This toolkit includes the annotated academic materials repository for the improvement plan developed to assist nurses in the implementation and sustainability of safety improvement measures within health care setting for patient identification errors at St. Joseph Hospital. It is classified into four classes with three sources annotated: The best practices overview of general organizational safety and quality, the risks of the disease associated with environmental safety and quality, preventive strategies driven by staff, and the best practices of reporting and improving environmental safety issues.
General Organizational Safety and Quality Best Practices
Dolansky, M. A., Moore, S. M., Palmieri, P. A., & Singh, M. K. (2020). Development and Validation of the Systems Thinking Scale. Journal of General Internal Medicine, 35. https://doi.org/10.1007/s11606-020-05830-1
The research by Dolansky et al. (2020) emphasized that health care organizations should adopt a holistic approach in which multiple factors can be taken into consideration in terms of how they interact with and influence the safety of the patients. Through an understanding and approach towards these factors that healthcare organizations are able to create a safer environment for their patients. In relation to St. Joseph Hospital, this approach can applied in identifying the root causes of patient identification errors and mitigating them. The authors underline some of the core elements of systems thinking scale, like leadership commitment, culture of safety, and continuous learning. The commitment by leadership is central; it sets the quality for initiatives in safety and is required to undertake the deployment of the needed resources. A culture of safety will secure the reporting of errors and near-misses by the members of staff, which promotes
transparency and continuous improvement. Furthermore, continuous learning involves periodic review and enhancement of safety practices in view of the best current evidence and feedback. Systems thinking approach can add a lot to help St. Joseph Hospital develop a robust, persistent culture of safety that could significantly reduce the occurrences of patient identification errors.
Organization, W. H. (2021). Global patient safety action plan 2021-2030: Towards Eliminating Avoidable Harm in Health Care. In Google Books. World Health Organization. https://books.google.com/books?hl=en&lr=&id=csZqEAAAQBAJ&oi=fnd&pg= PR7&dq=The+role+for+leaders+of+health+care+ organizations+in+patien t+safety+and+patient+idetification+ errors&ots=xKSY9_iozw&sig= 2TBwjzNH4Dp3nEgDtSO1mX3TjVY
The researchers in this study identifies the role of every leader in healthcare organizations to lead improvement in safety culture. According to research, for safety practices, leadership commitment is the critical ingredient for a culture of safety. Strong leadership at St. Joseph Hospital can genuinely drive improvement initiatives related to patient identification and safety. The authors underline some strategies that health care leaders can use in the pursuit of patient safety that includes: setting clear safety goals and ensuring the provision of the necessary resources, creating an environment in which staff feel empowered to report errors and near-misses, and engaging all levels of staff in safety initiatives, from frontline workers to senior management. By adopting such leadership strategies, St. Joseph Hospital will be able to foster a culture of safety that reduces the risk associated with patient identification errors.
Kulju, S., Morrish, W., King, L., Bender, J., & Gunnar, W. (2020). Patient Misidentification Events in the Veterans Health Administration. Journal of Patient Safety, Publish Ahead of Print. https://doi.org/10.1097/pts.0000000000000767
Kulju et al. (2020) highlights the strategies of high-reliability in healthcare, which concerns requirements for reliably minimizing adverse events. In the search for high reliability, core principles are developing a culture of safety and continuous learning along with robust process improvement methods. High reliability in healthcare for St. Joseph Hospital ensures patients’ identification processes are accurate and effective all the time. The authors visualize a culture of safety where all staff are actively engaged in patient safety, constantly striving for opportunities. They underscore the importance of having robust process-improvement methodologies such as Lean and Six Sigma, which will help identify and remove errors from the systems. With the incorporation of these, St. Joseph Hospital will be better equipped to improve its patient identification system and decrease all possibilities of errors.
Environmental Safety and Quality Risks
Rezende, H. A. de, Melleiro, M. M., Marques, P. A. O., & Barker, T. H. (2021). Interventions to reduce patient identification errors in the hospital setting: A systematic review. The Open Nursing Journal, 15, 109–121. https://repositorio.usp.br/item/003083762
This review article brings out the impact of healthcare design on patient safety and quality of care. Rezende et al. (2021) providing details on creating a safe physical environment to reduce the risk of errors, inclusive of the identification of patients. For St. Joseph Hospital, evidence-based design will help develop an environment supportive of accurate patient identification. The authors have pointed out several design features that
can promote patient safety, such as adequate arrangement of patient care areas. For example, good lighting would help health providers read patient information without mistakes. In addition, the arrangement of areas for patient care should reduce confusion and enhance workflow to decrease the chance of error. These design elements can lead St. Joseph Hospital to develop a much safer environment with respect to correct patient identification.
