Improvement Plan Tool Kit

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6 hours ago

Improvement Plan Tool Kit

Patient identification errors threaten patient safety and care quality. This toolkit provides evidence-based resources organized into three themes to help nurses and teams implement protocols, integrate technology, and improve training to reduce misidentification and enhance safety outcomes.

Annotated Bibliography

Standardized Patient Identification Protocols

De Rezende, H., & Melleiro, M. M. (2022). Towards safe patient identification practices: The development of a conceptual framework from the findings of a Ph.D. project. The Open Nursing Journal, 16(1). https://doi.org/10.2174/18744346-v16-e2209290

This article presents a conceptual framework that outlines how organizational structure, leadership, education, and continuous feedback must work together to sustain safe patient identification. The authors argue that focusing solely on frontline behavior is insufficient; change must be embedded at a system level. This resource supports long-term sustainability by helping nurse leaders identify gaps in leadership support, staff accountability, and policy enforcement. It is particularly useful during redesign efforts for identification workflows or when launching multi-disciplinary safety initiatives. The framework emphasizes that when education, culture, and policy are misaligned, misidentification risks remain high, even with protocols in place. It adds value by promoting systems thinking, accountability loops, and continuous improvement cycles. Nurses and QI teams can apply the model when identifying root causes of recurring ID errors or leading staff workshops. It can also serve as a theoretical basis for grant proposals or policy justification. This resource enriches the planning process by linking high-level leadership to unit-level practices.

De Rezende, H., 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(1), 109–121. https://doi.org/10.2174/1874434602115010109

This systematic review identifies successful interventions used in hospitals to reduce patient ID errors, such as wristband verification, verbal confirmation, and barcode scanning. The review confirms that combining multiple techniques provides better outcomes than single-method strategies. It supports evidence-based decision-making by showing which interventions have the highest impact, allowing nurse leaders to tailor solutions based on organizational capacity. Nurse educators can use the findings to prioritize interventions during simulation training or competency reviews. The article’s strength lies in its comparative data, which reduces uncertainty when choosing interventions. Quantifying safety outcomes across different strategies allows clinical teams to allocate resources efficiently and reduce trial-and-error implementation.

Nurses can use this review to propose new workflows, strengthen existing protocols, or support funding requests. It is also a strong reference for unit-based safety rounds or staff feedback sessions focused on continuous improvement.

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

This article analyzes patient identification techniques across healthcare systems, emphasizing the need for interoperability, proper training, and standardized workflows. It identifies barriers such as data duplication, inconsistent practices, and a lack of integration between EHR systems. This resource is highly useful during health IT upgrades or when standardizing identification processes across departments. It helps nurse informaticists and clinical educators understand where breakdowns occur in ID workflows, even when policies exist.

Its value lies in addressing failure points like record mismatches and scanning errors. The article encourages proactive audits, shared protocols, and strong staff training to close safety gaps. Nurses can use this resource to improve ID verification during transitions of care, admissions, and interdepartmental transfers. It also supports discussions in interdisciplinary safety committees and performance reviews. The article reinforces that successful identification requires consistent execution across technology, policy, and people.

The Joint Commission. (2023). National patient safety goals will be effective in January 2024 for the hospital program. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf

The Joint Commission’s National Patient Safety Goals (NPSGs) serve as the regulatory foundation for patient identification safety in U.S. healthcare settings. It mandates the use of at least two identifiers, such as name and date of birth, before treatment or procedures. These standards are intended to reduce wrong-patient mistakes in medication, surgery, and diagnostics. Their support is crucial to the application and continuation of any patient identification improvement plan. It helps maintain congruity with national requirements and assists nurse managers in achieving institutional readiness for accreditation. For nurse educators, it is a go-to guide during orientation and competency training. Its value lies in its proven impact: healthcare organizations adhering to the two-identifier rule have significantly reduced misidentification incidents. The guidelines also foster system-wide consistency across departments. Nurses can apply this resource in practice by incorporating protocols at every point of care, recording their actions, and assisting their peers in introducing verbal checks. It may also be used to map internal policy audits or organize an in-house simulation training exercise. In sum, this resource is a ready tool for designing safe and effective identification processes and minimizing associated risks.

Technology Integration for Safety

D’Angelo, A., & Kchir, H. (2023, July 24). Error management training in medical simulation. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK546709/

This resource discusses simulation-based training that reinforces the proper use of technology, including barcode scanning, EHR input, and patient ID protocols. It emphasizes how simulation helps staff identify error-prone situations and correct their behaviors in safe, controlled environments.

This article is crucial for reinforcing the use of ID technology. It enhances sustainability by embedding technological skills into ongoing competency programs. Nurse educators and simulation specialists will find this particularly relevant when developing high-fidelity scenarios. Its risk-reduction value lies in reducing human error during interactions with health IT systems. It increases confidence as well as the adherence to perfect compliance through practice and ensures a better understanding and the desired long-term retention of the executed processes in cases of exigent or stressful conditions.

