Running head: TAKE HOME PAPER 1

Take Home Paper

Katelyn Duncan

University of Wisconsin Eau Claire

NRSG 432

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Introduction with Purpose Statement

In recent years the issue of medical safety and errors has become a large area of concern.

Ensuring patients are receiving the care and medications specific to themselves is vital. Through

clinical practice it has occurred to me just how simple it is to ensure proper identification of your

patients and how easy it can be as well to let it be forgotten. Because of this, I have become

extremely interested in researching ways to promote proper identification methods in patients,

especially those that are vulnerable and/or may be harder to properly identify. Therefore, the

purpose of my paper is to further examine issues of medical safety, errors, and patient

identification.

Current Issue in Nursing

In current nursing practice the failure to properly identify patients can result in several

medical errors that can be detrimental to a patient’s health. According to World Health

Organization (2007), “The major areas where patient misidentification can occur include drug

administration, phlebotomy, blood transfusions, and surgical interventions (p.1)”. When patient

misidentification occurs, often times it can be a result attributed to a healthcare professional’s

failure to ensure proper identification procedures required by their facility or the lack of adequate

identification procedures within a facility. This issue affects patients of all ages and health

backgrounds. Some of those most vulnerable patients of this issue, in my opinion, however are

children, those who are cognitively impaired, and older adults who may not know enough about

their cares to be able to know to inform their healthcare provider if something doesn’t measure

up with potential wrong cares/medications they are being given.

History of Issue (Past and Current)

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According to Ballard (2003), “28% of adverse reactions to medications and 42%

of life-threatening events in health care are preventable (p.1)”. This means that

somewhere in the line of care, healthcare professionals such as nurses take some part in

being able to reduce the occurrence of medical errors. Although there is no current

research showing exactly how many medication errors are directly related to patient

misidentification issues, Mayo & Duncan (2004), explain that patient misidentifications

play a large role in these errors.

The issue of patient safety has been an area of concern for years.

“In 1999, the Institute of Medicine (IOM) described the nation’s health care

system as fractured, prone to errors, and detrimental to safe patient care. It defined

patient safety as freedom from accidental injury and further stated that ensuring

patient safety involves the establishment of operational systems and processes that

minimize the likelihood of errors and maximize the likelihood of intercepting

them when they occur (Ballard, 2003, p.1)”.

Ballard (2003) also explains that in past years patients have been passive while receiving

nursing care. Often times they were not informed of what procedures were being done, what

medications they were taking, and what they were supposed to do to comply with their illnesses.

However, in more recent years, patients have become more active in there cares and the

knowledge of their cares has helped to decrease medical errors, ensuring that they are the correct

individual to receive the care, treatment, or medication. Currently, hospital safety committees

have been advocating for healthcare teams to properly inform and educate patients and their

families of the cares/medications/treatments they are receiving to help minimize medication

errors attributes to misidentification gaps and issues that lead to medical errors. Safety

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committees continue to address this issue as they research new information regarding better

patient identification procedures.

Importance of Issue

The issues of patient misidentification are vastly impacting, especially when it causes any

type of medication error. “Medication errors strike at the heart of being a nurse- the

responsibility to do good and avoid harm (Mayo & Duncan, 2004, p.1)”. It is the duty of all

healthcare providers who are stakeholders in a patient’s care to ensure that they are properly

identifying patients to avoid any harmful consequences. According to Pham, J., Aswani, M.,

Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P (2012), “Medical errors account for

~98,000 deaths per year in the United States. They increase disability and costs and decrease

confident in the health care system (p.447)”.

Suggested Changes

When I was observing a surgery one day in my clinical course it was procedure to hang a

piece of paper on the end of each patient’s bed including all medications and there conversions of

dosages according to the patients weight upon going to surgery. The professionals were going

through all there identification procedures however while observing the room I noticed that the

name on the end of my patient’s bed did not match up with the name on the surgery board. I

immediately told the nurse monitoring the surgery and she instantly stopped the surgery to check

that we in fact had the correct person. Fortunately, they were operating on the correct patient,

however someone had accidentally placed the wrong medical sheet on the patient’s cart. This goes

to show just how easy it can be to have an error due to one improper check.

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I believe that medical errors within healthcare would decrease more if all healthcare

providers were required to get yearly education about strategies including proper patient

identification methods and other interventions that help to reduce errors. According to the Joint

Commission (2014), recommended protocol includes using at least two patient identifiers when

giving cares, treatments, or services. This may include “the individual’s name, an assigned

identification number, telephone number, or other person-specific identifier (Joint Commiss ion,

2014)”. Checking such identifiers to properly match patient with the correct treatment can be

highly beneficial. “The use of bar-coding systems, which utilize patient arm bands for name,

birthdate, and ID as their two patient identifiers, have been associated with elimina ting

transcription errors and reducing 50.8% of potential ADEs” or adverse errors (Pham et al., 2012,

p. 449). Lastly I believe that within these educational sessions for patient safety strategies, health

employees should go through routine teamwork simulations. Studies show that common safety

culture relationships associated with patient safety include quality handoffs and transitions, and

teamwork across and within units (p. 451)”.

Conclusion

Hopefully, by implementing some of these interventions and diligently continuing to

practice each of them on a daily basis, medical errors will begin to decrease more rapidly. As

technology and research continue to expand I am excited to see what will be available to

healthcare providers in the near future to more properly identify our patients and what ways we

will be able to strategize to continue to protect or patient’s health and ensure orchestrating safer

cares.

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References

Ballard, A. (2003). Patient safety: A shared responsibility. Online Journal of Issues in Nursing,

8(3).

www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/T

ableofContents/Volume82003/No3Sept2003/PatientSafety.aspx

Joint Commission. (2014, Jan 1). Patient safety goals. Retrieved from jointcommission.org

Mayo, A.M., Duncan D. (2004). Nurse perceptions of medication errors: What we need to know

for patient safety. Journal of Nursing Care Quality. 19(3), 209-217.

Pham, J., Aswani, M., Rosen, M., Lee, H., Huddle, M., Weeks, K., Pronovost, P. (2012).

Reducing medical errors and adverse events. Annual Review of Medicine, 63, 447-463.

World Health Organization. (2007). Patient safety solutions. WHO Collaborating Centre for

Patient Safety, 1, 1-4