Simamora, R. H. (2020). Learning of Patient Identification in Patient Safety Programs through Clinical Preceptor Models. Medico-Legal Update. https://doi.org/10.37506/mlu.v20i3.1457
The Study investigate the interaction of infection control practices and overall patient safety. This research centers on the use of a socio-technical systems approach in regard to both social and technical factors in error prevention. For St. Joseph Hospital, applying comprehensive measures of infection control will reduce the potential for patient identification errors by keeping the area clean and organized. The authors, therefore, state that the infection control practices, such as hand hygiene, and environmental cleaning, contribute to safety. They also discuss how healthcare providers in these practices are trained and observed. Introducing a socio-technical systems approach into St. Joseph Hospital will enable it to enhance its infection control measures to make the environment safe, thus supporting accurate patient identification.
Khaleghi, P., Akbari, H., Masoudi Alavi, N., Motalebi Kashani, M., & Batooli, Z. (2022). Identification and analysis of human errors in emergency department nurses using SHERPA method. International Emergency Nursing, 62, 101159. https://doi.org/10.1016/j.ienj.2022.101159
In this article Khaleghi et al. (2022) describe how human factors contribute to quality care for patients. The authors discuss human factor considerations cognitive load and workflow design, both considered as relevant variables in error prevention. Human factor considerations at St. Joseph Hospital, therefore, may help to reduce or avoid patient misidentification by designing processes and environments that facilitate staff’s ability to provide accurate and effective care. According to the authors, other strategies for mitigating human factors concerns are simplification of workflows, reducing cognitive workload, and designing systems to support human performance. For example, simplification of the process to verify patient identity can reduce the cognitive burden on healthcare providers about the correct identification of patients. In addition, well-designed, clear, informative systems can prevent mistakes. Attention to human factors will help St. Joseph Hospital improve the process of patient identification with a reduced risk of errors.
Staff-Led Preventive Strategies
Wiegmann, D. A., J. Wood, L., N. Cohen, T., & Shappell, S. A. (2021). Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. Journal of Patient Safety, Publish Ahead of Print (2), 119–123.
https://doi.org/10.1097/pts.0000000000000810
The study by Wiegmann et al. (2021) contribute to the understanding of human error provides insight into the cognitive processes involved with errors that are likely to occur in healthcare. It highlights the Reason’s “Swiss Cheese Model” that addresses the cause root of errors. It is postulated that accidents happen due to successive failures in the different defense layers. Reason’s model can be applied to identify the various intercept
points during which an error is captured and prevented at St. Joseph Hospital. Purposely, the Swiss Cheese Model identifies the need to establish multiple defenses, all having specific checks and balances. For instance, the use of a dual system of manual and electronic verification for checking the identity of patients could cause redundancies of the check, thereby avoiding the wrong identity. Moreover, the employees should have the right to report near-misses or errors without the fear of any punishment. This would assist in identifying systemic reasons and improvement in their safety protocols. Human factors contributing to the error will be identified and acted upon in order to improve the patient identification processes at St. Joseph Hospital.
Kwon, H., An, S., Lee, H.-Y., Cha, W. C., Kim, S., Cho, M., & Kong, H.-J. (2022). Review of Smart Hospital Services in Real Healthcare Environments. Healthcare Informatics Research, 28(1), 3–15. https://doi.org/10.4258/hir.2022.28.1.3
Kwon et al. (2022) discusses how to create and apply checklists in the health areas for the safety of the patient. Applying checklists is one of the simplest ways to ensure that crucial steps are not missed during complex processes like identification of the patient. Adopting checklists in St. Joseph Hospital will introduce identification of errors and improve the standard way of working by making clear procedure. More importantly, when working under high stress, where one is likely to make errors, in these cases checklists ensure everything that needs to be done drives through a set procedure. A checklist of admission with regard to a patient can include the verification of the identity of the patient with more than one identifier, confirmation of the medical history belonging to the patient, and completion of relevant documents. Creating a more reliable
and consistent approach to patient identification, reducing the risk of errors can be accomplished by embedding checklists into daily workflows.