Nurses could use it during the normal cycles of the performance training or orientation sessions. It also assists in defining the employees who may require additional training or time on activities that involve technology. This tool enhances simulation learning on safety practices, which require the application of technology and enhances the teaching of multi-disciplinary team projects.

Mulac, A., Mathiesen, L., Taxis, K., & Granås, A. G. (2021). Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ Quality & Safety, 30(12), 1021–1030. https://doi.org/10.1136/bmjqs-2021-013223

This study examines real-world deviations from barcode medication administration (BCMA) protocols in hospital settings. Despite BCMA’s proven role in reducing medication and identification errors, the study highlights challenges such as workarounds, device malfunctions, and noncompliance by staff.

This resource is necessary for safety improvement efforts because it identifies why technology implementation often fails in practice. For nurse managers, informatics teams, and educators, this study provides insight into both human and system-level barriers that undermine ID safety.

The article reduces risk by encouraging proactive responses to BCMA challenges, such as targeted training, improved device availability, and policy reinforcement. It also supports the need for ongoing staff engagement post-implementation. Nurses can apply this knowledge in barcode scanner training, compliance auditing, and safety rounding. It can also be used to revise standard operating procedures and troubleshoot workflow inefficiencies. This resource is vital for ensuring BCMA isn’t just implemented but actually sustained in daily clinical practice.

Popescu, C., El-Chaarani, H., El-Abiad, Z., & Gigauri, I. (2022). Implementation of health information systems to improve patient identification. International Journal of Environmental Research and Public Health, 19(22), 15236. https://doi.org/10.3390/ijerph192215236

This article examines how health information systems (HIS) enhance patient identification through real-time data validation and optimized electronic health records (EHRs). Case studies show reduced ID errors through digitized workflows and EHR-driven alerts. The resource supports sustainable safety improvements by reducing manual entry and promoting standardized templates. It is especially relevant for nurse informaticists and clinical IT teams working on system upgrades. Nurses can apply insights from this article by participating in EHR optimization, identifying workflow gaps, and supporting staff training. It bridges technical design and bedside practice, reinforcing the value of integrating smart systems to improve patient safety and reduce misidentification.

Rajurkar, S., Verma, T., Mishra, S. P., & Bhatt, M. (2024). Novel artificial intelligence tool for real-time patient identification to prevent misidentification in health care. Journal of Medical Physics, 49(1), 41–48. https://doi.org/10.4103/jmp.jmp_106_23

This article presents an artificial intelligence (AI) system designed to detect ID mismatches in real-time. The AI tool compares patient data across multiple records and alerts staff when duplication, conflicting information, or incomplete profiles are detected. This resource is vital for future-proofing patient safety systems. It supports both implementation and sustainability by introducing automation to monitor risk continuously. It is especially useful for nurse informaticists, safety leaders, and IT developers focused on high-reliability practices.

Its value lies in reducing the cognitive burden on staff and minimizing reliance on human memory or recognition. The AI system improves safety by preventing errors at registration, documentation, and clinical decision points. Nurses can use this tool to support safe patient handoffs, admission verification, and EHR documentation reviews. The article also helps staff understand how smart tools integrate into workflows to reinforce safety in high-volume or high-acuity settings. It provides a forward-looking lens for nurse leaders advocating for tech-enhanced patient safety.

Staff Training and Simulation

Burgener, A. M. (2020). Enhancing communication to improve patient safety and increase patient satisfaction. The Health Care Manager, 39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298

This article highlights the critical role of nurse-patient communication in reducing errors, especially during identification checks. It calls for such practices as listening intently, asking permission before doing anything to patients, and questioning how patients have been called by others.

This tool provides the nurses with the needed knowledge and practice for avoiding ID errors through the use of critical verbal communication. It enables the bedside nurses to put clients on familiar terms safely. Areas such as pediatrics, geriatrics, or patients with cognitive impairments are at high risk for falls; thus, the finding is highly relevant. The value of reducing patient safety risks is clear—patients are less likely to be misidentified when they are actively involved. By enhancing communication, nurses also promote trust, satisfaction, and shared accountability.

In practice, this article can be used to enhance simulation scenarios, onboarding education, and communication-focused workshops. Nurse managers and educators can incorporate these principles into verbal ID protocols and interprofessional team drills. It reinforces that patient safety starts with effective, intentional communication.

Park, J., & Han, A. Y. (2022). Medication safety education in nursing research: Text network analysis and topic modeling. Nurse Education Today, 121, 105674. https://doi.org/10.1016/j.nedt.2022.105674

This study explores gaps in nursing education regarding medication and ID safety using text network analysis of academic publications. It recommends integrating error prevention and ID protocols more deeply into clinical education and simulation programs. This resource is necessary for educators redesigning curricula and simulation content. It reveals that although patient ID is critical, it is underrepresented in many training programs. It supports the long-term success of safety initiatives by embedding these skills early in a nurse’s career.

