Enhancing Patient Safety- Applying Course Concepts to Address Medication Errors

Enhancing Patient Safety- Applying Course Concepts to Address Medication Errors

Quality In Health Care

The primary role of health organizations is to provide safe, quality, efficient, and patient-centered healthcare services. There are many challenges that healthcare organizations face in designing quality improvement programs to provide safe and quality healthcare services. The patient is at the center of the healthcare delivery industry, and all healthcare programs must thus be implemented to ensure that patient needs and preferences are met. Patient safety aims to prevent and reduce patient risk and preventable harm during the delivery of healthcare services (World Health Organization, 2019). Patient safety is essential in the delivery of quality healthcare services.

Safety Issue

The patient safety issue selected for this assessment is patient identification errors. A patient identification error is the misidentification of a patient. This safety issue negatively affects patient treatment, medication administration, diagnostic procedures, and patient recovery. Patient identification errors can result in medication errors, testing errors, transfusion errors, and the discharge of children to the wrong families (De Rezende et al., 2021). Patient identification errors occur when patients have identical names and many similarities to their names, increasing the chances of misidentification of patients.

Associated Challenges

Patient identification has always been an issue within the United States healthcare delivery industry. Patient identification errors result in severe consequences not only for patients but also for healthcare providers. Some of the issues that may result from patient misidentification include duplicate medical records, patient mix-ups, overlay, and medical identity thefts, among others (Ferguson et al., 2019). Some of the cases of identification errors do not result in severe consequences. Patient misidentification happens almost every day in the healthcare delivery industry, but most of these errors get identified when it’s already too late. Apart from patients and healthcare providers, caregivers are also affected by patient misidentification.

Patient misidentification results in treatment delays, repetitive lab tests, and incorrect medical procedures, which negatively affect patient outcomes and, as a result, jeopardize patient safety (Riplinger et al., 2020). In addition to this, it may result in high healthcare costs since patients can be billed for services they may not have received. It can also lead to high costs for healthcare providers since the claims may be denied by insurance payers. Healthcare providers may lose goodwill, have denied claims, unwanted attention, lower scores, and risk losing CME reimbursements linked to patient safety (Riplinger et al., 2020).

How EBP, Research, and PI Can Address Patient Identification Errors

Evidence-based practice is a diligent problem-solving effort in clinical practice that integrates the best evidence from well-conducted research, clinical expertise, and the patient’s preference to make decisions that affect patient care (Reid et al., 2017). Healthcare information technology has become an important player in the healthcare delivery industry, and EBP has been used to develop modern standard protocols and modifications of medical procedures. Many healthcare protocols were derived from medical textbooks, and these protocols were rarely modified to meet complex patient needs. The healthcare industry is constantly evolving and changing.

Healthcare informatics has allowed healthcare to conduct healthcare research successfully to improve healthcare outcomes (Dagliati et al., 2021). Healthcare researchers can utilize and investigate patient information using healthcare technology such as electronic health records. Patient misidentification has been present in the healthcare delivery industry since time immemorial, and this is a global issue affecting patient safety globally.  Patient identification errors have adverse effects. Despite this fact, the healthcare delivery industry has not implemented systematic structures to prevent patient identification errors. Through evidence-based practice, there should be at least two patient identifiers, patient identification standardization, and the use of reliable wristbands (Riplinger et al., 2020). There should be the implementation of standard procedures such as correct labeling of surgical tools and the use of operational checklists.

It is critical to conduct research to eliminate identification errors in clinical setups, and there should be at least patient identifies. It is vital to conduct research to determine the common causes of patient identification errors.  Research is critical in healthcare since it helps answer the unknown, fill knowledge gaps and change healthcare operations (Dobrow et al., 2017). Research on the causes of patient identification errors will help healthcare professionals understand how often patient identification errors occur and the probability of a patient misidentification occurring in a clinical environment.

Performance improvements are an organizational process that aims at optimizing processes or procedures to increase output and improve efficiencies (Crawford et al., 2015). Performance improvements can help optimize the current procedures that are in place to reduce patient misidentification. This would include regular education of hospital staff on the current protocols regarding current protocols to guide accurate patient identification. These procedures can be followed by healthcare professionals to reduce patient identification errors. Examples of at least two patient identifiers that can be used include name, date of birth, photo, or social security number. Healthcare professionals can also be educated not to classify patients based on diagnosis, room numbers, or bed positions.

Quality Improvement Process

Quality improvement is used to methodically improve the ways in which healthcare is delivered to patients. The QI process should be measurable, analyzable, improvable, and controllable. The quality improvement model that will be applied to reduce patient identification errors is the Model for Improvement (MFI). MFI uses Plan Do Study Act (cycles) to test the impact of small alterations, make them, and ultimately ensure effective changes throughout the organization (Coury et al., 2017). MFI asks questions about what the QI is trying to accomplish, how the change will be an improvement, and what changes will be made to result in quality improvement. After answering these questions, the QI team will then introduce and test these changes in successive PDSA cycles until a change that produces desirable results is ready to be implemented (Coury et al., 2017). The PDSA cycles have been selected for this process since the QI process will first be initiated at a specific unit to see whether the changes will effectively reduce patient identification errors. These changes will then be implemented at a full-scale level in the organization.

