NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Name

Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Enhancing Quality and Safety 

A fundamental part of the care process and a relevant resource for patients in healthcare settings is patient identification. It is crucial for healthcare professionals, including doctors, nurses, and hospital administrators, to understand that accurate patient identification is not just a routine task but a big responsibility that directly affects patient safety, as any errors in identifying a patient can lead to potentially serious medical mistakes. In the United States, a recent report reviewed medical errors as the third leading cause of death. Per the report, up to 1.1% of hospital admissions have resulted in deaths because of medical errors. In particular, in 2013, over 400,000 medical errors caused deaths. (Aghighi et al., 2022).

Factors Leading to Patient-Safety Risk

Some studies suggest that the most experienced nurses think they know patients well enough not to deem further identity checks necessary. They only use the identification process for safety from distractions and interruptions. Nitro et al. (2021). Patient identification errors occur when a healthcare staff member does not accurately identify a patient. This can involve similar patient names, asking for the patient’s names but not verifying with the identification armband, or not using the two identifiers, such as a patient’s full name, date of birth, or medical record number (MRN) number.

A study done for approximately six months in 2019 by the Joint Commission’s sentinel event statistics showed that 37 patient safety events out of 436 sentinel events occurred because of patient identification errors (Riplinger et al., 2020). Identification errors can lead to the wrong medication, surgery on the wrong person, or misinterpreted medical test results. The cascading effects of this basic mistake in patient care can cause not just harm but even death to a patient.

Numerous factors influence patient identification errors in healthcare. They include systemic, human, and technological problems. Systemic issues arise from a deficiency of uniform protocols for patient identification. These factors vary across departments and settings and can lead to errors (Paradis et al., 2021). The Institute of Safe Medication Practices reports that a lack of steady processes is a key reason for identification errors. It results in unfavorable events and reduced patient safety (Rodríguez & Llamazares, 2020). Insufficient training on identification measures further raises the risk of mistakes.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Healthcare staff with systematic training in identification protocols tend to make fewer patient identification errors. Human factors also play an important role in patient identification errors. High workloads, stress, and exhaustion among healthcare staff decrease focus and increase identification errors. These mistakes occur when patients have similar names and communication between departments is poor (Choudhury & Vu, 2020). The Agency for Healthcare Research and Quality (AHRQ) reports that mistakes linked to fatigue are common in healthcare and can lead to serious patient safety problems due to identification errors. Poor communication among team members during patient handoffs can increase misidentification risks (Choudhury & Vu, 2020). 

Technological restrictions also contribute to risks in patient identification and quality of care. Services that depend on redundant and ineffective identification methods, including paper records or unlinked electronic systems, face higher error rates. A study from 2016 reports that 64% of people believed misidentification events were far above the industry’s acceptable rate of 8-10%, with these errors costing healthcare systems about $17.4 million annually (Choudhury & Vu, 2020). Compliance with regulatory benchmarks is also critical. Missed adherence can lead to misidentification and adverse patient outcomes. The Centers for Medicare and Medicaid Services (CMS) gives rules for patient ID precision. It emphasizes the significance of obeying these values to reduce mistakes and improve patient safety (Sragow et al., 2020).

Over the years, the World Health Organization (WHO) has developed patient safety guidelines to prevent medical malpractice, including preventing patient falls, patient identification, hand hygiene, and safe surgery. The Joint Patient Safety Group has introduced several patient safety goals to help healthcare providers create a safer environment for patients and themselves. (Aghighi et al., 2022).

The identification wristband is one of the most critical and reliable strategies, followed by double-checking patient information to prevent identification and wrong patient treatment. Nurses and all healthcare workers should use two patient identifiers. Hospitals have a two-person verification process to improve the safety of high-alert medications such as heparin drips and insulin, and they perform tasks such as Foley catheter insertion, in which two nurses independently verify the patient’s identity before proceeding. Sometimes, when necessary, they include information that enhances identification, such as a 

photo.

Evidence-Based and Best Practice Solutions

To enhance patient safety, the use of patient identification wristbands is vital. Wristbands and labels, if they match the patient, are a reliable source of verification; they provide patient safety, reduce costs, promote efficiency, and make the information accessible to share among healthcare workers. Healthcare workers should double-check against the patient’s name, date of birth, and medical record number (MRN). (Nitro et al., 2021). Introducing two-person verification for high-alert medications such as insulin or heparin drips and procedures like the Foley catheter insertion can help prevent errors. Sometimes, adding a patient’s photo can also assist in accurate patient identification.

Using technology can assist in patient identification; using biometrics (fingerprints), facial recognition, and barcodes is another vital solution to help improve patient identification, according to Nitro et al. (2021). The financial implications of patient identification errors are significant. According to Maul et al. (2022), medical errors cause a loss of USD 20 billion each year and cause 100,000 deaths; patient identification errors make up a part of the medical errors. Usually, patient identification errors start at the beginning of patient registration (Maul et al., 2022). Wrong records can lead to repeating tests, which consumes time, and the refusal of insurance claims, which increases costs to the healthcare facility.

