Enhancing Quality and Safety
Patient identification errors pose significant risks in healthcare, leading to medication mistakes, incorrect procedures, and sentinel events. These mistakes result from misunderstandings, absence of procedure, and technology breakdown. After evaluating several limited measures, the Institute of Medicine emphasises safe settings for elders, while the Joint Commission and Quality and Safety Education for Nurses (QSEN) provide some ways to prevent misidentification (Rodziewicz et al., 2024): Enhancing Quality and Safety.
Since nurses are accountable for the daily management of care for patients, they have the duty of ensuring compliance with these standards by coordinating care, implementing quality improvement (QI), and promoting evidence-based practices. The topics addressed include the reasons for patient identification errors, suggested practices, key individuals, and other parties responsible for safety enhancement.
Factors Leading to Patient Identification Errors
Patient identification errors result from systematic and human errors that affect healthcare safety. The most common contributors include:
Miscommunication and Human Error
Due to the nature of fast-paced health care, there is poor communication, transcription errors, and handoffs, which contribute to patient misidentification. According to a survey conducted by Howick et al. (2024), the instances of misidentification caused by handoff mistakes account for 13%.
In emergency contexts, sometimes decision-makers may take actions that require urgency regardless of patience and accuracy, which worsens mistakes. However, absence or inadequate documentation increases misidentification hazards, which could even pose threats to patient safety (Howick et al., 2024). Proper verification protocols, which are critical in ironing out such mistakes, must be practised.
Lack of Standardized Protocols
Lapses in the proper identification of patients across the various practices in a hospital lead to gaps that facilitate errors. Riplinger et al. (2020) revealed that 5.5% of patients have their records assigned the wrong identification number and have duplicate records in the systems. The absence of certain guidelines in the process of verifying leads to confusion and wrong identification of patients with similar names, repeat records, or missing medical history.
Also, variations in the wristband labelling and documentation of the patient between the inpatient and outpatient departments make it possible for wrong identification to occur. Facilities that implemented standardised identification of patients in healthcare experienced a reduction of the incidents of misidentification by 60%, as revealed by Riplinger et al. (2020).
Patient-Related Factors
Patient peculiarities and their characteristics influence the likelihood of misidentification in certain ways. Specifically, patients who cannot respond verbally, like confused, unconscious, or comatose patients, are most at risk (Bauer et al., 2020). In total, errors in name correlate with 11% of misidentifications worldwide.
Hence, language barriers, cognitively impaired patients who might not understand questions correctly, and patients with other patients with similarities in their names also contribute to errors. Patients of young age, old age, and those with sensory problems need additional verification processes due to numerous patient identification risks (Bauer et al., 2020).
Staffing Shortages and High Workload
Lack of enough personnel in health facilities worsens fatigue and stress and leads to a high error rate. According to the study conducted by Twigg et al. (2021), with an increase in the nurse’s workload by 20%, there is a likelihood of increased patient identification errors by 15%. When nurses and clinicians attend to several patients at once, they neglect to verify the identity of the patient or take shortcuts that contribute to misidentification. Temporary or float staff, who may be newcomers to the particular facility, have a high chance of developing issues related to the identification of patients.
Evidence-Based and Best-Practice Solutions
To improve patient safety and minimise identification errors, healthcare facilities must implement evidence-based strategies.
Use of Two Patient Identifiers
Joint Commission’s National Patient Safety Goals are one of the most critical areas for the general health of the people that require healthcare professionals to use at least two means of identifying the patient before providing medication, carrying out any procedures, or before transfer of the patient (Joint Commission, 2023). This may include the patient’s complete name, date of birth, or hospital-assigned unique identification number. A study by De Rezende et al. (2021) found that implementing this verification process reduced patient identification errors by 50% in hospital settings. This measure helps reduce cases of medication errors, wrong surgeries, and misplaced patient records, which increases patient safety.
Barcode Scanning Technology
Automatic identification through barcodes is a popular method in the administration of medication, as well as the identification of patients to eliminate human mistakes. Howick et al. (2024) opine that there is a reduction of between 43–80% in medication administration errors through barcode checking technology, as this assures the appropriate mix of the constituent and the patient.
