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- BHA FPX 4004 Assessment 1 Address A Patient Safety Issue.
Address a Patient Safety Issue
Throughout this paper, I have selected a patient safety threat and what it can mean for the Organization and patients. First, I will discuss the potential safety threat and what it means for the patients. Secondly, address the implications of not addressing the threat and which regulatory agency oversites this issue. Thirdly, the roles of a patient safety officer and how a safety plan is being carried out should be analyzed. Lastly, a five-point plan should be prescribed to reduce this threat to patient safety.
Potential threat to patient safety
The safety scenario I have selected to delineate is about patient identification mistakes. Safety mistakes could cause numerous complaints from the Organization and patients. For the Organization, it could lead to fines, lawsuits, or even loss of accreditation. As for the patient, it can cause draw-out admission, unjust diagnosis, prescribing incorrect medications, or even death. As the patient safety officer, I conducted my safety throughout the hospital today. As I was in the pediatric unit, which is located on the eighth floor, I noticed a potential patient safety concern.
I spoke to the charge nurse, Virginia, and explained a serious issue they may or may not be aware of. I told Virginia that I noticed two patients had the same name, and their rooms were straightforward across from each other. Virginia’s charge nurse also informed me that they have similar birth dates. In BHA FPX 4004 Assessment 1 Address A Patient Safety Issue, this scenario underscores the importance of addressing such critical concerns. I expressed my worries to the charge nurse and asked how they had addressed this situation. I wanted to know how they are making sure not to confuse the two patients since they have identical names and similar dates of birth.
Virginia told me they had my concerns covered by ensuring the two patients had various nurses so there would be no misidentification errors. She also explained that their charts had been noted so that other staff members would be familiar with these two patients with identical names and similar dates of birth. Virginia also informed me that there had been a staff shortage this week and addressed that this could also cause a ton of shifting around.
With staff shifting around, this could be a serious issue with a patient misidentification mistake because not all staff members would be familiar with this patient safety threat. Patient misidentification is a rising mistake, and it is easy to underestimate the scale of the issue (Thomas et al., 2004). Improving patient safety care is created by communicating with your staff and ensuring your patients have great care (Colorado Technical University, 2022). Patient identification could impact the quality of care for the patients. Addressing and improving patient identification mistakes is an important issue that needs a resolution.
Implications of not addressing the threat
The safety scenario I selected and wanted to address is patient identification errors. This safety threat is a serious issue that can place patients in circumstances that can be forestalled. Patient misidentification is an everyday issue in healthcare and can be particularly harmful (Abraham et al., 2021). There are multi-factorial issues as to why patient misidentification errors happen, and correcting patient identification poses a serious challenge within a hospital because of the large volume of patients (Thomas et al.,2004).
The healthcare imperative relates to the patient safety issue of the scenario in the following ways because it can lead to unjust medication administration, misdiagnoses, improper procedures, or even death. As an organization, we want to ensure the staff engages with their patients and their families, uses the two-patient identifier, and communicates with their patients (Leape et al., 2009). We want an open, transparent staff time and resolve to learn. Also, the providers, nurses, and other healthcare workers treat each other and their patients respectfully.
The Organization must educate the staff, and when entering a patient’s room, they must distinguish themselves. Then, they need to continue to locate an identifying article that will determine the patient, whether it be a wristband or the patient’s chart. At the point when they find an identifying article that will distinguish the patient, the healthcare specialist should do the two patient identifiers. The two-patient identifier can ask for their total name, first and last name, and the patient’s date of birth. Several examples that are not considered patient identifiers are the patient’s room number, phone number, or electronic identification, such as scanning bar codes (The Joint Commission, 2021).
BHA FPX 4004 Assessment 1 Address A Patient Safety Issue
Another extraordinary way to see a patient is for them to have an NHS number, which will assist with preventing misidentification (Thomas & Evans, 2004). As stated above, the healthcare imperative applies in this case because misidentifying a patient could not only cause misdiagnoses but also lead to death. An example of a patient identification screw-up that could cause a serious issue is having a patient who is a Jehovah’s Witness, and you misidentify them for another patient and give them blood products.
That Organization could now be under a lawsuit and potentially lose its accreditation. Also, the nurse could lose their work by not going the extra mile and accurately identifying the patient appropriately. Misidentifying a patient can have serious outcomes; it can cause a patient to be administered some unacceptable medication, carry out an off-base strategy, or even cause overexposure to radiation. Staff should be engaged with their patient throughout their stay in the hospital because that could lead to misidentification with the patients.
If the patient safety threats noted in the scenario are not addressed, there may be risks to patients, employees, and the Organization. These risks include lawsuits, death, and staff shortages because they show that our Organization is not as expected to educate or train our staff. In any case, most staff are unaware of the substantial errors they can cause, making them vulnerable, which is why patient misidentification occurs in multi-factorials. The issue must be tackled (Thomas et al., 2004).
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Joint Commission’s Regulatory Impact
The regulatory agency that oversees this issue is the Joint Commission. The Joint Commission is to make sure patient safety is ensured and standards are kept across the whole healthcare system. The Joint Commission conducts safety inspections as anticipated. These safety inspections finish up asking staff members and leadership questions that will prevent them from making medical errors, and counteractive actions are in place to address them. The Joint Commission suggests that the two patient identifiers be used to lessen the cause of patient misidentification.
