Introduction: Issue Summary
This is a scenario where two patients have almost identical names. In addition, the patients are admitted on the same hospital floor in rooms adjacent to each other. More troubling is that both have very confusing birth dates. Similarly, the facility has a shortage of nurses, which may cause burnout, making them overlook these specific details, leading to misidentification, which may threaten the patients’ safety.
The hospital should have clear policies and procedures outlining how to document patient information. As delineated in NPSG.01.01.01, the goal of addressing this issue is two-fold: first, to correctly identify people that treatment is intended; second, to match the services to those individuals (The Joint Commission, 2020). In this case, improving identification accuracy can prevent patient data integrity failure and clinical errors that can compromise patients’ safety leading to detrimental health outcomes.
The focus will be on improving the nursing staffing level. The nurse in charge has stated that the hospital has recently been understaffed increasing shift time. This is a serious concern because when nurses attend to many patients, they may be fatigued, fail to fully engage with patients, and overlook specific details. Another item that will require much attention is the patient identification system used in the hospital. The issue of mismatched records is exacerbated when patients share similar identifiers, given that certain names are extremely common
Culture
Culture involves the behaviors, values, beliefs, and expectations that direct and inform the actions of all members in a given setting, such as a hospital. Such factors influence how employees communicate and collaborate to achieve set goals (Maheshkar & Sharma, 2018). It also impacts how the staff responds and adapts to new changes. A good work culture attracts top talents and also results in workers’ satisfaction which ultimately leads to positive outcomes.
A good organizational culture demonstrates positive behavior that contributes to enhanced performance. Conversely, a dysfunctional culture contributes to low staff engagement, well-being, and a high turnover rate. In this case, an organization cannot enhance patients’ experience without a great culture. A hospital setting where workers can freely report errors or near misses without fear of punitive responses significantly improves patient safety and high-quality services (Paradiso & Sweeney, 2019). However, if a facility focuses on punishing medical personnel for errors in the care process, the healthcare professionals may fail to report the mistakes, thus endangering patients’ lives.
Based on the patient ID scenario, the existing hospital culture in this healthcare setting is characterized by poor teamwork and collaboration. In this case, not all the care providers at the hospital are aware that two patients with almost identical names and birth dates have been placed on the same floor and opposite each other. This indicates poor communication among the staff, which may result in errors that threaten patient safety. In addition, handoffs should be done face to face beside the patient’s bed, but in this case, the nurses rely only on chart notes to guide them on how to administer care. This may lead to confusion, particularly during shift change, resulting in patient misidentification, which may cause medical blunders.
The evidence-based strategies that could be employed to create a safety culture include leadership walk rounds. In this case, the senior leaders in the healthcare setting should make regular visits to the patient care areas to discuss patient safety with the care providers. During the walk rounds, the leaders may be informed about any issues of patient safety to enact effective measures that address the concerns. Additionally, creating a reporting system where the staff can freely report any errors or safety concerns that could lead to adverse events without fear of punishment may help cultivate a culture of safety (Farokhzadian et al., 2018). Similarly, designating a patient safety officer and offering structured educational training on teamwork collaboration may also promote a safety culture in the hospital.
IHI Triple Aim
IHI Triple Aim is designed to guide healthcare institutions to improve patients’ care experience by boosting quality, reliability, and access. Secondly, the concept helps providers find ways to reduce the cost of services they offer while increasing the quality. Thirdly, the framework help address the health concerns of the community and determine at-risk populations (Institute for Healthcare and Improvement, 2022). The simultaneous pursuit of these three objectives can help providers channel resources on services that directly impact health outcomes.
The Triple Aim applies to this incident because it increases quality and safety awareness. The framework can help identify previously intractable challenges, such as patient identification and staffing ratios concerns and develop solutions to improve patients’ experience (Merry et al., 2017). This shows that IHI can accelerate the systematic improvement of care and mobilize health systems to decrease harm. In this case, the organization can preemptively create strategies to coordinate care, improve patient experience and reduce costs, which are crucial to its survival.
Various IHI Triple Aim components may be incorporated into the organizational improvement strategy. One element involves the focus on individuals and families, which can help establish partnerships among patients, caregivers, and families to coordinate services among multiple care providers (Institute for Healthcare and Improvement, 2020). Additionally, it will be crucial to redesign primary care services and structures to have a multidisciplinary team deliver high-quality services. Lastly, system integration is vital to match the demand and supply for healthcare. The bureaucratic system’s requirement often acts as an obstacle for clinicians providing the care they believe is best for patients and being compensated reasonably, contributing to frustration and burnout.
Leadership and Collaboration
The key departments that need to be involved in the corrective action process include the management, medical, nursing, and information and technology (IT). All these departments are vital and responsible for the patients’ care process. Therefore, they need to be involved in any issues that threaten patient safety in order to create more effective measures to enhance safety and quality, which improve positive health outcomes.
The management, medical, nursing, and IT departments are critical in addressing the patient identity scenario. The administration should be involved because they are in charge of the hospital operations, and therefore, they should be privy to any issues involving patient safety. The medical and nursing department should address the patient identity concern because they directly provide care to the patients in question. This would assist them in avoiding making errors during the care process. Additionally, the IT department needs to be involved in the corrective action plan because they manage and update all patient records used in various hospital departments, including the medical wards.
The action plan will involve the collaboration of the chief nursing officer (CNO), a medical social worker, and a registered nurse. In this case, the CNO will ensure that all other nursing staff are aware of the patient identity concern and the changes involved to rectify the issue. Similarly, the medical social worker who acts as part of the multidisciplinary team will ensure that healthcare providers, including physicians, nurses, and other support staff, are cognizant of the corrective action plan. Finally, the registered nurse will ensure that other primary caregivers in charge of the patients in question adjust to the action plan.
