NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

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Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

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Enhancing Quality and Safety

Patient identification errors are one of the key safety threats in patient care, with major consequences for patients and the functioning of healthcare facilities. These errors can lead to wrong medication, diagnosis, or even no treatment at all, prolonged time to treatment, or deaths (Sheedy & Richard, 2020). In addition, it exposes healthcare professionals to emotional and legal consequences. This paper focuses on the problem of patient identification errors in Greenfield Community Hospital, examining the factors contributing to the problem and providing evidence-based solutions. Moreover, it focuses on the nurses’ part in promoting patient safety measures and reducing medical mistakes.

Case Study

In Greenfield Community Hospital, a 62-year-old patient, Mr Robert Hayes, was admitted for a planned herniorrhaphy. Because of a mix-up in labeling patients during admission, his clinical records were changed with that of another patient, Mr. Richard Hale, who had been admitted for a colonoscopy. In the operating room, the surgical team started drugging Mr. Hayes for the wrong surgery. The first time when a nurse pointed out the difference between the consent form and the surgery plan was at the anesthesia induction stage. Even though a mistake was prevented, it led to considerable troubles, patient discomfort, and analysis of the hospitals’ practices.

Factors Causing the Issue

Patient identification errors, as illustrated in the Greenfield Community Hospital case, have many root causes. One key factor includes failure to use at least two patient identifiers as required by the Joint Commission’s National Patient Safety Goals (NPSGs) (The Joint Commission, 2022). In the case study, the error occurred at the admission stage because the record was incorrectly labeled, which shows a failure of the verification process. Other factors are staff burnout and heavy workloads, especially in busy health facilities. These factors make it even more likely that such mistakes will be made. Research has indicated that overworked healthcare professionals are more likely to develop small attentional errors, which are likely to cause major medical errors such as patient identification (Popescu et al., 2022).

Further causes of patient identification error in Greenfield Community Hospital include inter-staff communication challenges, inadequate identification procedure training, and error-prone manual way of processing data. Additionally, the absence of a health information system notification or protection measures for mismatched patient identifiers was a concern (Popescu et al., 2022). Lastly, the lack of a double-check system for the patient’s records is a major problem in quality assurance. Continuing education and adherence to standard precautions help to eliminate exposure to serious mistakes and conform to safety guidelines provided by accrediting organizations.

Evidenced-based Solutions for the Issue

To address patient identification errors, healthcare organizations can implement the following evidence-based solutions that enhance safety and reduce costs:

The use of protocols of two patient identifiers before treatment is effective in minimizing the errors. According to The Joint Commission, this approach will improve safety and standards compliance (The Joint Commission, 2022). Familiarizing staff with these standards enhances efficiency in their practices and reduces mistakes that attract reckless litigation lawsuits or remedial treatment, thus reducing institutional financial liabilities.
Health Information Systems (HIS) can greatly minimize patient identification errors. HIS systems also allow users to view the most recent and, therefore, correct patient data and notify of inconsistencies in the information. This eliminates mistakes made by hand and helps properly identify the patient. Research shows that adopting HIS reduces misidentification, enhancing patient safety while lowering expensive occurrences (readmissions or complex treatment), operations, and legal expenses (Popescu et al., 2022).
Wearing of identification wristbands with labels and use of color-coded alerts for allergy or other conditions enhances patient safety. Wearable bands for various risk conditions are quite useful and safe for identification by all healthcare workers who will encounter patients in a hospital (Lema-Florez et al., 2021). Such lower differentiation reduces identification mistakes and costly consequences such as medication mistakes and operations on the incorrect limb, as it reduces mishaps, thereby improving the quality of healthcare.
Multifaceted patient identification education enhances staff adherence and knowledge (Romano et al., 2021). Skilled personnel are less likely to give out wrong information, thus avoiding unfavorable outcomes such as lawsuits or increased hospitalization periods. Most of these programs are inexpensive and effective for developing safety and culture change. Therefore, they increase staff familiarity with patient safety measures, guarantee the healthcare organization’s safety culture, increase patient survival, diminish the likelihood of litigation, and result in cost savings in the long run.

