Root-Cause Analysis and Safety Improvement Plan
Patient misidentification is a critical issue in healthcare, contributing to medication errors, wrong-site surgeries, delayed treatments, and adverse patient outcomes. This not only affects the patients, their rights, as well as their quality of healthcare but is also costly to healthcare institutions, thus increasing the financial liability of patients. According to Rodziewicz et al. (2024), patient identification errors cause about 13 percent of the total medical mistakes, hence the need to address the issue. Misidentification of patients is one of the significant factors contributing to adverse events, and the application of evidence-based approaches to this problem is essential for increasing patient safety: Root-Cause Analysis and Safety Improvement Plan.
Analysis of the Root Cause
Patient misidentification occurs when healthcare providers fail to accurately confirm a patient’s identity before delivering treatment, medication, or procedures. Patient identification errors can originate from communication breakdown, lack of policies and standard practices related to patient factors, and staff shortages. In everyday practice, especially in emergency departments, ICUs, and surgical wards, time factors and mistakes of employees further contribute to the increased risk of misidentification.
Lack of adequate identification involving patients can be attributed to misunderstandings and mistakes, which are common in humans. Miscommunication or misunderstandings may occur in spoken words, including name confusion, poor spelling, or improper relay of information from shift to shift or practitioner to practitioner, thus resulting in multiple charts, incorrect medication orders, or wrong-side surgeries. Notably, a study by Howick et al. (2024) found that poor communication and human error were responsible for 13 percent of patient misidentification. Due to the pressures of work, staff members in hectic healthcare organizations may fail to follow identification procedures.
The lack of identification protocols is a causal factor of the problem. Patient verification is not standardized in care organizations, hence disparities in patient data among the clinical departments. For instance, wristband labeling may vary between the inpatient and outpatient departments, thus posing a challenge in identification. Romano et al. (2021) note that the failure to follow proper protocols results in about 5.5% of patients being misidentified or having duplicate records.
Secondly, patient-related factors may be contributing to misidentification.
Identity verification is challenging to accomplish, particularly in cases involving patients who are unconscious, those with cognitive issues, or where patients may not be in a position to reply or grant permission, consequently raising the risk of mistakes. According to Romano et al. (2021), these factors account for roughly 11% of all misidentification cases. This causes confusion in treatment, as patients with similar names or birth dates can easily have their records swapped.
Lastly, a shortage of staff and increased workload also lead to the compromise of the time given for patients’ identification. Considering that the responsibility of establishing patient identification belongs to nurses, the latter can omit this procedure when they have too many patients to work with. Haddad et al. (2023) note that workload has an impact on the identification errors by nurses, adding that each twenty percent increase in workload is associated with a fifteen percent rise in identification errors. Besides, fatigued staff are known to have low adherence to proper verification procedures.
Application of Evidence-Based Strategies
Several evidence-based strategies have proven effective in reducing patient misidentification and improving patient safety. One of the most widely recommended practices is the use of two patient identifiers before administering medications or performing procedures. As stated in The Joint Commission’s National Patient Safety Goals for 2023, it is possible to establish at least two forms of identifiers before providing treatment or performing any procedure, such as name, date of birth, or an assigned patient number. This approach can achieve up to a 50% decrease in the number of misidentification errors (Wadhwa & Boehning, 2023).
Barcode scanning technology is yet another good practice. Patient wristbands that contain information and details about the patient can help in different operations like determining the right medication to give to the right patient, tests, or surgeries that have to be performed on the patient. According to Howick et al. (2024), the uptake of barcode scanning eliminates medication errors by 43-80%, while hospitals that have integrated this technology have recorded a 65% reduction in misidentification cases.
The use of standardized patient identification procedures is especially important in relation to the achieved consistency across departments. Hospitals that use patient verification every time a patient enters a facility or before doing any procedure have few incidents of misidentification. Riplinger et al. (2020) stipulate that, through the implementation of this strategy in hospitals, a reduction in misidentification errors can be achieved at 60%.
Another important factor is staff training and simulation-based learning. Continuing assessment assures healthcare workers about the correct process of patient identification, and constant training ensures that they remain aware of its significance. In their prospectively observational study, Rodziewicz et al. (2024) argue that if the respective hospitals conduct training sessions every quarter, there is likely to be a reduced rate of misidentification errors. The intervention involves staff engagement in simulation to identify patients in situations that help the staff improve their competency levels and confidence during actual scenarios.
Lastly, the use of AI in alerts in EHR systems assists in the detection of duplicated patient records and inconsistencies in patient information. This helps healthcare providers establish real-time alerts in case of a mismatch of the details of a patient, which will, in turn, call for confirmation. This integration also means that other records are not fragmented across departments, and, therefore, the risks associated with identification errors subside.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The following approaches should be adopted to reduce the cases of patient identification errors across healthcare institutions. The two important actions include two patient identifiers, a care coordinator, and corneal measurements. This requires healthcare institutions to check and confirm the patient’s identity, for instance, with two identifiers that are unique, which include the patient’s name, date of birth, or hospital number. This measure reduces the risk of misidentification errors to a very low level.
