Assessment 02: Root-Cause Analysis and Safety Improvement Plan
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Root-Cause Analysis and Safety Improvement Plan
The present paper aims at developing a Root-Cause Analysis (RCA) and safety improvement plan for the problem of patient misidentification in Harmony Valley Hospital. A sentinel event arose when two patients with the same name and age of 60 years were admitted to the same facility on the same day thus assigning the two patients the same identification name led to confusion which confused treatment. This assignment will discuss the causes of this misidentification error and discuss a safety improvement plan with a focus on training, technology, communication, and organizational resources.
Analysis of the Root Cause
The patient safety issue is the following misidentification error that happened at Harmony Valley Hospital. Two patients were admitted with the same name; Mary Jones both are 60 years old. The first patient had hypertension disease while the second patient was due for a colonoscopy examination. Because of a breakdown in the patient identification process, Mary Jones admitted with hypertension was given colonoscopy preparation which was a regimen for bowel cleansing. This error resulted in the following complications with the patient; dehydration and a prolonged stay in the hospital. This a good example of why is important to have strict identification measures in place to avoid such mistakes and maintain patient safety.
A root cause analysis pointed out the following causes of this patient misidentification. Firstly, the researchers could not establish that the employees received their formal education or training on the patient identification protocols (Riplinger et al., 2020). The staff of Harmony Valley Hospital failed to identify the patients correctly despite following the minimum identification norms which included only the name and age of the patient. This omission took place because healthcare practitioners were not knowledgeable and made uniform on the necessity of applying many patient identifiers as prescribed in the guidelines. If these protocols were being practiced it would have been very difficult for the two patients to be distinguished because they both were named Mary Jones.
The other factor was the lack of effective communication between the various healthcare givers (Gupta & Sahoo, 2020). In particular, there were some breakdowns when passing patients from the nursing side to the administrative shift, which was in charge of identification. Lack of communication caused the failure to convey the essential patient information and thus the wrong patient was administered colonoscopy preparation. Such poor communication was topped up by the absence of formal communication means like checklists or proper handover protocols that could reduce patient identification errors. This study showed that information that should be passed on when changing shifts or between departments was not passed in full, and this affected the administration of care leading to misidentification. Major causes of the error include the absence of proper tools to identify patients in the operating room. Most healthcare organizations use barcodes, such as barcode scanning and electronic health records (EHRs) with integrated identification tools, but they have not done this at Harmony Valley Hospital (Vanneman et al., 2020).
Finally, staffing difficulties and high patient-to-staff ratios were other reasons (Vanneman et al., 2020). As we have seen, when there are few employees or high turnover in health facilities, the chances of malevolent actors being rushed through the verification processes increase. In this case, the staff members did not have enough time or resources to cross-verify the patient identifiers as well as they should. They said this led to the elimination of a key identification process that could have helped avoid the mix-up.
Application of Evidence-Based Strategies
Patient identification errors represent one of the major safety concerns in the healthcare system; thus, resolving this problem must be based on the identification of the best practices and ideal approaches. In the root-cause analysis, the occurrence of the event at the Harmony Valley Hospital where two patients with the same name; Mary Jones was caused by multiple. Consequently, strategies to address these areas based on available evidence are crucial in the prevention of redesign and enhancement of patient safety.
1. Enhancing Education and Training on Patient Identification Protocols
Several researches have indicated that inadequate knowledge of identification procedures is always to blame, especially when patients are confused by resemblance in their names or other characteristics. Thus, extensive training interventions have to be designed to increase staff knowledge and skills regarding the application of multiple identifiers including medical record numbers and date of birth (Samadbeik et al., 2020). Orientation of new employees and annual in-service education for other employees can make sure that proper identification of patients is conducted in all the departments.
2. Enhancing Interprofessional Relations Among the Health Care Team
Failure in the communication system is the major cause of misidentification errors that may occur in the process. Nasiri et al. (2021) prove that the lack of effective communication especially during handovers when transferring information between shifts or departments is a root cause of safety concerns. One of the best practices for managing this issue is to follow organized communication methods such as SBAR tools, which may help enhance the communication process by providing methods of passing over patient information (Coolen et al., 2020). It has been ascertained that the SBAR system minimizes confusion and guarantees that all the paramount patient information, including their identification information, is communicated accurately and coherently.