In a separate analysis of the application of barcode technology in various hospitals, it was established that there was a reduction of 65 per cent in cases of medication misidentifications, according to an AHRQ report in the year 2024. Patient identification in the patient is done by using bar-coded wristbands that are checked before giving drugs, transfusing blood, or carrying out diagnostics. This process helps to do away with the challenges of manual documentation, communication breakdown, and misidentification of vessels.
Standardised Patient Identification Protocols
Interfacing and sequential patient identification adoption across the department, various clinics, and surgical units are found to be essential to minimise the error rate. Hospitals that adopted such policies lowered identification errors by about 60%, as conducted by AHRQ in 2024. Measures such as patient acknowledgement verbally, confirming patient identification immediately when the patient is admitted, and the use of wristband comparison against the EHR when there is any process to deliver. These structured protocols increase productivity and decrease aspects of interpersonal variability that can result in non-treatment, mismanagement, and patient harm, thus promoting patient safety as a whole.
Staff Training and Simulation-Based Learning
The staff should undergo constant training on patient identification to reduce the occurrences of adverse effects. The competency is explained to rise by 35% via the effective adoption of simulation-derived learning, which is known to decrease misidentification (De Rezende et al., 2021). Twigg et al. (2021) maintained that hospitals should consider conducting regular refresher training and competencies tests as a part of quality enhancement protocols.
Electronic Health Record (EHR) Integration and Real-Time Verification Systems
AI-driven alerts can help identify possible duplication or errors in a patient’s data, which is important to patient safety. Organizations should closely integrate EHRs across departments to avoid EHR incompatibility.
Through these solutions, healthcare organisations will be able to reduce the instances of patient misidentification, maintain patient safety, and ultimately avoid legal lawsuits that arise from these errors, thus cutting down the costs entailed in such procedures.
The Role of Nurses in Coordinating Care for Patient Safety
Nurses have key responsibilities in the identification and prevention of errors for patient safety and for the implementation of QI practices to improve healthcare. However, their responsibility also lies in reducing costs, as errors in patient identification lead to huge financial losses in health facilities. By optimally identifying patients, nurses aid in the early detection of errors, decrease procedures that are likely to bring about malpractice suits and eliminate preventable errors, all of which contribute to saving resources and time in the provision of health care.
One of the primary responsibilities of nurses is to verify patient identity before administering medication, conducting assessments, or preparing for surgery. Joint Commission (2023) requires that a nurse should identify a patient using two identifiers, for instance, name and date of birth, before performing any procedures, which eliminates the risks of misidentification to a large extent. Involving the patients ensures validity and reliability, and this may reduce cases of mistakes in diagnosing the disease and the subsequent treatments to be given, hence reducing the overall cost of treating the disease.
Misidentification errors not only compromise patient safety but also lead to financial losses due to duplicate testing, delayed treatments, extended hospital stays, and legal claims. According to research conducted by Rodziewicz et al. (2024), the cost of each misidentification ranges from $1000 to $5000 during the provision of wrong treatments, compensation of patients to malpractice, and administrative work carried out as a result of cases of misidentification.
Nurses who adhere to verification procedures and utilise barcode scanning, EHR systems, and AI-enabled verification systems reduce the liability of healthcare organisations for unnecessary costs. According to research, hospitals adopting the use of barcode scanning recorded a decrease of 90% in duplicate records, which in turn saved thousands of dollars (Rodziewicz et al., 2024).
Additionally, nurses educate patients on self-identification, reducing errors caused by incorrect information or duplicate records. Enhancements in patient comprehension have been correlated with a 30% reduction in misidentification events as well as healthcare costs (Bauer et al., 2020). A nurse makes a vital contribution to safety measures and the production of information across the wards, events, physicians, pharmacists, and laboratories in labelling and documentation.
Through compliance with patient identification procedures, the safety of patients is boosted even as unnecessary costs in the healthcare sector are managed. By means of verification, technology implementation, patient awareness, and cooperation, nurses contribute to increasing the productivity of healthcare organisations and preventing significant losses.