Sittig, D. F., Wright, A., Coiera, E., Magrabi, F., Ratwani, R., Bates, D. W., & Singh, H. (2020). Current challenges in health information technology–related patient safety. Health Informatics Journal, 26(1), 146045821881489.
https://doi.org/10.1177/1460458218814893
This framework describes key elements for safe, reliable, and effective care. It centers the key issues, such as adoption of technology and leadership commitment to a culture of safety and reliability, continuous learning, and maintaining patient-centered care. For St. Joseph Hospital, this framework can help in creating an environment where cases of patient identification errors are less likely to occur. Within the structure, it is underlined that the leadership and technology will work in a manner that supports patient safety with resources provided to encourage this course toward safety. Again, in a robust safety culture, empowerment to speak regarding potential safety concerns is endorsed for the staff in preventing patient misidentification. Involving patients in patient-centered care processes can further help to improve the accuracy of identification. With the incorporation of this approach, St. Joseph Hospital could develop overall patient safety methodologies that reduce errors in the identification process.
Best Practices for Reporting and Improving Environmental Safety Issues
Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2020). A systems approach to analyzing and preventing hospital adverse events. Journal of Patient Safety, 16(2), 1. https://doi.org/10.1097/pts.0000000000000263
This study under the Journal of Patient Safety, analyzes the amount of medical errors and provides recommendations on how to build a safer health system. It emphasizes that error prevention depends on a systems approach by reporting systems, safety culture, and the need for interdisciplinary collaboration. In addition to this, the recommended strategies will serve best for St. Joseph Hospital in describing and taking proper measures for systemic causes of patient misidentification. The report recommends: to establish error-reporting mechanisms that will allow the staff to report errors and near-miss incidents without fear of being persecuted, encourage transparency, and put mechanisms in place to identify patterns and root causes of the errors. It also focus on a strong safety culture in which patient safety is primary responsibility. Such interdisciplinary team effort, wherein members of diversified specialty providers of healthcare are consulted, would ensure the robustness and comprehensiveness of the process of patient identification. In this way, St. Joseph Hospital can adopt better practices and a safer environment for the patients in terms of elimination of risks pertaining to errors in patient identification.
Stawicki, S. P., & Firstenberg, M. S. (2022). Contemporary Topics in Patient Safety: Volume 1. In Google Books. BoD – Books on Demand. https://books.google.com/books?hl=en&lr=&id= FtJuEAAAQBAJ&oi=fnd&pg=PA9&dq=What+ practices+will+most+improve+safety%3F+Evidence- based+study+and+patient+identification+errors .+JAMA&ots=OOMBvK9ekG&sig=D-QA_ fBYIdKNfZ5bYcdUeTGX-vg
This study by Stawicki & Firstenberg, (2022) explain how practices in patient safety must be inclusive of the practice of evidence-based modifications. It is important to implement proven and applied safety interventions such as standardizing protocol and checklists-to
Hospital will be better placed for the identification of patient bases, hence reducing errors.