Several evidence-based solutions can help enhance patient safety and control costs by addressing risks to care quality. Each technique decreases the chance of harmful events and the related economic or legal impacts. Standardized identification measures across healthcare facilities, combined with barcode scanning and biometric tools. These measures aid in improving precision. The WHO highlights reliable patient ID practices to lower error rates and boost safety in healthcare environments (Lima et al., 2022). This method helps reduce medical mistakes and reduces adverse events.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

It cuts costs tied to patient harm, extended treatments, and legal fees from malpractice. Developing robust training programs for healthcare workers is dynamic to safeguard accurate patient identification. These programs underline the critical role that correct identification plays in patient safety. Efficient training reinforces staff abilities. It helps them avoid mistakes in identification. Trained healthcare staff are more likely to obey standard procedures, which leads to better patient outcomes. This method can also decrease costs by avoiding issues tied to identification mistakes (Bhati et al., 2023).

Technology, like integrated Electronic Health Records (EHRs) and barcode systems, can automate patient identification and reduce dependence on manual entry. The AHRQ highlights that technology integration improves workflow proficiency and maximizes resource use. It leads to cost savings and increased patient confidence (Riplinger et al., 2020). Another best practice involves executing double-check systems and verification protocols for key tasks like medication administration, surgical site confirmation, and patient transfers. This action safeguards precise identification and decreases the chance of costly errors.

It has legal and monetary consequences (Koyama et al., 2019). The involvement of patients and their families in the identification process is useful. It confirms details, invites questions, and educates staff on the value of precise identification. The National Patient Safety Foundation (NPSF) highlights that this proactive method builds trust, drops the chance of errors, and improves patient satisfaction (AHRQ, 2023). Identifying mistakes can lead to costly consequences. It includes extended hospital stays, additional treatments, potential legal activities, and straining healthcare budgets.

NURS FPX 4020 Assessment 1 Enhancing Quality and Safety

Constant quality improvement and monitoring are also vital for identifying areas needing improvement. These efforts include tracking identification steps, reporting incidents, and collecting feedback. Implementing standardized patient identification procedures and inclusive training programs for healthcare staff cut costs associated with errors. Utilizing barcode scanning and integrated EHRs can reduce reliance on manual entry. It results in fewer identification mistakes (Riplinger et al., 2020). 

Role of Nurses

 Nurses play an essential role in coordinating care to improve patient safety. The goal is for nurses to follow the patient identification protocols and perform double-checks, thus minimizing errors. For instance, nurses ensure that the correct patient receives the care during the informed consent, marking or flagging the operating site and conducting “time out” checks (Nitro al., 2021). Collaboration helps avoid unnecessary medical interventions, thus reducing error costs.

Errors in patient identification are costly to the patient and cost healthcare billions of dollars. This can lead to significant issues with their care and safety, potential problems with billing and payment because of incorrect records, and complications with sharing medical data across different healthcare systems because of the lack of accurate patient matching. If a patient does not accurately match their health information, financial and resources are wasted. This leads to repetitive tests and treatments that add to costs and impact the timeliness of care delivery.

From a revenue cycle perspective, there may be claims denials and implementation of time-consuming and costly processes to correct medical records. Nurses should ensure the proper patient matches across healthcare systems to avoid data billing issues and compromise patients’ health and safety. These challenges can contribute to inefficiencies in the healthcare system and lead to avoidable financial losses. Studies report that 10 to 15% of all health insurance denials result from incorrect patient identification. (Riplinger et al., 2020). Cost reduction interventions to reduce the healthcare system’s financial burden may include team-building exercises. According to a study by Havaei et al. (2019), having nurses work in a team does not mean they will work effectively and efficiently; team-building strategies are necessary for collaboration. Once there is collaboration, medical errors are less likely to occur. 

Role of Stakeholders

The stakeholders with whom nurses can work to drive quality care to avoid patient identification errors, according to Deming (2022), are the “system leadership, technical leadership, and day-to-day.” Under the system leadership, we have a unit manager for the department who can enforce a change. Technical leadership comprises those who know and understand the problem and are the nurses themselves. The day-t o-day leadership is those who see the project details and how the operations work daily. Nurses should coordinate with stakeholders such as providers, families, and coworkers who interact directly with patients.

These play a crucial role in correctly identifying patients and ensuring proper care is directed to the right person. Significantly, nurses should coordinate with information technology professionals (IT) to enhance safety and quality. IT professionals can help implement technology solutions, such as bar coding systems or electronic health records, to reduce the risk of patient identification errors. More healthcare systems use modern technology (Laurisz et al., 2023). Advanced technology like the Internet, telecommunications tools, and the latest artificial intelligence (AI) are reducing patient identification errors. For instance, 3D photos and fingerprints can accurately identify an individual.