Key Stakeholders in Patient Identification Safety Enhancements
According to De Rezende et al. (2021), patient identification is one of the most critical processes in the successive steps of a treatment course when implementing patient safety. Staff nurses and nurse managers are the first defence mechanisms in verifying patients before any procedure is carried out. They also enhance policy and technological advancements, including barcode scanning and EHR.
Hospital leadership and risk management can design and implement a hospital-wide patient identification policy. They also provide funds for increasing safety, such as a budget for increasing IT, EHR, and barcode scanner technology. Some ways are drug ordering and procedures in which doctors and surgeons make sure that they attend to the right patient, and through doctors and surgeons engage in safety education and preventive measures of medical errors.
Pharmacists play an important role since they double-check the patient’s identification details before dispensing drugs. They work with nurses, thereby reducing the incidence of wrong medication identification. Health IT (HIT) specialists are responsible for the management of EHR systems and integration when real-time alerts for misidentification occur. Similarly, state and federal agencies regulate patient safety with related accreditation organisations like the Joint Commission and the CMS, which set up regularly imposed compliance checks to sustain standard safety regulations.
Conclusion
Identification errors are regarded as potentially dangerous and can lead to an improper choice of diagnosis and therapy. In line with the study in Interior Two, patient identifiers, the process of scanning barcodes and enhancing the EHR prevents the aforementioned errors. Nurses are required to ensure that patients effectively receive the needed treatment per standards, as well as participate in patient education to the other teams in the health facility. Interprofessional approaches enhance patient safety as well as the quality and cost of the treatment to be offered to the patients.
References
AHRQ. (2024). Agency for Healthcare Research & Quality. Ahrq.gov; Agency for Healthcare Research and Quality. https://www.ahrq.gov/
Bauer, Z. A., De Jesus, O., & Bunin, J. L. (2020). Unconscious Patient. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538529/
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
Howick, J., Bennett-Weston, A., Solomon, J., Nockels, K., Bostock, J., & Keshtkar, L. (2024). How does communication affect patient safety? Protocol for a systematic review and logic model. BMJ Open, 14(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11131125/
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
Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024, February 12). Medical error reduction and prevention. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499956/
The joint Commission. (2023). National patient safety goals®, effective January 2024 for the hospital program. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
Twigg, D. E., Whitehead, L., Doleman, G., & El‐Zaemey, S. (2021). The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. Journal of Advanced Nursing, 77(12). https://doi.org/10.1111/jan.14909
ORDER A PLAGIARISM-FREE PAPER HERE
We’ll write everything from scratch
Question 
For this assessment, you will develop a 3–5 page paper that examines a safety quality issue in a health care setting. You will analyze the issue and examine potential evidence-based and b
Health care organizations and professionals strive to create safe environments for patients; however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013).
The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based s
You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safet
References
- Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? https://www.npr.
org/sections/health-shots/ .2013/09/20/224507654/how-many- die-from-medical-mistakes-in- u-s-hospitals - Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. National Academy Press.
Enhancing Quality and Safety
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.
Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based
As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a safety quality issue in a health care setting. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM.
Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding a specific safety quality issue, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based
Scenario
Select one of the safety quality issues presented in the Assessment 01 Supplement: Enhancing Quality and Safety [PDF] resource and incorporate evidence-based
Instructions
For this assessment, you will analyze a safety quality issue in a health care setting and identify a quality improvement (QI) initiative.
Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score.
- Explain factors leading to a specific patient-safety risk in a health care setting.
- Explain evidence-based and best-practice solutions to improve patient safety and reduce costs.
- Explain how nurses can help coordinate care to increase patient safety and reduce costs.
- Identify stakeholders with whom nurses would coordinate to drive safety enhancements with a specific safety quality issue.
- Communicate using writing that is clear, logical, and professional, with correctgrammar and spelling, using current APA style.
Additional Requirements
- Length of submission: 3–5 pages, plus title and reference pages.
- Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
- APA formatting: References and citations are formatted according to current APA style.