This regulatory agency impacts healthcare organizations because their accreditation could be removed if they do not obey their standard of care and strategy. One high risk of misidentification could cause illegitimate insurance claims to Medicaid and Medicare. This could flag the Joint Commission, and they would have to conduct direct surveys to address the issue, which could capably cause the Organization to lose its accreditation. Not only does this hurt the Organization by not fixing patient misidentification goof, but it also hurts the patients because their trust in this Organization is lost and could cause the hospital to lose cash.
Patient safety officer’s role in effective implementation of patient safety plans
Another role in healthcare is evolving, called the patient safety officer, aka PSO. The patient safety officer is not another role, and it was carried out in the 1970s and 80s by The Joint Commission (Chicago, IL: American Society of Healthcare Risk Management,2004.) A patient safety officer provides leadership and bearing to the Organization’s safety strategy. The patient safety officer continuously evaluates and improves patient safety within the Organization. PSO’s role is to work on patient safety and coordinate efforts with the senior leadership, clinical leaders, and clinical staff.
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Strategies for Patient Safety
As a patient safety officer in this scenario, I would coordinate a meeting with clinical leaders of each department within the hospital. I would see the issue and address my anxiety about how a particular unit had two patients with the same name and especially dates of birth. We could think of a plan together so these patients and future patients will not be misidentified. After we think of a plan, I would execute another strategy on steps to forestall patient identification mistakes.
While an approach cannot guarantee a successful patient safety program, we want to coordinate regular training and countless weeks of walk-throughs. Regular training will educate the staff on patient misidentification, and this will ideally reduce and avoid medical errors.
Recommendations to reduce patient safety threat
A recommendation plan to address issues demonstrated in the scenario would include reeducating the staff, doing countless weeks’ rounds, establishing a standardized protocol and incentive, and adding safeguards to the clinical work process. First, we would reeducate the staff yearly by making this mandatory, which would be borne by The Joint Commission. Secondly, performing countless weeks of rounds to all the units ensures that the staff constantly identify themselves, check wristbands, and use two patient identifiers while addressing the patient.
The most critical step is using the two patient identifiers; it prevents high-risk medical errors (Downs, 2020). Patient misidentification usually happens at registration (Downs, 2020). Thirdly, standardized protocols for patient identifiers should be established. The staff should continually educate on this protocol (Downs, 2020). Limiting patient identifier errors will continue to be an issue unless handled accurately and as expected. This could be taught at orientation (Downs,2020).
Fourthly, quarterly incentives should be given to implement the proper methods to reduce patient misidentification errors. Lastly, safeguards should be added to the clinical work process. The Organization could adopt safeguards by adding photos to the patient’s wristband (Psqh, 2017). Also, some hospitals apply biometric identifiers such as fingerprints, retina, or palm scans (Psqh,2017).
Conclusion
Research shows that patient identification errors are a high worry in healthcare. Not only is it the patient safety officer’s responsibility to address this threat, but as healthcare providers, we can aid the PSO. As a healthcare supplier, we want to ensure we use the two patient identifiers: their first and last name and date of birth. In BHA FPX 4004 Assessment 1 Address A Patient Safety Issue, this critical topic highlights how careful and accurate patient identifiers, combined with appropriate training, can significantly decrease this patient safety threat.
References
Abraham, P., Augey, L., Duclos, A., Michel, P. & Piriou, V. (2021). Descriptive Analysis of Patient Misidentification From Incident Report System Data in a Large Academic Hospital Federation. Journal of Patient Safety, 17 (7), e615-e621. Doi: https://10.1097/PTS.0000000000000478.
Colorado Technical University. (2022, January 19). The impact of evidence-based practice on quality care and patient safety. Evidence-based Nursing Practice | CTU. Retrieved January 26, 2022, from https://www.coloradotech.edu/degrees/studies/nursing/articles/evidence-based-practice-quality-care-patient-safety
Downs, J. (2020, June 16). Four ways to improve patient identification in your hospital to Drive Patient Safety – ConnectID. connectID – PDC Healthcare Blog. Retrieved January 30, 2022, from https://blog.pdchealthcare.com/articles/patient-safety/four-ways-to-improve-patient-identification-in-your-hospital-to-drive-patient-safety/
Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., . . . Isaac, T. (2009). Transforming healthcare: A safety imperative. Quality & Safety in Health Care, 18(6), 424. doi:http://dx.doi.org/10.1136/qshc.2009.036954
Psqh. (2017, December 19). Preventing patient identification errors. Patient Safety & Quality Healthcare. Retrieved January 30, 2022, from https://www.psqh.com/analysis/preventing-patient-identification-errors/
The growing role of the Patient Safety Officer: Implications for Risk Managers. Patient Safety Network. (n.d.). Retrieved January 30, 2022, from https://psnet.ahrq.gov/issue/growing-role-patient-safety-officer-implications-risk-managers
Thomas, P., & Evans, C. (2004). An identity crisis? Aspects of patient misidentification. Clinical Risk, 10(1), 18-22. http://library.capella.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fscholarly-journals%2Fidentity-crisis-aspects-patient-misidentification%2Fdocview%2F208966608%2Fse-2%3Faccountid%3D27965000001545.
The Joint Commission. (2021, October 19). Retrieved January 30, 2022, from https://jointcommission.org/standards/standard/faqs/homecare/nationalpatientsafetygoalsnpsg/000001545/
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