3. Integrating Advanced Patient Identification Technologies
Harmony Valley Hospital has shown that patient misidentification errors are partly due to the lack of strong patient identification systems. A recent study on the use of EHRs and barcode medication administration also proposes that these are effective ways of reducing errors by enhancing patient identification(Pruitt et al., 2023). As found in the literature, BCMA has been revealed to reduce medication errors dramatically, especially due to the confirmation of the patient’s identity before the administration of treatments (Hutton et al., 2021). Similarly, when EHRs contain features with a patient’s specific identification like the medical record number, a photo, or biometrics, identification accuracy will be enhanced given identical first and last names and ages. However, for these technologies to be properly used in the hospitals the staff should be trained on how to use the barcode scanners and how to incorporate the EHR systems into their working systems.
4. Optimizing Staffing Levels and Reducing Workload Pressures
High patient-to-staff ratios and staff fatigue are well understood as the main causes of misidentification errors. Under-staffing and high workload hike the probability of incomplete or hurried patient identification. According to the recommendations, hospitals should attempt to operate at staff utilization, which means that healthcare providers should not be overworked and should have too many patients to attend during certain hours of the day or night (Liu et al., 2020). From different works, it was found that proper staffing leads to better patient safety since nurses and other healthcare workers have adequate time to do proper examinations and devote their attention to the patient.
Improvement Plan with Evidence-Based and Best-Practice Strategies
The first key activity of the safety improvement plan involves improving the process of identifying patients. A major weakness, which led to the problem at Harmony Valley Hospital, was the use of inadequate identifiers including the patient’s name and age which are not distinctive enough. Literature has shown that increased use of patient identifiers can greatly decrease the likelihood of patient misidentification (De Rezende & Melleiro, 2022). The objective of this action is to decrease the number of wrong patient identification mistakes and create a better and safer identification process, to guarantee that the correct patient gets the right treatment.
Besides, the plan will aim at increasing identification measures because the misidentification error stemmed from poor communication between the staff at Harmony Valley Hospital. To resolve this problem, the SBAR (Situation-Background-Assessment-Recommendation) process of communication will be introduced as a formal approach to patient handover. Ruhomauly et al. (2019) have found that the application of the SBAR framework leads to the enhancement of clarity, and minimization of mistakes during handovers since the six ‘Cs’ of information exchange are maintained. The expected result of the change is an enhancement of communication and coordination among the members of the healthcare team to pass all essential information and patient identification without fail. The other core activity in the safety improvement plan is the use of an enhanced patient identification system. The plan also says it will employ barcode scanning systems and a more secure EHR system that will integrate photographs and biometric information of the patient. Barcode scanning helps to minimize the chances of patient identification mistakes, including cases where the patients’ names and other features are similar.
Last but not least, the management’s safety improvement plan has a particular focus on staff training and professional enhancement (Zajac et al., 2021). A primary contributor to the misidentification error identified at Harmony Valley Hospital was insufficient training in the correct patient identification procedures. To resolve this, the hospital intends to implement new training sessions that will be obligatory for all personnel and will be devoted to the identification of multiple patient identifiers and the correct methods of verifying patient identity.
The first two months of the plan will be spent on planning and policy-making and it will involve the development of the two-patient identifier policy, implementation of the bar-code scan, and the use of the SBAR communication system (Samadbeik et al., 2020). The next two months will be spent on staff training and the introduction of new technologies to the company. The hospital will implement training and start the process of using bar-coded devices and newly developed EHR systems. In the last two months, the hospital will perform audits and assessments to see the benefits of the changes that have been made and improvements if any will be made. The new communication practices will also be assessed through feedback received from the staff during team huddles. Health checks will enable one to determine any recommendations for change and guarantee that the safety improvement plan is yielding the right results.
Existing Organizational Resources
Implementing new identification protocols involves nursing staff and nurse managers who can enforce the protocols while the job of overseeing the adherence to the new plan and evaluating its effectiveness can be assigned to the QI team. These personnel are in a better place to change and enforce the new policies. Such assets of the hospital as Electronic Health Records (EHR) and barcode scanning technology should be effectively used for patient identification (Vanneman et al., 2020). As the technologies advance, these advancements can add even more patient identifiers including photographs making the identification process far easier. The IT department is expected to have a large say in how these systems will be integrated and adapted.
