NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

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NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Name

Capella university

NURS-FPX 4020 Improving Quality of Care and Patient Safety

Prof. Name

Date

Improvement Plan Toolkit

The improvement plan toolkit developed in this assessment aims to enhance understanding of the safety improvement plan for reducing patient identification errors among healthcare staff and the relevant workforce. As the Arnold Palmer Hospital has been facing patient identification errors lately, a safety improvement plan is developed in the previous assessment. To better understand this plan, the improvement plan toolkit is designed to comprise research-based evidence focusing on patient identification errors and a tailored safety improvement plan. The toolkit is built by delving into research articles and drawing relevant articles as evidence-based practices to prevent patient misidentification.  The four categories focusing on patient identification errors and safety improvement plans are patient identification and its significance in healthcare, procedures, and protocols to prevent patient identification, technology integration, and innovation and human-centered approaches towards correct patient identification.

Patient Identification and its Significance in Healthcare

Rahmawati, T. W., Sari, D. R., Ratri, D. R., & Hasyim, M. (2020). Patient identification in wards: What influences nurses’ complicance? Jurnal Medicoeticolegal Dan Manajemen Rumah Sakit9(2). https://doi.org/10.18196/jmmr.92121 

This article by Rahmawati et al. (2020) highlights the patient identification as a critical factor in patient safety. Moreover, it delves into the factors associated with low compliance with patient identification among nurses in inpatient settings. The article emphasizes the significance of patient identification with two identities: before diagnostic or therapeutic procedures and before administering medications and blood transfusions. It also highlights that patient identification is not limited to bracelet identifiers. Still, patient and family engagement in treatments by communicating with healthcare professionals should also be encouraged to promote a safety culture by reassuring patient identity. The article also states some stats on patient identification errors; for instance, the article mentioned that about 12 near misses in one hospital in 2019 occurred due to patient identification errors, showing the non-compliance of nurses towards patient identification protocols, procedures, and technologies.

The root problems that lead to identification errors among patients identified by authors include lack of education and nurse awareness on patient identification, lack of implementation of SOPs for patient identification, late printing of bracelet identifiers, and lack of documentation of patients’ lists for registration. These factors have led to low compliance with patient identification among ward nurses. This resource is helpful for nurses to understand patient identification and why patient identification occurs in the first place. Moreover, this article has valuable data on factors required to promote patient safety by accurate patient identification and factors that trigger patient misidentification. This article can be valuable for all healthcare and non-clinical staff to understand patient safety, patient identification, and factors contributing to patient identification errors.

Sheedy, C., & Richard, S. (2020). Patient identification errors in the operating room. In Making healthcare safer III: A critical analysis of existing and emerging patient safety practices. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555511/ 

This book chapter discusses patient identification errors in operating rooms. The study highlights that a review of 106 articles showed that wrong patient practices account for almost 0.9-1.86% of patient misidentification. The errors occur during surgery due to communication barriers, wristband errors such as removed wristbands, or absence of wristbands. After discussing the factors leading to the wrong patient and wrong-site surgery due to the misidentification of patients, the article highlights the methods to promote patient safety practices by emphasizing patient identification. These methods include implementing checklists and protocols such as the JC Checklist and the World Health Organization’s checklist for safe surgery.

Other methods included marking the surgery site among patients with an indelible pen to avoid errors due to patient misidenfticiation. Additionally, the study considered using verification protocols and forms for accurate patient identification before surgery. These methods were effective in lowering the rates of surgical errors due to wrong patient identification. This study is useful for nurses to understand how patient identification errors occur in operating rooms. Moreover, healthcare professionals can find this resource valuable as it suggests methods to prevent surgical errors due to the misidentification of patients. By implementing these practices, healthcare professionals, including surgeons and nurses, can alleviate surgical mistakes and promote patient safety.

Romano, R., Marletta, G., Sollami, A., La Sala, R., Sarli, L., Artioli, G., & Nitro, M. (2021). The safety of care focused on patient identity: An observational study. Acta Bio Medica : Atenei Parmensis92(Suppl 2), e2021038. https://doi.org/10.23750/abm.v92iS2.11328 

This article focuses on patient safety care from the perspective of patient identity. The study was performed to evaluate nursing students’ knowledge regarding the correct identification of patients. The study showed homogeneity in considering the correct patient identification protocols applicable within the internship. The study considered bracelet identifiers as the most beneficial strategy for accurate patient identification. This resource is helpful for nurses as it shows them the patterns of knowledge of patient identification among nursing students and how various methods and strategies can be used, as stated by the article. Further, the article is valuable as it educates nurses on using patient identifiers like bracelets to prevent errors in patient identification. It guides nursing educators on ways to improve the attitude of nursing students toward patient identification during internship programs.

