Analysis of Patient Safety Procedures in Healthcare Settings Report

This report analyzes patient safety procedures within a healthcare setting, highlighting the critical issue of patient misidentification. It presents a case study where a patient was wrongly treated due to misidentification, leading to a near-fatal incident. The report emphasizes the role of patient safety officers in establishing and enforcing protocols to prevent errors. It discusses the importance of accurate patient identification, the consequences of procedure failures, and the interventions of organizations like the National Patient Safety Goals (NPSGs). The report recommends improvements such as enhanced electronic identifiers, automated systems, improved monitoring, and the involvement of patient families to minimize errors and ensure patient safety. It concludes by underscoring the critical role of medical institutions in maintaining patient trust and the ongoing need for system redesign to improve reliability.

Running head: ASSIGNMENT ON PATIENT SAFETY PROCEDURES
ASSIGNMENT ON PATIENT SAFETY PROCEDURES
Name of the Student:
Name of the University:
Author note:

1ASSIGNMENT ON PATIENT SAFETY PROCEDURES
Introduction
The health care industry has a vast array of responsibilities to perform in short deadlines.
Patient identification is one such stage where the hospital fails badly. To correctly identify the
patient and perform corrective procedures on them is as important as passing the exam. There is
a huge chance that due to wrong identification a patient may lose his life (Masri, 2018). Chances
for wrong blood transfusion, testing errors, medication errors, wrong person procedures, and
surgical interventions are some of the major problems surfacing in recent years.
As per ECRI’s analysis, the point of identification procedure at first meet is 72%, half of
it at diagnostic procedures or treatment almost 36.95% and rest 10% is while documenting the
patient details. It was found out that 7,600 wrong-patient misidentifications were occurring in a
span of 3 years period in 181 healthcare organizations. About 9% of the events were not caught
before time led to temporary or permanent harm, or even death (Stafseth, Tønnessen, &
Fagerström, 2018). Around 45,000 to 97,000 patients die each year in the U.S as a result of
medical errors according to the Institute of Medicine (IOM).
The incident
One such incident surfaced in our hospital that had the potential to kill the patient. A 21-
year-old patient named Frank Twain was admitted for skin allergy treatment on the bed which
was of a patient who suffered cancer. The room number and bed with the name of the old patient
was not removed. This made everyone believe that Frank Twain was having cancer and his
doctor read his charts with started to treat him accordingly. A strong dose of Doxorubicin was
given to the patient. It reacted to the patient and he fainted in some while. The incident alerted
the doctor and the nurse was asked to recheck the record chart and there it was found that his
name on the write band and the chart did not match. This was a near miss if the treatment was

1ASSIGNMENT ON PATIENT SAFETY PROCEDURES
continued for cancer instead of skin disease he as suffering there could have been irreversible
consequences.
Role of Patient Safety Officer
To prioritize the safety of the patient is their foremost duty. They have to follow the rules
and laws of the hospital along with ensuring that the patient receives the best possible care. They
are a support system in the health care facilities; they shape the healthcare services so that
mistakes can be avoided. They train the staff team for prioritizes patient safety (Neyrinck, &
Vrielink, 2019). They design ways in which the staff can report the incidents. They can access
individual staff performance and report the mistakes to the authority or leaders. They also create
policies and procedures to train their staff to ensure that patients receive quality treatment with
no complications.
The reporting of the incident
The senior leaders were informed about the incident. The data of past years were checked
and it was confirmed that this was not the first misidentification case in this hospital history. It
was time to take essential steps to strengthen the procedures. The consequences of procedure
failure are completely bared by the innocent patient. They are at no fault and get the wrong
treatment that can be fatal or irreversible sometimes. Improving the present scenario was
essential for the safety of the patient. This was a clear mistake of admitting the patient to the
other patient records. The patient's identity was not confirmed before administrating medication.
Institutes looking after these issues
National Patient Safety Goals (NPSGs) is a program commissioned by Joint especially
looking after the national-level safety goals. It was created to look after a matter with high
priority areas in the context of patient safety. Its first work was to minimize the use of