Lack of effective communication between healthcare departments about making safety and quality a top priority increases the chances of medical errors. This is because inadequate or wrong information results in poor decision-making, which may harm the patients (Busari et al., 2017). For example, if the pharmacy department is unaware of the patient identity scenario, they may dispense the wrong medication for the patients due to misidentification. This may cause acute harm or even death to the patients. Therefore, failure to incorporate all departments in prioritizing safety and quality results in more medical errors that may compromise the patients’ well-being.
The involvement of other departments in addressing the incident and cultural issue may be achieved through holding an emergency staff meeting where all members are present. This would create awareness about the identity scenario and what measures should be implemented to ensure that the care providers and support staff do not confuse the patients. The meeting would also be ideal for emphasizing the need for effective communication, teamwork, and collaboration among all departments for continued improvement in decision-making, which is fundamental in guaranteeing patient safety and quality.
Several hospital leaders would considerably assist in addressing the patient identity case and help in making patient safety and quality a priority in the organization. These leaders will include the CNO, the patient safety officer, and the chief medical officer (CMO). Since the leaders have more influence on other subordinate staff at the hospital, they would create awareness about the patient identity case and recommend improving patient safety and quality within the hospital.
Each leader has a unique role in handling the identity scenario and the organizational culture. In this context, the CNO will ensure that all other nurses are privy to the patient identity case and stress the need for effective communication and collaboration between the nursing department and other departments. Alternatively, the CMO will ascertain that the physicians and other hospital administrators are cognizant of the issue and encourage teamwork and collaboration between the physicians and other staff in different departments. Additionally, the patient safety officer will ascertain that all staff in the hospital coordinate in addressing the identity incident to promote patient safety.
Numerous best practices may be used to enlist the hospital leaders’ help in the improvement effort. The practices may include setting a clear goal to direct the actions of the leaders towards addressing the patient identity issue and the organizational culture (Institute for Healthcare Improvement, 2008). In this case, the hospital’s goal is to generally improve patient safety and quality. Another practice involves assigning specific responsibilities to the leaders. This will ensure that all leaders actively participate in implementing an effective solution to the problem.
Leadership Action Plan
Three evidence-based actions are recommended to help solve the patients’ ID incident. World Health Organization recommends utilizing at least two identifiers after admission and before the treatment procedures. The institution also proposes that hospitals use standardized patient identification methods (2007). Clear protocols must also be introduced to identify homonymous patients, such as assigning identification numbers and other person-specific identifiers. It is also vital to incorporate continuous training regarding patient identification protocols to health professionals, service users, and families about the importance of correct identification. Lastly, the hospital can invest in technological resources to enhance identification (De Rezende et al., 2021). These steps will ensure that treatment or service is given to intended patients and improve their health outcomes.
The evidence-based practices (EBP) that health professionals can use include the best approach for nurse-to-nurse shift change. The most significant element in nursing practices is communication, particularity during handoffs. During sign-out, nurses transfer patient data, and the information must be accurate and complete. Any communication breakdown can omit crucial details that compromise patients’ health (Raeisi et al., 2019). Secondly, the hospital can implement EBP for patient identification by using technology to perform patient identity checks through armband barcoding scanning to limit the risks of misidentification (De Rezende et al., 2021). Thirdly, best-practice protocols extend beyond patients’ care; they also apply to nurses’ well-being. Some proven practices include self-care and Mindfulness-Based Stress Reduction (MBSR), which help decrease psychological stress among staff (Lin et al., 2018). This is because inadequate staffing can lead to work burnout and depression.
Opportunities to Enlist Governing Board
As a corporate entity with a statutory oversight role, the organization’s governing board is responsible for the overall safety and quality of care that the hospital provides. Therefore, it actively engages in service improvement by defining priorities, developing strategy, and shaping the system and culture of the organization. Institute for Healthcare Improvement (IHI) advises boards to undertake key governance leadership activities to enhance quality and decrease hospital harm. In this case, the governing body can begin by allocating over 25% of their meeting time to safety issues (Institute for Healthcare Improvement, 2008). They can also have talks with at least one patient or family member of a patient who suffered an injury at the hospital.
The governing board’s aid can be enlisted in the hospital improvement initiative by guaranteeing they oversee healthcare quality. The hospital governing body needs to have a clear priority and a common understanding of improving care (Feeley et al., 2019). The board’s responsibility for ensuring safe and harm-free care to the patients should not be delegated to the executive leadership and medical staff. A more active partnership with frontline workers can set overall expectations and promote accountability for high performance and harm elimination.
The board needs to be provided with additional information to increase their involvement in the hospital’s safety and quality improvement efforts. IHI recommends that the governing body have access to data about safety (Institute for Healthcare Improvement, 2008). Similarly, the quality manager can organize the board to go to the bedside to directly hear stories about the institution’s quality of services. Such information can strengthen board engagement with their frontline clinical teams to focus on improved healthcare outcomes.
Conclusion
The issue of mismatched records is exacerbated when patients share similar identifiers, given that certain names are extremely common. Rare but still worrying is the phenomenon of confusing birth dates, as shown in the patient identify incident. Therefore, as a newly appointed quality manager, it is vital to invest resources into cultivating an organizational culture that not only creates a conducive work environment but also improves patients’ care experience. Evidence-based actions and practices include continuous training on identification protocols and best practices for nurse-to-nurse shift change. Additionally, IHI Triple Aim will guide the hospital in crafting an effective reporting system. To achieve this, various hospital departments and leaders are incorporated in this change process. Senior members, such as the governing board, CMO, CNO, and patient safety officer, are pivotal in implementing this action plan because they are in charge of other staff members in the hospital.
References
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