Patient Identification Errors

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 Safety17(7), 1. https://doi.org/10.1097/pts.0000000000000478 

The article by Abraham and colleagues (2021) analyzes patient identification errors using incident report systems data. The resource found various factors that contributed to patient misidentification. The most frequently occurring errors were due to missed wristbands, which accounted for 34% of errors. Other contributing factors were wrong labeling, wrong charts, and administrative errors. This resource is useful for healthcare staff, including nurses, to gain insights into why patient identification errors occur and what factors lead to the onset of these errors. Nurses can use this article to enhance knowledge on patient identification errors and can further raise awareness among nursing staff. This resource is considered valuable as it provides a list of risk factors causing patient misidentification events in healthcare organizations.

Kulju, S., Morrish, W., King, L., Bender, J., & Gunnar, W. (2020). Patient misidentification events in the veterans health administration. Journal of Patient Safety19(7). https://doi.org/10.1097/pts.0000000000000767 

These evidence-based resources connect the patient safety culture with errors, patient safety grades, and incident reporting by evaluating its impact on the latter factors. The study evaluated that patient identification and medication errors directly impacted the patient safety culture. The patient safety culture scores diminish when errors due to patient identification mistakes and subsequent adverse events occur. This resource is useful for nurses as it educates them on how patient identification errors contribute to patient safety and patient safety culture. As the article expands to further concepts beyond patient identification, this resource is valuable to enhance the knowledge of healthcare professionals on use of incidence reporting systems after patient identification and its impact on prospective patient safety culture.

Alkhaqani, A. L. (2023). Patient identification errors in the hospital setting: A prospective observational study. Al-Rafidain Journal of Medical Sciences ( ISSN: 2789-3219 )4, 1–5. https://doi.org/10.54133/ajms.v4i.95 

This evidence-based resource delves into patient identification errors at Al-Najaf Teaching Hospital. The article delves into the factors contributing to the incidence of these errors, such as lack of communication with patients to acquire name and identity questions and incompletion of the identification process. The authors also conducted a patient identity program to fulfil the needs of healthcare personnel in training sessions. About 37.1% of clinic doctor did not perform the identification and verification process for correct patient identification, which made a major portion of data with human errors leading to patient misidentification.

The training programs on raising awareness about patient identification were conducted for the healthcare workforce. Nurses can use this resource to understand the behaviors and attitudes of the healthcare workforce in neglecting patient safety. Moreover, the attitudes can be avoided by nurses as they learn from the key findings of this resource. This resource shows its value by briefing out the attitudes and behaviors of the healthcare workforce towards patient identification. This paves the way for the healthcare staff of our hospital to avoid such attitudes to improve patient safety.

Procedures and Protocols for Preventing Patient Identification Errors

Campbell, A., Ok, S., Esguerra, J., Luo, D., Ajala, A., Edwards, C., Hilton, S., Khrone, N., Monroe, N., Nichols, J., Porter, R., Simms, D., Smith, L., Puthenparampil, E., & Gonzalez, C. G. (2022). Using a patient identification checklist: How to make this a never safety event in perioperative services. Journal of PeriAnesthesia Nursing37(4), e2. https://doi.org/10.1016/j.jopan.2022.05.004 

The article mentioned above describes the procedure to alleviate the incidences of patient identification errors during perioperative services. For this purpose, a checklist is developed considering the patient wristbands during check-in events and further audits are conducted to ensure maximal compliance measures. The study created a realistic and achievable goal of promoting patient safety and reducing harm due to patient identification errors by 25% in six months. The implementation process included developing a checklist for patient identification, educating staff, and conducting digital audits.

Other procedures included placing checklists in laminated form for coordinators, improving lighting to avoid human errors, and allocating alphabetical orders for patient chart files to lessen adjustments to charts. These procedures and protocols helped diminish patient identification errors and enhanced patient safety. This article is helpful for healthcare professionals and policymakers to create protocols and checklists for reducing patient identification errors and improving the safety of patients. Moreover, this article is valuable as it provides a systematic method of implementing the protocols and procedures to enhance patient safety and address patient identification errors.