Regulatory Bodies and Accreditation Organizations such as the Joint Commission are entities that set standards for patient safety and can provide guidance and resources for improving patient identification processes. Hospital administrators implement policies and procedures that promote patient safety. They provide resources and support for initiatives to reduce patient identification errors. Health Information Management (HIM) staff manage patient records and other health information. They ensure that patient identification information is accurately recorded and easily accessible.

Conclusion

Improvement in patient identification processes is vital to safeguarding quality and safety in healthcare. Precise identification assistance avoids mistakes that result in harm and raised expenses. Healthcare services can employ solutions like standardized methods and advanced technologies by addressing systemic, human, and technological factors. Involving nurses and other stakeholders nurtures a culture of safety and practice adherence. Joint efforts among healthcare staff can notably decrease identification errors. It enhances patient safety and health outcomes.

References

Aghighi, N., Aryankhesal, A., & Raeissi, P. (2022). Factors affecting the recurrence of medical errors in hospitals and the preventive strategies: a scoping review. Journal of medical ethics and history of medicine, 15(7). https://doi.org/https://doi-org.library.capella.edu/10.18502/jmehm.v15i7.11049

AHRQ. (2023). AHRQ-funded patient safety project highlights improving healthcare safety by engaging patients’ and families’ overview. AHRQ.gov. https://www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-pfe.pdf 

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10). https://doi.org/10.7759/cureus.47731 

Choudhury, L., & Vu, C. (2020). Patient identification errors: A systems challenge. Psnet.ahrq.gov. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge 

Deming, W. E. [W. Edwards Deming]. (2022). Every team include members that represent three different kinds of expertise: system leadership, technical expertise, and day-to-day [Comment on the article “Quality Improvement”]. Johns Hopkins Nursing Center for Nursing Inquiry. https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/quality-improvement.html

Havaei, F., MacPhee, M., & Dahinten, S. (2019). The effect of nursing care delivery models on quality and safety outcomes of care: A cross-sectional survey study of medical-surgical nurses. Journal of Advanced Nursing, 75(10). https://doi.org/10.1111/jan.13997

Koyama, A. K., Maddox, C.-S. S., Li, L., Bucknall, T., & Westbrook, J. I. (2019). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality & Safety, 29(7), 595–603. https://doi.org/10.1136/bmjqs-2019-009552 

Laurisz, N., Cwiklicki, M., Zabinski, M., Canestrino, R., & Magliocca, P. (2023). The Stakeholders’ Involvement in Healthcare 4.0 Services Provision: The Perspective of Co-Creation. International journal of environmental research and public health, 20(3)(2416). https://doi.org/https://doi-org.library.capella.edu/10.3390/ijerph20032416

Lima, M. S. M. de, Santos, K. V. G. dos, Silva, T. T. M. da , Dantas, J. K. dos S., Araújo, S. C. M. de, Genuino, A. K. de O., Dantas, D. V., & Dantas, R. A. N. (2022). Effectiveness of implementing an improvement cycle in the identification of critically ill patients. Revista Brasileira de Enfermagem, 75(6), 1–8. https://doi.org/10.1590/0034-7167-2021-0346 

Maul, J., & Straub, J. (2022). Assessment of the Use of Patient Vital Sign Data for Preventing Misidentification and Medical Errors. Healthcare (Basel, Switzerland, 10(12)(2440). https://doi.org/10.3390/healthcare10122440

Nitro, M., Romano, R., Marletta, G., Sollami, A., La Sala, R., Artioli, G., & Sarli, L. (2021). The safety of care focused on patient identity: an observational study. Acta bio-medica : Atenei Parmensis, 92(S2)(e2021038). https://doi.org/https://doi-org.library.capella.edu/10.23750/abm.v92iS2.11328.

Paradis, E., De Freitas, C., Heisey, R., Burrell, K., Fernandes, L., McLeod, J., & Whitehead, C. R. (2021). Getting standardization right. Canadian Family Physician, 67(5), 323–325. https://doi.org/10.46747/cfp.6705323 

Riplinger, L., Piera-Jiménez, J., & Dooling, J. P. (2020). Patient Identification Techniques – Approaches, Implications, and Findings. Yearbook of medical informatics [Abstract from PMC]. year book of medical informatics, 29(1), 81–86. https://doi.org/10.1055/s-0040-1701984

Rodríguez, S. M., & Llamazares, C. M. F. (2020). Standardization for safety: A feasible challenge. Farmacia Hospitalaria, 44(3), 79–80. https://www.redalyc.org/journal/3659/365964773001/html/ 

Sragow, H. M., Bidell, E., Mager, D., & Grannis, S. (2020). Universal patient identifier and interoperability for detection of serious drug interactions: Retrospective study. JMIR Medical Informatics, 8(11), e23353. https://doi.org/10.2196/23353