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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 Sakit, 9(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.

NURS FPX 4020 Assessment 4 Improvement Plan Tool Kit

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. Th