Data Sources

The primary data sources for this QI will be patient surveys, health professional surveys, and information retrieved from patient electronic health records. The secondary sources of data for this quality-improved process will be scholarly articles on patient identification errors. Secondary data sources will also include databases of international organizations such as WHO or government databases such as the CDC. These websites have information on evidence-based interventions to reduce patient misidentification. Many studies have been conducted on the causes and prevention of patient identification errors. These scholarly articles will be obtained from reputable databases such as PubMed, Cochrane, Google Scholar, and Medline.

Outcome data will refer to the impact of the healthcare intervention on the health status of patients. The outcome data for this quality improvement process will be obtained from patient surveys and patient electronic health records. Patient surveys will reveal the number and frequency of patient misidentification after implementing a quality improvement process. Electronic health records will also be reviewed to see if patients received wrong diagnoses, procedures, or treatments due to misidentification. Process data will be used to monitor the implementation of the quality improvement processes. The data will be obtained from healthcare professional surveys. Nurses and other healthcare professionals will report how often they implemented the changes to reduce patient identification errors.

Data Capturing and Dissemination

The data for these processes will be captured using collection forms, and questionnaires will be used to collect data. The questionnaires will have checkboxes on the frequency of patient misidentification in the healthcare organization. These data can then be analyzed, and the results presented methodically for analysis. In addition to questionnaires, emails will be used to send the questions to the study participants. Data dissemination will be done through the organization’s website, and the data will be reported to the various stakeholders. Furthermore, this data will be published in reputable journals. This will help to ensure that the information reaches many healthcare professionals to implement strategies to prevent identification errors.

Organizational Culture Considerations

Attitude to change is one of the most important organizational cultures that should be considered during the implementation of this project. Senior management should motivate employees and support research to ensure the implementation of EBP and reduce patient identification errors. Furthermore, teamwork and interprofessional collaboration should be a culture that should be promoted. Interprofessional collaboration enhances patient outcomes and improves patient outcomes (Webster, 2016). The quality improvement team must thus consider these factors since they will impact the success of this project.

In conclusion, patient identification errors are a common problem affecting patients, healthcare professionals, and the healthcare delivery industry. Healthcare organizations must thus implement evidence-based strategies to reduce patient identification errors and improve patient safety.

References

Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B., Taplin, S. H., Green, B. B., & Coronado, G. D. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Services Research, 17(1). https://doi.org/10.1186/s12913-017-2364-3

Crawford, B., Skeath, M., & Whippy, A. (2015). Multifocal clinical performance improvement across 21 hospitals. Journal for Healthcare Quality, 37(2), 117-125. https://doi.org/10.1111/jhq.12039

Dagliati, A., Malovini, A., Tibollo, V., & Bellazzi, R. (2021). Health informatics and EHR to support clinical research in the COVID-19 pandemic: An overview. Briefings in Bioinformatics, 22(2), 812-822. https://doi.org/10.1093/bib/bbaa418

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

Dobrow, M. J., Miller, F. A., Frank, C., & Brown, A. D. (2017). Understanding relevance of health research: Considerations in the context of research impact assessment. Health Research Policy and Systems, 15(1). https://doi.org/10.1186/s12961-017-0188-6

Ferguson, C., Hickman, L., Macbean, C., & Jackson, D. (2019). The wicked problem of patient misidentification: How could the technological revolution help address patient safety? Journal of Clinical Nursing. https://doi.org/10.1111/jocn.14848

Reid, J., Briggs, J., Carlisle, S., Scott, D., & Lewis, C. (2017). Enhancing utility and understanding of evidence based practice through undergraduate nurse education. BMC Nursing, 16(1). https://doi.org/10.1186/s12912-017-0251-1

Riplinger, L., Piera-Jiménez, J., & Dooling, J. P. (2020). Patient identification techniques – Approaches, implications, and findings. Yearbook of Medical Informatics, 29(01), 081-086. https://doi.org/10.1055/s-0040-1701984

Webster, A. (2016). The health of collaborations. Collaboration across Health Research and Medical Care, 217-226. https://doi.org/10.4324/9781315572611-11

World Health Organization. (2019, September 13). Patient safety. WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/patient-safety

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This assignment aims to apply the concepts you have learned in this course to a situation you have encountered. Choose one quality or patient safety concern you are familiar with and have not yet discussed in this course. In a 1,250-1,500 word essay, reflect on what you have learned in this course by applying the concepts to the quality or patient safety concern you have selected. Include the following in your essay:

Enhancing Patient Safety- Applying Course Concepts to Address Medication Errors

Briefly describe the issue and associated challenges.
Explain how EBP, research, and PI would be utilized to address the issue.
Explain the PI or QI process you would apply and discuss why you chose it.
Describe your data sources, including outcome and process data.
Explain how the data will be captured and disseminated.
Discuss which organizational culture considerations will be essential to the success of your work.