Improving patient safety in the healthcare sector remains a paramount issue despite years of research, policies, and development. In 1999, the Institute of Medicine (IOM) published a report, To Err is Human. The report estimated that American hospitals experience between 44000 and 98000 deaths from preventable medical errors (King et al., 2008). In the report, IOM argued that preventing medical errors required dramatic and system-wide changes. The report then provided strategies to recognize, prevent and mitigate the harm that results from medical errors. Today, the joint commission helps organizations implement rigorous standards and leading practices to improve patient safety to achieve leading the way to zero harm. A common patient safety issue is patient identification errors. Lack of accurate patient identification, as witnesses from the case scenario, could lead to preventable medical errors that could lead to injury or in the worst case scenario, patient death.
Potential Threat to Patient Safety
The issue in the scenario can be identified as a case of a patient identification error. According to Rashid (2021), wrong patient identification is a common problem in the United States due to the lack of a standardized method of identifying patients by all facilities. Wrong patient identification is a potential threat to patient safety as it may lead to wrong medication, wrong transplants, and wrong treatment plans (Wyatt, 2017). Patient identification errors could lead to death or irreversible health conditions.
In the case scenario provided, the officer identified B. Moore as B.R. Moore using the date of birth leading to the treatment of the wrong patient. This resulted in a patient identification errors between the officer and nurses involved. Due to the lack of a standardized patient identification method, the officer used the date of birth to identify the patient while the nurses involved used the name. Furthermore, the two patients were in rooms that are in close proximity, and worse still, the same the two patients were assigned the same nurses leading to wrong patient identification. Without a unique patient identifier, the proximity of the rooms the patients were in, failure to assign different nurses to each patient, same date of birth, and similar names could all lead to wrong patient identification.
Implications of Not Addressing Threat
Patient identification error is a common problem and hospitals nationwide have come up with an initiative to reduce such errors. The healthcare safety imperative about wrong patient identification says that before a procedure is performed, the entire care team should stop, and verify that they are at the correct site to perform the correct procedure on the right patient (Blouin, 2013). In this care, the healthcare imperative applies in that before administering any medication or performing any procedure on the patient, the nurses should have stopped to verify whether the procedure was for the patient name B. Moore or B.R. Moore. Once verified that the correct patient is B. Moore, the nurses would then verify whether it is the correct room for the procedure.
The Department of Health and Human Services (HHS) Office for Civil Rights is responsible for ensuring that patients are safe. Under the Patient Safety and Quality Improvement Act of 2005, the department creates Patient Safety Organizations (PSOs) that collect, aggregate, and analyze data to create uniform reporting for safety events. PSOs assist healthcare organizations by providing them with insights into effective methods of improving quality and safety (Agency for Healthcare Research and Quality, 2022). The Joint Commission regulates patient safety by helping organizations implement quality improvement strategies and patient safety techniques in healthcare.
The Joint Commission has national patient safety goals intended to reduce patient identification errors in all stages of diagnosis and treatments. In its first patient safety goal, the Joint Commission aims at improving the accuracy of patient identification using two methods. First, reliably identify the individual as the person to whom the treatment is intended (The Joint Commission, 2022). This will ensure that no patient undergoes a procedure or receives medication meant for a different person. Second, to match the treatment to that individual. To achieve this goal, the Joint Commission recommends the use of different unique identifiers to identify the patient (The Joint Commission, 2022). Examples of unique identifiers include name, date of birth, telephone number, or a unique person-specific identifier. To correctly identify a patient, the Joint Commission recommends the use of at least two identifiers to identify a patient, having specimen containers labeled in the presence of the patient, and using distinct methods to identify newborns.
Regulatory agencies have a significant impact on organizations’ patient safety programs. The joint commission, for example, visits healthcare organizations between 18 to 36 months after the previous survey and surveys the organization to ensure that healthcare organizations remains in compliance with patient safety regulations. TJC commission also uses surveys to track performance standards and outcome measures. To ensure that healthcare organizations incorporate regulatory agency’s guidance when establishing reporting and investigation practices, TJC makes unannounced visits to healthcare organizations and ensures that they are continuously preparing for the TJC visit. Healthcare organizations must have the TJC certificate to obtain liability insurance and gain support from the state and federal government through Medicare and Medicaid.
To protect the public from unscrupulous healthcare organizations, TJC has specific standards and quality measures to keep healthcare organizations accountable. However, to encourage accurate reporting, TJC makes accreditation of healthcare facilities voluntary. Despite accreditation being voluntary, being accredited is a sign that a healthcare organization is committed to high standards of patient safety and thus encourages organizations to pursue the best practices. Rather than punishment, TJC encourages a culture of trust in healthcare staff and healthcare organizations and works to eliminate the fear of punishment and rather encourage learning from safety incidents (Sentinel Event Alert, 2018). However, the commission draws a clear line between human error and at-risk or reckless behaviors to encourage organizations to engage in the process of improvement.
Patient Safety Officer’s Role in Effective Implementation of Patient Safety Plans
The Patient Safety Officer in a healthcare organization is responsible for ensuring that patients receive highly effective and safe care. According to Pratt (2014), a typical day of a patient safety officer involves lots of communication on patients’ events and processes and putting ways to prevent adverse effects in the processes. However, the American Society of Health-System Pharmacists (ASHP) believes that for a healthcare organization to provide safe medical care, it has to have an innovative leader who identifies opportunities to improve the medication-use system (American Society of Health-System Pharmacists, 2014). This leader sets vision and direction and oversees the implementation of error-prevention strategies. A patient safety leader, therefore, leads the organization in change, research, and education, providing expertise in patient medication and leading the organization to a healthcare safety culture.