There are organized training systems that can be employed to support the changes in identification in the hospital. The nurse education team can conduct a simulation of training to ensure that the correct identification policies are followed (Koukourikos et al., 2021). Also, the use of the SBAR communication model will enhance handoffs and guarantee the proper transfer of information across the practitioners. To implement the plan, the hospital may require brand new and improved patient identification techniques like biometric scans, and outside education sources to further develop employee expertise for the long haul.
Conclusion
In conclusion, the root cause for the patient misidentification problem and the safety improvement plan for Harmony Valley Hospital show that the hospital must develop better identification processes, better communicative practices, and apply new technologies. This approach to patient safety addresses the causes of problems, including insufficient training, ineffective communication, and obsolete technology. The measures proposed in the present work will help avoid similar mistakes in the future and enhance safety for both patients and healthcare staff through proper training, technological modernization, and improved communication.
References
Coolen, E., Engbers, R., Draaisma, J., Heinen, M., & Fluit, C. (2020). The use of SBAR as a structured communication tool in the pediatric non-acute care setting: Bridge or barrier for interprofessional collaboration? Journal of Interprofessional Care, 1–10. https://doi.org/10.1080/13561820.2020.1816936
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
Gupta, S., & Sahoo, S. (2020). Pandemic and mental health of the front-line healthcare workers: a review and implications in the Indian context amidst COVID-19. General Psychiatry, 33(5), e100284. https://doi.org/10.1136/gpsych-2020-100284
Hutton, K., Ding, Q., & Wellman, G. (2021). The effects of bar-coding technology on medication errors. Journal of Patient Safety, 17(3), 192–206. https://doi.org/10.1097/pts.0000000000000366
Koukourikos, K., Tsaloglidou, A., Kourkouta, L., Papathanasiou, I., Iliadis, C., Fratzana, A., & Panagiotou, A. (2021). Simulation in clinical nursing education. Acta Informatica Medica, 29(1), 15–20. https://doi.org/10.5455/aim.2021.29.15-20
Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., Xia, L., Liu, Z., Yang, J., & Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), 790–798. https://doi.org/10.1016/S2214-109X(20)30204-7
Nasiri, E., Lotfi, M., Mahdavinoor, S. M. M., & Rafiei, M. H. (2021). The impact of a structured handover checklist for intraoperative staff shift changes on effective communication, OR team satisfaction, and patient safety: a pilot study. Patient Safety in Surgery, 15(1). https://doi.org/10.1186/s13037-021-00299-1
Pruitt, Z. M., Kazi, S., Weir, C., Taft, T., Busog, D.-N., Ratwani, R., & Hettinger, A. Z. (2023). A systematic review of quantitative methods for evaluating electronic medication administration record and bar-coded medication administration usability. Applied Clinical Informatics, 14(01), 185–198. https://doi.org/10.1055/s-0043-1761435
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
Ruhomauly, Z., Betts, K., Jayne-Coupe, K., Karanfilian, L., Szekely, M., Relwani, A., McCay, J., & Jaffry, Z. (2019). Improving the quality of handover: Implementing SBAR. Future Healthcare Journal, 6(2), 54. https://doi.org/10.7861/futurehosp.6-2s-s54
Samadbeik, M., Fatehi, F., Braunstein, M., Barry, B., Saremian, M., Kalhor, F., & Edirippulige, S. (2020). Education and Training on Electronic Medical Records (EMRs) for health care professionals and students: A Scoping Review. International Journal of Medical Informatics, 142(1), 104238. https://doi.org/10.1016/j.ijmedinf.2020.104238
Vanneman, M. W., Balakrishna, A., Lang, A. L., Eliason, K. D., Payette, A. M., Xu, X., Driscoll, W. D., Donovan, K. M., Deng, H., Dzik, W. H., & Levine, W. C. (2020). Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis. Anesthesia & Analgesia, 131(4), 1217–1227. https://doi.org/10.1213/ane.0000000000005084
Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: A team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6(1), 1–20. https://doi.org/10.3389/fcomm.2021.606445