Another essential strategy is the expansion of barcode scanning technology. This system should be adopted universally to the wards, operating theaters, and blood transfusion departments to enhance identification accuracy during sensitive operations. AI-based alerts featured in EHRs will also be essential as these can help detect and prevent the appearance of twin patient records and data mismatches in real time.
Additionally, staff training and simulation-based learning for healthcare providers must be held on a quarterly basis. This will help the staff to check on the proper identification of a patient, hence improving the flow of communication and increasing the chances of correctly identifying the patient’s profile. The key objectives of the plan are to cut the number of patient identification errors by 60% within the year, comply with standards and administer more safely by decreasing the number of medication errors and misplaced records.
Table 1
Implementation Timeline
| Phase | Action | Timeframe |
| Month 1 | Initial assessment and planning | 4 weeks |
| Months 2-3 | Staff training and technology integration | 8 weeks |
| Month 4 | Pilot implementation | 4 weeks |
| Months 5-6 | Full rollout and continuous monitoring | Ongoing |
Existing Organizational Resources
To successfully advance the patient identification safety improvement plan, new and available human, material, and financial resources should be utilized, and more should be gained when necessary. Employees and medical workers are primarily responsible for adhering to the safety measures throughout the hospital. It is the responsibility of nurse managers to monitor and enforce compliance with patient identification procedures followed in the healthcare facility.
Health IT personnel will oversee the change of the EHRs and integrate the barcode issues to minimize cases of misidentification. Moreover, patient safety officers are responsible for monitoring compliance with the new policies and staff training programs in the framework of patient identification procedures, thus helping to support the education of newly inculcated protocols.
The use of technology and equipment can greatly help reduce errors. Currently, used barcode scanners will be adopted to cover all the patient touches, including surgery and blood transfusion. With intelligent, alert systems that are ready and effective EHR, real-time patient identification and evaluation of duplicate data and inconsistencies will be possible so as to avoid creating errors. For the plan to be implemented, there is a need for financial and administrative support.
Training would include such probabilities as funding by hospital leadership for the continued expansion of the barcode system and upgrading the EHR. Government patient safety grants will help to finance the acquisition of new scanners and safety-oriented artificial intelligence systems. Therefore, healthcare facilities can perpetually support the plan of enhancing the safety of patients by applying the aforesaid organizational resources.
Conclusion
Patient identification is an essential aspect of hospitals that helps in medication management and other practices; in this case, wrong patient identification leads to medication mistakes, wrong procedures, and patient harm, among others. Other significant causes include misunderstandings, lack of standard processes, and job pressure. Verification methods may be tested, compared to the standard, barcodes, AI-based alerts, and training can decrease error rates. Other aspects involve using the EHR systems, IT support, and quality teams in an effective manner, which would enable the improvement of patient safety.
References
Haddad, L. M., Butler, T. J. T., & Annamaraju, P. (2023). Nursing shortage. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493175/
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/
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
Wadhwa, R., & Boehning, A. P. (2023, March 16). The Joint Commission. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557846/
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Question 
For this assessment, you can use a supplied template to conduct a root-cause analysis. The completed assessment will be a scholarly paper focusing on a quality or safety issue in a health care setting of your
Introduction
As patient safety concerns continue to be addressed in the health care settings, nurses can play an active role in implementing safety
Once the causes of failures have been determined, a safety improvement plan can be developed to prevent recurrences. The baccalaureate nurse’s role as a leader is to create safety improvement plans as well as disseminate vital information to staff nurses and other health care
As you prepare for this assessment, it would be an excellent choice to complete the Quality and Safety
Professional Context
Nursing practice is governed by health care policies and procedures as well as state and national regulations developed to prevent problems. It is critical for nurses to participate in gathering and analyzing data to determine causes of patient safety issues, in solving problems, and in implementing quality
Root-Cause Analysis and Safety Improvement Plan
Scenario
For this assessment, use the specific safety concern
Instructions
The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the safety quality issue presented in your Assessment Supplement PDF in Assessment 1. Based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting, provide a rationale for your plan.
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.
- Analyze the root cause of a specific patient safety issue in an organization.
- Apply evidence-based and best-practice strategies to address the safety issue.
- Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
- Identify organizational resources that could be leveraged to improve your plan.
- Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.
Keep in mind that your Assessment 2 will focus on the quality issue you selected in Assessment 1.
Example Assessment:You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like but keep in mind that your Assessment 2 will focus on the quality issue you selected in Assessment 1 (Order 59648 ).
- Assessment 2 Example [PDF] (Attached)
Additional Requirements
- Length of submission: Use the provided Root-Cause Analysis and Improvement Plan template to create a 4–6 page root cause analysis and safety improvement plan
pertaining to a specific patient safety issue. - Number of references: Cite a minimum of 3 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
- APA formatting: Format references and citations according to current APA style.