In the specific case of patient identification error between B. Moore and B.R. Moore, the role of the patient safety officer is to encourage healthcare staff to accurately and promptly report the safety incident to allow for intervention measures. Once the incident has been resolved, the patient safety officer’s role extends to providing expertise in patient safety by performing team training, developing patient identification procedures, and motivating staff who reported to encourage reporting in the future. An example of a Patient Safety Officer’s role, in this case, is provided by Pratt (2014) where she encourages a safety culture by opening a discussion on transparency in incident reporting. This will enable the organization to understand the pain points and implement strategies to reduce cases of patient identification errors, for example, using more than two patient features for identification.
Recommendations to Reduce Patient Safety Threat
To reduce patient safety threats associated with patient identification errors, the following is the five-point plan to improve patient identification, incident response, incident reporting, and operational considerations to mitigate future occurrences.
- Use at least two patient identification methods
For healthcare staff to perform a procedure or administer medication, they should reliably identify a patient and match the service or treatment to that individual using at least two methods of identification. The Joint Commission (2022) recommends using the patient’s name, date of birth, or a unique medical record number. All specimens must be labeled in the presence of the patient and newborns should have a distinct method of identification.
The pre-scanning workflow must not be interrupted and should use an electronic identification tool with another staff performing manual verification using both names of the patient and a unique medical Record Number (MRN) (Vu, 2020).
- Utilize electronic medical records
To reduce errors associated with manual verification and identification, implement electronic medical records where patient identification will be done using barcode scanners on barcodes printed wristbands that admitted patients will at all times while in the healthcare facility. Healthcare staff must scan the wristbands using a barcode scanner before performing a procedure or administering medication.
- Efficient allocation of duties to staff
According to Vu (2020), 80% of patient identification errors occur due to one staff working on too many patients. Efficient deployment and duty allocation using a staff management tool can significantly reduce cases of patient identification errors. Healthcare organizations should use the tool to increase the number of staff during peak periods, for example, late afternoons. Efficient deployment of staff will reduce burnout and ensure that healthcare staff is active during patient identification.
- Use convenient medication error reporting tools
Healthcare organizations should implement medication error reporting tools that accurately capture the system and processes that led to the occurrence of the error. According to Nosek et al. (2005), a standardized error reporting tool that allows anonymous reporting will reduce staff’s fear of malpractice lawsuits, disciplinary action, and public embarrassment. It will enable staff to freely report errors and thus accurately capture consistency and enable internal error tracking.
- Measure and analyze medical errors
A combination of measurements is necessary to effectively monitor and analyze medical errors. Latent errors can be identified and analyzed by tracking malpractice claims, morbidity and mortality differences, and autopsies. However, careful analysis using visualization tools such as charts in dashboards and calculating rates would effectively assist in reducing medical errors (Thomas & Petersen, 2003).
Conclusion
Despite the great advancements in technology, medical errors remain an issue in the healthcare sector around the world. Patient identification error is a medical error that involves misidentifying a patient and giving the wrong medication, performing the wrong transplant, or giving the wrong treatment plans. Such errors result in irreversible effects and sometimes death of the patient. Patient identification errors can be reduced by using more than one identification method, accurately reporting errors in identification, and encouraging a reporting culture.
References
Agency for Healthcare Research and Quality. (2022). Patient safety organizations program. AHRQ. Retrieved October 27, 2022, from https://www.ahrq.gov/cpi/about/otherwebsites/pso.ahrq.gov/index.html
American Society of Health-System Pharmacists. (2014). ASHP statement on the role of the medication safety leader. Best Practices for Hospital & Health-System Pharmacy, pp. 207–210.
Blouin, A. S. (2013). High reliability: Truly achieving healthcare quality and safety. Frontiers of Health Services Management, 29(3), 35–40. https://doi.org/10.1097/01974520-201301000-00005
King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J. … & Salisbury, M. (2008). TeamSTEPPS™: team strategies and tools to enhance performance and patient safety. Advances in patient safety: new directions and alternative approaches (vol. 3: performance and tools).
Nosek, R. A., McMeekin, J., & Rake, G. W. (2005). Standardizing medication error event reporting in the US Department of Defense. Advances in patient safety: from research to implementation, 4, 361-74.
Pratt, N. (2014). Quality officer takes on patient safety challenges. Biomedical Instrumentation & Technology, 48(4), 277–280.
Rashid, S. (2021, June 22). Wrong patient identification has severe consequences for hospitals and patients. Patient Safety & Quality Healthcare. Retrieved October 27, 2022, from https://www.psqh.com/analysis/wrong-patient-identification-has-severe-consequences-for-hospitals-and-patients/
Sentinel Event Alert (2018). Developing a reporting culture: Learning from close calls and hazardous conditions.
The Joint Commission. (2022). National Patient Safety Goals® Effective January 2022 for the Hospital Program.
Thomas, E. J., & Petersen, L. A. (2003). Measuring errors and adverse events in health care. Journal of General Internal Medicine, 18(1), 61–67. https://doi.org/10.1046/j.1525-1497.2003.20147.x
Vu, C. T. (2020, January 29). Patient identification errors: A systems challenge. Patient Safety Network. Retrieved October 27, 2022, from https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
Wyatt, R. (2017). Building safe, highly reliable organizations: CQO shares words of wisdom. Biomedical Instrumentation & Technology, 51(1), 65–69.
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