Fukami, T., Uemura, M., Terai, M., Umemura, T., Maeda, M., Ichikawa, M., Sawai, N., Kitano, F., & Nagao, Y. (2020). Intervention efficacy for eliminating patient misidentification using step-by-step problem-solving procedures to improve patient safety. Nagoya Journal of Medical Science82(2), 315–321. https://doi.org/10.18999/nagjms.82.2.315

The article by Fukami and colleagues (2020) evaluates the effectiveness of reducing patient misidentification by using a step-by-step methodology in which a problem-solving approach was implemented. First, the number of patient misidentification incidents was calculated from reports. Next, the factors or reasons which caused these errors were found. The next step involved setting a target to decrease misidentification errors among patients and achieving this by standardizing the policies and procedures for accurate patient identification.

The last step was to educate staff members by sharing educational videos on the safe identification of patients and making policies to increase adherence to the patient identification protocols. These steps helped the organization reduce patient misidentification mistakes and achieve the set target. This article is useful for healthcare staff, showing step-by-step guidelines to implement patient identification protocols and policies. Moreover, healthcare professionals can find this resource valuable as it aims to reduce patient identification errors by establishing SMART goals that are specific, measurable, achievable, realistic, and time-bound.

De Rezende, H., Melleiro, M. M., O. Marques, P. A., & Barker, T. H. (2021). Interventions to reduce patient identification errors in the hospital setting: A systematic review. The Open Nursing Journal15(1), 109–121. https://doi.org/10.2174/1874434602115010109 

This evidence-based resource draws results on interventions from a pool of studies on patient identification interventions. This article identified a number of interventions to alleviate the incidence of patient identification errors, including educating the staff and enhancing patient engagement with healthcare professionals through education. These educational processes are essential to raise awareness about controlling patient identification errors to prevent subsequent adverse events. This resource is useful for healthcare professionals as they can delve into deeper studies to educate the healthcare staff and patients for accurate patient identification. Moreover, this article explains each intervention alone and with a combination of patient education and technology integration, considering multiple perspectives and their effectiveness. Hence, this article is valuable for all healthcare professionals to foster a safety culture by encouraging correct patient identification.

Technology Integration and Innovation

Riplinger, L., Piera-Jiménez, J., & Dooling, J. P. (2020). Patient identification techniques – approaches, implications, and findings. Yearbook of Medical Informatics29(1), 81–86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442501/ 

This article discusses accurate patient identification techniques by delving into various approaches, including technologies. The technological approaches discussed in this article are biometric identification systems, Radio Frequency Identification (RFID), and algorithmic approaches within Electronic Health Records (EHRs). The biometric identification system uses fingerprints, iris matching, palm veins, and facial feature scanning. The RFID is more effective than barcoding technology as it can store more data and does not require user intervention. The algorithmic method installed in EHRs promotes matching health information with a patient’s identity and creates an effective patient-matching solution. This article is helpful for healthcare staff and administration as it gives an overview of approaches and implications to promote patient safety by correctly identifying patients. RFID is considered the most valuable technology as it requires no user intervention. Healthcare professionals can find all these interventions and technologies valuable as they can potentially reduce patient identification errors.

Anne, N., Dunbar, M. D., Abuna, F., Simpson, P., Macharia, P., Betz, B., Cherutich, P., Bukusi, D., & Carey, F. (2020). Feasibility and acceptability of an iris biometric system for unique patient identification in routine HIV services in Kenya. International Journal of Medical Informatics133, 104006. https://doi.org/10.1016/j.ijmedinf.2019.104006 

This article highlights the use of iris biometric systems to reduce patient identification inaccuracies in monitoring routine HIV care programs. For this purpose, the authors included the patients and captured the images of the iris for the template. After template storage, an ID number comprising 12-digit numbers was assigned to each template. Upon every follow-up, the patient’s iris was scanned against the archived template, and the ID number was retrieved accordingly. This article is helpful for healthcare professionals as it can be a more accurate method to prevent patient identification errors. Nurses can use this while providing care treatments to patients. This strategy was applied in Kenya to overcome inaccuracies due to patient identification errors. This resource is valuable for Arnold Palmer Hospital healthcare professionals as it provides a thorough method to integrate innovative biometric technology systems, such as iris scanning of patients’ eyes.

