- BHA FPX 4004 Assessment 1 Address A Patient Safety Issue
Address a Patient Safety Issue
In this paper, I will pick a patient safety threat and examine how it impacts patient safety. I will also evaluate the risk of this threat on a healthcare organisation if it is not addressed. Lastly, I will analyze the role of a patient safety officer and how regulatory agencies’ recommendations affect patient safety.
Identify and Describe the Issue
The safety scenario I have chosen to elaborate on is entitled Patient Identification Screw-up. This safety threat places patients in preventable circumstances that can impact a patient’s treatment, medications, or recuperation process. Patient Safety Officer Kyra Dailey leads daily rounds throughout various hospital departments. One of Mrs Dailey’s obligations is to ensure the hospital’s patient care arrangements are consistently carried out by the staff, thus reducing safety mishaps and ensuring each patient receives optimal healthcare administration.
Addressing the Risk of Patient Identification Errors in Healthcare
While leading her rounds, Kyra noticed two patients occupying rooms on the unit with identical names. The similarities in the names are unremarkable, and the probability of a patient identification screw-up is high. In addition, both patients’ birthdays are almost identical. Kyra addressed her concerns with the unit’s charge nurse, who explained that the two patients have separate medical caretakers and that documentation is made in each patient’s chart to avoid misidentification.
Patient safety is a crucial part of healthcare that requires daily reevaluation and improvement (Thomas & Evans, 2004). It impacts the quality of care that can be provided to patients. Providing care without errors positively impacts a hospital’s reputation within its community and its medical reimbursement. Therefore, addressing and further developing identification errors is a paramount issue that needs a solution.
Apply Safety Imperative
The healthcare safety imperative suggests that to prevent patient identification errors, hospitals should incorporate and engage patients as active participants in their care and perform yearly education changes for staff (Leape et al., 2009). Healthcare organizations can educate their staff by reminding them to identify themselves when entering a patient’s room. Continue locating an identifying article containing the patient demographics, wristband, patient chart, medication bags, or lab label. Ask the patient their first and last name, followed by the date of birth. An additional identifier can be the patient’s medical record number; this unique number can be a game-changer if patients with similar names are on the same floor (Thomas & Evans, 2004).
BHA FPX 4004 Assessment 1 Address A Patient Safety Issue
As the patient answers your questions, engage and reaffirm the answers by repeating their responses, ensuring that both the patient and the care team agree that all identifiers are correct. If any identifiers are incorrect, include team members in deciding the best strategy (Leape et al., 2009). Denham (2007) states that staff should remain engaged with their patients, remembering that patients have choices throughout their stay in the hospital.
Regulatory Agencies
The regulatory agency that enforces policies to ensure patient safety is maintained at the highest standards across the healthcare system is The Joint Commission (TJC). TJC consistently conducts safety investigations and performs studies questioning staff and leadership if medical mistakes occur and what countermeasures are in place to address them. Also, TJC encourages healthcare organizations to stand out by offering excellent and reliable care at the pinnacle of quality to all individuals who seek it (Clancy, 2005). According to TJC, between 44,000 and 98,000 patients yearly are affected by injuries associated with medical mistakes. Therefore, proposed enactments are being implemented to reduce these mistakes. Number one on TJC’s patient safety goals of 2019 is the improvement of the identification process for patients (Clancy, 2005).
TJC proposes that organizations select two patient identifiers and apply them as standard practice throughout the healthcare system. Safety updates should also be presented so that staff are aware of patients with similar names and birthdates and can take steps to avoid misidentification (Clancy, 2005). These measures and others are guidelines established by TJC to ensure that critical treatments, medications, medical procedures, meals, transfusions, etc., are safely administered to the correct patient.
The Role of Regulatory Agencies in Enhancing Patient Safety
The impact of regulatory agencies is significant in patient safety programs. These agencies promote improvements, enhance the quality of care, and provide transparency to an organization’s surrounding community about the steps to improve safety concerns (Clancy, 2005). To incorporate these practices, an organization should reevaluate their current safety structure, eliminate ineffective practices, and fine-tune the successful ones. Additionally, they should provide education workshops and hospital training, ensuring all healthcare associates are familiar with the organization’s new safety action plan (Pysyk, 2018).