Al-Worafi, Y. (2023). Patient Safety in Developing Countries: Education, Research, Case Studies. In Google Books. CRC Press. https://books.google.com/books?hl=en&lr=&id=83LREAAAQBAJ&oi=fnd&pg= PT11&dq=Safer+Healthcare:+Strategies+for+the+Real+World .+Springer+Open.&ots=OB3RPqEZDx&sig= TeciXcouX4_gCyWcK_OWHzqsh88
This research by Al-Worafi (2023) highlights some practical methods to enhance patient safety in the practice of health care in the real world. It affirms resiliency, adaptability, and proactive safety. Through these practices, the following strategies can be implemented in St. Joseph Hospital to adapt improvements and prevent errors in the identification of patients. The authors introduced the concept of the resilience engineering of health systems, which should be ready for unexpected problems and disruption of services. This would involve the design of robust safety protocols, staff training so that everyone can anticipate events and respond appropriately when errors occur, combined with a culture of learning and improvement. It emphasizes proactive safety, whereby potential risks are identified and acted on before they lead to an error. Such strategies can make a robust and flexible system for St. Joseph Hospital, reducing the errors of patient identification to the least possible extent
Dolansky, M. A., Moore, S. M., Palmieri, P. A., & Singh, M. K. (2020). Development and Validation of the Systems Thinking Scale. Journal of General Internal Medicine, 35. https://doi.org/10.1007/s11606-020-05830-1
Al-Worafi, Y. (2023). Patient Safety in Developing Countries: Education, Research, Case Studies. In Google Books. CRC Press. https://books.google.com/books?hl=en&lr=&id=83LREAAAQBAJ&oi=fnd&pg= PT11&dq=Safer+Healthcare:+Strategies
s+for+the+Real+World.+Springer+Open. &ots=OB3RPqEZDx&sig=TeciXcouX4 _gCyWcK_OWHzqsh88
Organization, W. H. (2021). Global patient safety action plan 2021-2030: Towards eliminating avoidable harm in health care. In Google Books. World Health Organization. https://books.google.com/books?hl=en&lr=&id=csZqEAAAQBAJ&oi=fnd&pg=PR7&d q=The+role+for+leaders+of+health+care+organizations +in+patient+safety+and+patient+ idetification+errors&ots=xKSY9_iozw&sig=2TBwjz NH4Dp3nEgDtSO1mX3TjVY
Kulju, S., Morrish, W., King, L., Bender, J., & Gunnar, W. (2020). Patient Misidentification Events in the Veterans Health Administration. Journal of Patient Safety, Publish Ahead of Print. https://doi.org/10.1097/pts.0000000000000767
Kwon, H., An, S., Lee, H.-Y., Cha, W. C., Kim, S., Cho, M., & Kong, H.-J. (2022). Review of Smart Hospital Services in Real Healthcare Environments. Healthcare Informatics Research, 28(1), 3–15. https://doi.org/10.4258/hir.2022.28.1.3
Khaleghi, P., Akbari, H., Masoudi Alavi, N., Motalebi Kashani, M., & Batooli, Z. (2022). Identification and analysis of human errors in emergency department nurses using SHERPA method. International Emergency Nursing, 62, 101159. https://doi.org/10.1016/j.ienj.2022.101159
Leveson, N., Samost, A., Dekker, S., Finkelstein, S., & Raman, J. (2020). A systems approach to analyzing and preventing hospital adverse events. Journal of Patient Safety, 16(2), 1. https://doi.org/10.1097/pts.0000000000000263
Simamora, R. H. (2020). Learning of Patient Identification in Patient Safety Programs Through Clinical Preceptor Models. Medico-Legal Update. https://doi.org/10.37506/mlu.v20i3.1457
Rezende, H. A. de, Melleiro, M. M., Marques, P. A. O., & Barker, T. H. (2021). Interventions to reduce patient identification errors in the hospital setting: A systematic review. The Open Nursing Journal, 15, 109–121. https://repositorio.usp.br/item/003083762
Sittig, D. F., Wright, A., Coiera, E., Magrabi, F., Ratwani, R., Bates, D. W., & Singh, H. (2020). Current challenges in health information technology–related patient safety. Health Informatics Journal, 26(1), 146045821881489.
https://doi.org/10.1177/1460458218814893
Stawicki, S. P., & Firstenberg, M. S. (2022b). Contemporary Topics in Patient Safety: Volume 1. In Google Books. BoD – Books on Demand. https://books.google.com/books?hl=en&lr=&id=FtJuEAAAQBAJ&oi=fnd&pg=PA9&dq= What+practices+will+most+improve+safety %3F+Evidence-based+study+and+patient+identification+errors. +JAMA&ots=OOMBvK9ekG&sig=D-QA_fBYIdKNfZ5bYcdUeTGX-vg
Wiegmann, D. A., J. Wood, L., N. Cohen, T., & Shappell, S. A. (2021). Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. Journal of Patient Safety, Publish Ahead of Print (2), 119–123.
https://doi.org/10.1097/pts.0000000000000810
NURS FPX 4020 Assessment 4
Empower your academic journey with NURS FPX 4020 Assessment 4 PDF. This guide simplifies nursing concepts to aid your understanding. Need assistance or expert support? Feel free to contact us for personalized help and achieve excellence in your nursing studies.