Barakat, S., & Franklin, B. D. (2020). An evaluation of the impact of barcode patient and medication scanning on nursing workflow at a UK teaching hospital. Pharmacy8(3), 148. https://doi.org/10.3390/pharmacy8030148 

This evidence-based resource evaluates the impact of patient and medication scanning via barcode technology in teaching hospitals in the UK. The study showed that patient identification checks were 100% acquired through this technology. This process involves the scanning of patients’ wristband barcodes with that of the medicine before the medication administration. This technology-enhanced patient safety by increasing the scanning rates among patients. Nurses can use this resource to implement this technology for patient identification before administering medications. This resource is valuable as it delves into BCMA technology for preventing medication errors due to patient misidentification. Moreover, this resource will guide nurses on the tools required for implementing BCMA technology for patient identification as well as medication safety. By using this valuable resource, and healthcare professionals can provide improved quality of care by reducing the risk of patient identification errors by scanning patient’s identities before administering medication.

Conclusion

The improvement plan toolkit is developed by using four categories focussing on patient identification errors and patient safety. These categories revolve around patient identification and its significance in healthcare, patient identification errors, procedures and protocols for preventing patient identification errors and technology integration and innovation. For each category, three evidence-based resources are drawn from a plethora of evidence-based research data. This toolkit aims to help healthcare professionals in alleviating patient misidentification rates by enhancing their understanding of this subject and safety interventions.

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 Safety17(7), 1. https://doi.org/10.1097/pts.0000000000000478 

Alkhaqani, A. L. (2023). Patient identification errors in the hospital setting: A prospective observational study. Al-Rafidain Journal of Medical Sciences ( ISSN: 2789-3219 )4, 1–5. https://doi.org/10.54133/ajms.v4i.95

Anne, N., Dunbar, M. D., Abuna, F., Simpson, P., Macharia, P., Betz, B., Cherutich, P., Bukusi, D., & Carey, F. (2020). Feasibility and acceptability of an iris biometric system for unique patient identification in routine HIV services in Kenya. International Journal of Medical Informatics133, 104006. https://doi.org/10.1016/j.ijmedinf.2019.104006 

Barakat, S., & Franklin, B. D. (2020). An evaluation of the impact of barcode patient and medication scanning on nursing workflow at a UK teaching hospital. Pharmacy8(3), 148. https://doi.org/10.3390/pharmacy8030148 

Campbell, A., Ok, S., Esguerra, J., Luo, D., Ajala, A., Edwards, C., Hilton, S., Khrone, N., Monroe, N., Nichols, J., Porter, R., Simms, D., Smith, L., Puthenparampil, E., & Gonzalez, C. G. (2022). Using a patient identification checklist: How to make this a never safety event in perioperative services. Journal of PeriAnesthesia Nursing37(4), e2. https://doi.org/10.1016/j.jopan.2022.05.004 

De Rezende, H., Melleiro, M. M., O. Marques, P. A., & Barker, T. H. (2021). Interventions to reduce patient identification errors in the hospital setting: A systematic review. The Open Nursing Journal15(1), 109–121. https://doi.org/10.2174/1874434602115010109

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

Fukami, T., Uemura, M., Terai, M., Umemura, T., Maeda, M., Ichikawa, M., Sawai, N., Kitano, F., & Nagao, Y. (2020). Intervention efficacy for eliminating patient misidentification using step-by-step problem-solving procedures to improve patient safety. Nagoya Journal of Medical Science82(2), 315–321. https://doi.org/10.18999/nagjms.82.2.315 

Kulju, S., Morrish, W., King, L., Bender, J., & Gunnar, W. (2020). Patient misidentification events in the veterans health administration. Journal of Patient Safety19(7). https://doi.org/10.1097/pts.0000000000000767 

Rahmawati, T. W., Sari, D. R., Ratri, D. R., & Hasyim, M. (2020). Patient identification in wards: What influences nurses’ complicance? Jurnal Medicoeticolegal Dan Manajemen Rumah Sakit9(2). https://doi.org/10.18196/jmmr.92121

Riplinger, L., Piera-Jiménez, J., & Dooling, J. P. (2020). Patient identification techniques – approaches, implications, and findings. Yearbook of Medical Informatics29(1), 81–86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442501/ 

Romano, R., Marletta, G., Sollami, A., La Sala, R., Sarli, L., Artioli, G., & Nitro, M. (2021). The safety of care focused on patient identity: An observational study. Acta Bio Medica : Atenei Parmensis92(2), e2021038. https://doi.org/10.23750/abm.v92iS2.11328 

Sheedy, C., & Richard, S. (2020). Patient identification errors in the operating room. In Making healthcare safer III: A critical analysis of existing and emerging patient safety practices. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555511/

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