Nurses Role in Enhancing Safety and Reduce Costs

Nurses’ coordination of care leads to patient safety enhancement and reduction in costs as seen at Greenfield Community Hospital regarding patient identification errors. Nurses are the first line of the patient-clinician interface; hence, they have the greatest opportunity to minimize the risk of errors due to the incorrect identification of patients. Firstly, nurses must recognize that patient identification processes are one of the priority areas in which they are committed to promoting patient safety (De Rezende et al., 2021).

They should enhance and encourage the use of identification of patient measures, for example, confirming two identifiers before giving medicine or for a procedure. As for the mistake with Mr. Hayes, a nurse could have checked his identification using his name and date of birth before surgery and prevented the misidentification at the operating stage. That simple act would have saved time and helped avoid some of the complications and, thus, related costs of corrective measures and litigation.

Moreover, the nurses can guarantee that all the patients’ information is well recorded in the EHR systems. Nurses can maintain an overview of the quality of the data, looking for any inconsistencies and reporting any potential problems. This proactive approach reduces the chances of administrative mistakes, brings down operational intermissions, and maintains the client’s care flow (Popescu et al., 2022). Nurses can also help patients and families become more aware of identifying themselves correctly and inform them to report if something is wrong. This makes patients trust you, improves their health status, and decreases the chances of making costly mistakes because of incorrect identification.

Nurses’ Coordination with Stakeholders

Nurses must engage several essential stakeholders to support quality and safety improvements concerning patient identification errors. These include:

Physicians: Physicians must check patient data when treating patients or performing procedures for patient safety. Nurses need to engage physicians in reminding patients of appropriate identification processes, especially before surgeries or other interventions, to avoid using incorrect details in the treatment process (Sheedy & Richard, 2020).
Healthcare Administrators: Policymakers are supposed to be in charge of policy compliance and enforcement throughout an organization, including patient identification standards. Associated with administrators, nurses will be able to ensure that different protocols formulated and implemented in hospitals are refined to fit the current recommended practices and legal requirements. They are also sourcing the required funds to implement technology, like barcoding or Electronic Health Records (EHR), to reduce identification mistakes.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Information Technology (IT) Staff: This role requires IT professionals to ensure the hospital’s EHR systems are well maintained and that the efficient tools that prevent patient misidentification are integrated (Popescu et al., 2022). The IT department employees need to be consulted to ensure that the systems are working well, updated, and easily used to identify and track patients to avoid medical errors and protect the quality of the data.
Patients and Families: Patients and families are very important in preventing misidentification. They can also be taught the right approach to identification and should be involved in the process as much as possible.
Quality and Safety Officers: These stakeholders facilitate ensuring safety performance and the direction of change. Nurses should engage these officers in evaluating patient safety data to develop change strategies that eliminate identification errors throughout the facility.

Conclusion

In conclusion, patient identification errors threaten patient safety, healthcare productivity, and organizational expense. Therefore, when these causes of errors are known, corrective measures can be implemented. Since they are among the major coordinators in patient care, nurses are in a central position to participate in accurate identification with physicians, IT staff, administrators, and patients. One way in which safety and accountability may be accomplished within healthcare organizations is through identifying patients accurately and reducing the risk associated with patient identification errors, which can have a positive impact on patient satisfaction, organizational reputation, and cost.

References

De Rezende, H., Melleiro, M. M., O. Marques, P. A., & Barker, T. H. (2021). Interventions to reduce patient identification errors in the hospital setting: A systematic review. The Open Nursing Journal, 15(1), 109–121. https://doi.org/10.2174/1874434602115010109

Lema-Florez, E., Gomez-Menendez, J. M., Ariza, F., & Marin-Prado, A. (2021). Wristbands use to identify adult patients with difficult airway: A scoping review. Brazilian Journal of Anesthesiology (English Edition), 71(2), 142–147. https://doi.org/10.1016/j.bjane.2021.02.022

Popescu, C., Chaarani, H. E., Abiad, Z. E., & Gigauri, I. (2022). Implementation of health information systems to improve patient identification. International Journal of Environmental Research and Public Health, 19(22). https://doi.org/10.3390/ijerph192215236

Romano, R., Marletta, G., Sollami, A., La Sala, R., Sarli, L., Artioli, G., & Nitro, M. (2021). The safety of care focused on patient identity: An observational study. Acta Bio Medica: Atenei Parmensis, 92(Suppl 2), e2021038. https://doi.org/10.23750/abm.v92iS2.11328