1ASSIGNMENT ON PATIENT SAFETY PROCEDURES
abbreviation that was confusing and misleading. To eliminate the potential of medical error they
issued a list for abbreviation not to be used in the future. They are working with many
institutions to minimize the causality due to misidentification. Some of the interventions were
done from their end to understand the main reason and find a proper solution.
Recommendation for improvement.
Improving electronic identifiers design can decrease misidentification- Role of technology
cannot be neglected, using the physical and electronic identifier within the electronic health
record [EHR]. In the operating room or in neonatal care, the wristband identifier plays a crucial
role in identifying the patient. The identified wristbands should be legible with clear font and
color-coding that are not degradable on exposure to water (Wistrand, Falk-Brynhildsen, &
Nilsson, 2018). There were cases where the identifier was removed from the patient's hand and
there was no identification sign. Two-way confirmations should be introduced with name, age, Id
number along with the photo to be introduced.
Introducing new technology with automated Systems- To minimize the errors the automated
level system check monitoring can be a progressive step. Barcoding and radiofrequency
identification (RFID) tags help incorrect identification it also works in a real-time monitoring
system. It has worked well in many hospitals by significantly reducing wrong-patient medication
administration errors.
Improving monitoring and boycotting local cultural Processes – It is important to avoid work
around the local culture of performing the same duty continuously. The staff performing duties
often does not pay attention to proper procedures. Most of the times they do not scan the bar
code or check the band before giving the medicines to the patient (Sonoda, Onozuka, &
Hagihara, 2018). It is compulsory to scan the medicines and link them to electronic medicines

1ASSIGNMENT ON PATIENT SAFETY PROCEDURES
records. Another thing noticed is that even before the patient has entered the operation room their
details are already punched in the system. A continuous monitoring and regressive feedback have
been compulsory to save the lives form misidentification causalities.
Asking patients relative or families to be present- In case of delivery of baby, or operation or
any critical situation a patient should be assisted with someone trustworthy. The patient may or
may not be conscious while operating thus to avoid error the partner should keep a close check
on the condition of the patient along with keep monitoring the medicine and the medical board
on the bed. They should express concern and ask a question about their correct procedures.
It’s a protocol to not ask patients leading questions- The nurses have to avoid asking
“leading” questions while labeling their details. For example instead of saying “are you,
Samuel,” they should ask “what is your name”. Sometimes the patients overhear or are old and
they give wrong answers leading to misidentification error. Following the correct protocol is as
essential as taking training to pass the nursing exam.
All these procedures are very important before labeling the patient. The correct identification can
save a patient life. It’s the duty of the staff and the nurses to follow all the orders of the medical
procedure and abide by the policy.
Conclusion
As per the case analysis of the incident, it becomes very clear that proper patient ID
confirmation is the correct procedure for clinical care. The role of the medical institution is very
essential in society it is considered that some of the most intelligent, fine and skillful people
work there. An incident of such a minute mistake only ruins the reputation and breaks the trust of
people. The joint commission is working continuously towards eliminating even one percent
error but a variety of interventions, for the same has very low impact and generally ends up in

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the same manner. The electronic identification will only work perfectly when applied at every
process step. It is important to redesign systems for safety and reliability.

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References
Masri, R. G. (2018). Neonatal nursing orientation: a two tiered approach (Doctoral
dissertation).
Neyrinck, M. M., & Vrielink, H. (2019). Performance of an apheresis procedure: The apheresis
nurse-operator and nursing aspects. Transfusion and Apheresis Science, 58(3), 296-299.
Sonoda, Y., Onozuka, D., & Hagihara, A. (2018). Factors related to teamwork performance and
stress of operating room nurses. Journal of nursing management, 26(1), 66-73.
Stafseth, S. K., Tønnessen, T. I., & Fagerström, L. (2018). Association between patient
classification systems and nurse staffing costs in intensive care units: An exploratory
study. Intensive and Critical Care Nursing, 45, 78-84.
Wistrand, C., Falk-Brynhildsen, K., & Nilsson, U. (2018). National Survey of Operating Room
Nurses' Aseptic Techniques and Interventions for Patient Preparation to Reduce Surgical
Site Infections. Surgical infections, 19(4), 438-445.