The risk-reduction value comes from its call to address educational gaps that lead to clinical errors. A simulation that reflects high-risk ID situations prepares staff for real-life decision-making. Nurses can use the article’s findings to advocate for updated clinical competencies. Educators may apply it to justify improvements in case-based learning or objective structured clinical examinations (OSCEs). This resource ensures that nursing education keeps pace with evolving patient safety demands.

Rodziewicz, T. L., Houseman, B., Vaqar, S., & Hipskind, J. E. (2024, February 12). Medical error reduction and Prevention. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499956/

This foundational text explores types of medical errors and strategies to prevent them, with emphasis on identification-related incidents. It outlines common contributing factors such as distractions, cognitive overload, and communication failures—all relevant to patient misidentification. This resource is critical for developing comprehensive training modules and reinforcing nurses’ responsibility for patient safety. Its wide scope enables nurse leaders and educators to use it as a primer in multi-disciplinary training or safety huddles.

Its value lies in offering root-cause insights that connect directly to ID failures. It encourages proactive safety cultures and emphasizes that nurses are key defenders against harm. In practice, nurses can apply lessons from this resource in near-miss analyses, risk management discussions, and quality improvement planning. It supports simulation scenario development and helps reinforce safe practices during all points of care. This article functions as both a reference and a teaching tool.

Zenani, N. E., Sehularo, L. A., Gause, G., & Chukwuere, P. C. (2023). The contribution of interprofessional education in developing competent undergraduate nursing students: Integrative literature review. BMC Nursing, 22(1), 315. https://doi.org/10.1186/s12912-023-01482-8

This integrative review highlights how interprofessional education (IPE) enhances nursing students’ competencies in communication, teamwork, and patient safety. It emphasizes that early exposure to collaborative learning fosters safer practices and shared accountability in clinical care, including patient identification. The resource supports sustainable safety initiatives by promoting team-based training and cross-checking during high-risk situations. It is particularly useful for educators designing curricula that integrate interdisciplinary simulations. By reinforcing patient ID as a collective responsibility, IPE prepares nurses to reduce errors, clarify roles, and contribute confidently to safe, coordinated care across healthcare teams.

References

Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager, 39(3), 128–132. https://doi.org/10.1097/hcm.0000000000000298

D’Angelo, A., & Kchir, H. (2023, July 24). Error management training in medical simulation. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK546709/

De Rezende, H., 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(1), 109–121. https://doi.org/10.2174/1874434602115010109

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Question

Improvement Plan Tool Kit

For this assessment, build on the work done in your first three assessments and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan pertaining to a specific patient safety issue and put the plan into action.
Google Sites is recommended for this assessment; the tools are free to use and should offer you a blend of flexibility and simplicity as you create your online tool kit. Please note that this requires a Google account; use your Gmail or GoogleDocs login, or create an account following the directions under the “Create Account” menu.

Improvement Plan Tool Kit

Using Google Sites, assemble an online resource tool kit containing at least 8 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed.

It is recommended that you focus on the 3 most critical categories or themes with respect to your safety improvement initiative. For example, for an initiative that concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues.

Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories focusing on a specific patient safety issue. Each resource listing should include the following:

An APA-formatted citation of the resource with a working link.
A description of the information, skills, or tools provided by the resource.
A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative pertaining to a specific patient safety issue.
A description of how nurses can use this resource and when its use may be appropriate.

Remember that you must make your site “public” so that your faculty can access it. Check out the Google Sites resources for more information.

Additionally, 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 you understand what is needed for a distinguished score.

Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to a specific patient safety issue.
Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on a specific patient safety issue.
Analyze the value of resources to reduce patient safety risk related to a specific patient safety issue.
Present reasons and relevant situations for use of resource tool kit by its target audience.
Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting.
Example Google Site: You may use the example found on the Assessment 4: Google Sites reading list, Resources for Improved Heparin Infusion Safety, to give you an idea of what a Proficient or higher rating on the scoring guide would look like for this assessment but keep in mind that your tool kit will focus on promoting safety with the quality issue you selected in Assessment 1.

Competence Measured.

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Analyze the elements of a successful quality improvement initiative.
Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements focusing on a specific patient safety issue.
Competency 2: Analyze factors that lead to patient safety risks.
Analyze the value of resources to reduce patient safety risk related to a specific patient safety issue.
Competency 3: Identify organizational interventions to promote patient safety.
Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative pertaining to a specific patient safety issue.
Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care.
Present reasons and relevant situations for resource tool kit to be used by its target audience.
Communicate resource tool kit in a clear, logically structured, and professional manner that applies current APA style and formatting.