk of an error. For instance, Alshammari et al. (2022) showed that in cases of medication administration being interrupted, the risk of error increases significantly to ratio of 2.14 which can lead to misidentification and further errors. Another major factor is the poor employment of technology. According to Brennan and Laura (2020), institutions that do not integrate the bar-coded wristbands properly with EHRs are at a higher risk of misidentification. Besides, Alsabri et al. (2020) underline human factors related to the lack of training and failure in adhering to the protocols of identification, remarking on the fact that staff has to be more adherent to safety protocols with continuous education and training. Through this study, it has been quite obvious that the incident rates of patient identification error could be reduced to a large extent by frequent training sessions and competency assessments.
Some of the evidence-based interventions to minimize safety risks include the following recommended interventions: First, integrating the bar-coded wristbands into EHR systems, which ensures correctness in obtaining and confirming patient data, the strategy has eliminated the problem of inappropriate use of the technology. According to a study by Highfill, (2019), hospitals that put into place these systems depict an intense reduction in the identification mistakes. The technology will ensure that all the scanners are in good condition and that their interfaces with the EHRs are proper and functioning properly to reduce the risks that lead to patient misidentification. Another measure in this regard can be improved education and training of staff, which can be adopted by introducing regular and detailed training programs regarding patient identification protocols and proper use of technologies. The training programs ought to incorporate workshops, simulation exercises, and periodic competency assessments to ensure competent staff. Continuous
education and training have greatly improved the staff’s compliance with procedures of identification by reducing error rates, asserts Duffy et al. (2020). A non-interruption zone should finally be provided for patient identification. This can be accomplished by scheduling procedures for admission during low interruption periods and by implementing policies that reduce multitasking of the staff during these times of the patient identification process. A research study previously carried by Bukoh and Siah (2020) on medication administration that revealed how Interruptions can be minimized to eliminate errors. Together with these evidenced-based approaches, St Joseph Hospital will decrease the underlying factors responsible for patient identification errors. That means a much safer environment for patients and better quality care will be provided by integrating robust technological solutions with enhanced staff training, along with a decrease in the level of interruptions.
The strategy for the evidence-based patient-safety improvement plan at St. Joseph Hospital related to identification errors will be implemented by execution of new activities, processes, and professional development activities targeting root causes. The first step involves the improvement in the effectiveness of technology through the integration of the bar-coded wristband into the electronic health record system for capturing and verifying accurate information of the patients. Brennan and Laura (2020) suggest that those hospitals that have successfully integrated these technologies have reduced identification errors. This involves updating the EHR software, ensuring all barcode scanners are working properly, and teaching staff how to use them properly. The next step that will be follow is amplification of staff training and education. There will be regular training that will be provided so that all health care providers are up-to-date in patient identification protocols as well as use of new technologies. A study by Duffy et al. (2020)
emphasize that constant education with competency assessments has a great impact and role in reducing errors. Workshops, simulations, and periodic review sessions will also be provided to reinforce best practices. In addition, strategies will incorporate the reduction of interruptions to the patient identification process through the identification of specific times for admission with minimal interruptions and protocols that provide for limited multitasking in tasks requiring patient identification. A no-distraction environment facilitates staff focusing on the accurate identification of patients (Alshammari et al., 2022)
The goals of tis safety improvement plan is to reduce the rate of patient identification errors, promotion of patient safety, and improvement in the quality of care provided to patients. Desired outcomes include improved patient safety, staff compliance with identification processes, and accuracy in patient care processes. These actions will greatly help in making St. Joseph Hospital a much safer health care environment.
This improvement plan will be implemented within a time frame of approximately 12 months. The first three months would be used for upgrading the EHR system and implementing bar-coded wristbands. Programs for staff education would also be developed and initiated within this period. The next three months would be used for the actual implementation of the new technologies, with intensive training sessions. By six months, the hospital will have implemented the new identification policies and will start monitoring the effectiveness of the policies. The proposed strategies will be continuously assessed and modified for the remaining six months to ensure that the desired outcomes are achieved.
The improvement plan to identify patient identification errors will be successfully executed in St. Joseph Hospital with available organizational resources and personnel. First and foremost,
the QI (Quality Improvement) team will be instrumental in leading necessary changes to deal with patient identification errors. This team has expertise in evaluating and improving safety practices, and thus their involvement can be very critical in monitoring how the technologies and the training programs are working effectively. According to (Yuce et al., 2020), QI teams have a very big role in improving patient safety; therefore, QI will facilitate and manage implementation. There will also be an important role for the IT department, since they will update the EHR systems and ensure that the bar-coded wristbands are functioning correctly. According to Sheikh et al. (2021) the IT departments must have effective technology implementation and maintenance practices that are more supportive of patient safety. Besides, the Nursing Education and Training department play a very key role in designing the training programs for staff. This department will ensure that all health providers are current and competent in patient identification processes and new technologies (Carter & Phillips, 2021).