In terms of patient identification, implementing monitoring systems that can detect identification errors and duplicate patient records or charts can raise awareness among staff about patients with similar names and birthdates or patients who are on the same unit with a common last name (De Rezende, Melleiro, & Shimoda, 2019).
The Financial and Operational Risks of Patient Identification Errors
The risks that may result if corrective actions for patient identification errors are not addressed include increased medical mistakes by healthcare staff, which can reduce patient satisfaction and volume. This can, in turn, affect the organization’s profitability, as reimbursements from insurance claims such as Medicaid, Medicare, and private insurance companies would be reduced (Cunningham, 2012). According to a study by healthcare IT security firm Imprivata, hospitals lose an average of $17 million yearly from denied insurance claims due to patient misidentifications (Bryant, 2016).
Patient Safety Officer
A hospital’s Patient Safety Officer (PSO) identifies, gathers, and analyzes issues that may hinder patient safety within the organization’s health system. PSOs play a critical role in reducing patient identification errors. The five-point plan I will establish to help decrease patient identification errors includes:
BHA FPX 4004 Assessment 1 Address A Patient Safety Issue
- Re-educating staff yearly by assigning mandatory hospital competencies on hospital standards and TJC identification regulations.
- Gradual changes will involve unit managers and physicians. Staff will be encouraged to consistently and accurately check patient wristbands and use two identifiers when identifying patients.
- Implementing preventive safeguards that will involve a two-person verification system. Before administering medication, blood work, etc., a second healthcare provider will confirm that the correct patient is receiving care.
- Offering incentives such as monthly recognition for hospital units that successfully implement procedures to reduce patient identification errors.
- Creating an incident reporting system where staff can log and self-report events and suggest the best action to prevent recurring incidents.
Conclusion
Today, with all the issues surrounding hospital and patient safety, Patient Safety Officers (PSOs) address these significant issues daily. As healthcare providers, we can aid the PSO by properly identifying our patients and adhering to TJC safety protocols. Carefully checking the patient’s date of BHA FPX 4004 Assessment 1 birth and name and assigning separate caretakers to patients with similar names are steps we can take to contribute to patient safety.
References
Bryant, M. (2016). Patient mix-ups a major drain on hospital revenues, physician productivity. Healthcare Dive.https://www.healthcaredive.com/news/patient-mix-ups-a-major-drain-on-hospital-revenues-physician-productivity/432307/
Clancy, C. M. (2005). AHRQ Quality and Safety Initiatives. The Joint Commission Journal on Quality and Patient Safety, 31(6), 354–356.https://doi.org/10.1016/s1553-7250(05)31047-6
Cunningham, B. (2012). Positive patient identification begins at step one. Health Management Technology, 33(8), 10-11.http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F1034737789%3Faccountid%3D27965
De Rezende, H., Melleiro, M., & Shimoda, G. (2019). Interventions to reduce patient identification errors in the hospital setting. JBI Database of Systematic Reviews and Implementation Reports, 17(1), 37–42. https://doi.org/10.11124/JBISRIR-2017-003895
Denham, C. R. (2007). The new patient safety officer. Journal of Patient Safety, 3(1), 43-54. https://doi.org/10.1097/PTS.0b013e318036bae9
Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Lawrence, D., Isaac, T. (2009). Transforming healthcare: A safety imperative. Quality and Safety in Health Care, 18(6), 424–428.https://doi.org/10.1136/qshc.2009.036954
Nedved, P., Chaudhry, R., Pilipczuk, D., & Shah, S. (2012). Impact of the unit-based patient safety officer. JONA: The Journal of Nursing Administration, 42(9), 431–434. https://doi.org/10.1097/NNA.0b013e318266810e
Pysyk, C. L. (2018). A change to the surgical safety checklist to reduce patient identification errors. Canadian Journal of Anesthesia, 65(2), 219-220. https://doi.org/10.1007/s12630-017-0997-7
Thomas, P., & Evans, C. (2004). An identity crisis? Aspects of patient misidentification. Clinical Risk, 10(1), 18–22.https://doi.org/10.1258/135626204322756556