Additional resources, however will be needed to support the successful implementation of plan. This will involve advanced bar-code scanning equipment and updated modules of EHR software to be able to implement the technological enhancements fully. It may also be desirable to secure external training consultants to ensure that comprehensive training programs and simulations are developed to accomplish thorough staff preparedness.
Leveraging existing resources such as the expertise of the QI team, the technical skills from the IT department, and the educational capabilities from the Nursing Education and Training department will enhance and improve the plan. With this combination and other additional required tools and resources, St. Joseph Hospital will be better positioned to successfully handle the problem of patient identification errors, hence promoting better patient safety.
Root Cause Analysis plays a huge role in identifying the ‘root causes’ of the error in patient identification at St. Joseph Hospital. Some of the factors that may disturb the process, identified, are poor integration of technology, insufficient training of staff, and interruptions during the identification process. Existing resources that will complement this plan are the IT department, nursing staff, and the quality assurance team. They will be supplemented by new tools and comprehensive training programs. Evidence-based strategies identified for implementation in the plan will reduce identification, hence improving the safety of patients. Further, St. Joseph Hospital shall reach and maintain enhancements in the quality of care delivered to patients through constant evaluation and modification.
Alsabri, M., Boudi, Z., Lauque, D., Roger, D. D., Whelan, J. S., Östlundh, L., Allinier, G., Onyeji, C., Michel, P., Liu, S. W., Jr Camargo, C. A., Lindner, T., Slagman, A., Bates, D. W., Tazarourte, K., Singer, S. J., Toussi, A., Grossman, S., & Bellou, A. (2020). Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments. Journal of Patient Safety, Publish Ahead of Print (1). https://doi.org/10.1097/pts.0000000000000782
Alshammari 1, W. A., Alharbi 2, S. A., Aldhafeeri 3, A. M., Aldhafeeri 4, M. O.,
Alharbi 5, S. A., & Aldhafeeri 6, W. O. (2022).Medication administration time study (mats):
health professional’s performance of medication administration. Chelonian Research Foundation, 17(2), 1522–1530.
http://www.acgpublishing.com/index. php/CCB/article/view/472
Brennan, & Laura. (2020). Optimization of Simulated Electronic Medication Administration for Safe Management During Nursing Education – ProQuest.
Www.proquest.com. https://www.proquest.com/openview/ 1ad6404c2992e15d76b942d9bae32de1/1?pq- origsite=gscholar&cbl=18750&diss=y
Bukoh, M. X., & Siah, C.-J. R. (2020). A Systematic Review and meta-analysis on the Structured Handover Interventions in Improving Patient Safety Outcomes. Journal of Nursing Management, 28(3), 744–755. https://doi.org/10.1111/jonm.12936
Carter, B. M., & Phillips, B. C. (2021). Revolutionizing the Nursing Curriculum. Creative Nursing, 27(1), 25–30. https://doi.org/10.1891/CRNR-D-20-00072
Duffy, B., Miller, J., Vitous, C. A., & Dossett, L. A. (2020). Intersystem Medical Error Discovery. Journal of Patient Safety, 1.
https://doi.org/10.1097/pts.0000000000000625
Highfill, T. (2019). Do hospitals with electronic health records have lower costs? A systematic review and meta-analysis. International Journal of Healthcare Management, 13(1), 1–7. https://doi.org/10.1080/20479700.2019.1616895
Sheikh, A., Anderson, M., Albala, S., Casadei, B., Franklin, B., Richards, M., Taylor, D., Tibble, H., & Mossialos, E. (2021). Health Information Technology and Digital Innovation for National Learning Health and Care Systems. The Lancet Digital Health, 3(6), e383–e396. https://doi.org/10.1016/S2589-7500(21)00005-4
Yuce, T. K., Yang, A. D., Johnson, J. K., Odell, D. D., Love, R., Kreutzer, L., Schlick, C. J. R., Zambrano, M. I., Shan, Y., O’Leary, K. J., Halverson, A., & Bilimoria, K. Y. (2020). Association Between Implementing Comprehensive Learning Collaborative Strategies in a Statewide Collaborative and Changes in Hospital Safety Culture. JAMA Surgery, 155(10), 934. https://doi.org/10.1001/jamasurg.2020.2842