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Root-Cause Analysis and Safety Improvement Plan

This assessment highlights the issue of patient identification errors prevailing in Arnold Plamer Hospital. This hospital is dedicated to serving children, particularly providing pediatric healthcare services. In this hospital, the emerging patient-identification errors have impacted the health of many children. This paper will delve into root-cause analysis of misidentified patients and errors in patient identification. Furthermore, the safety improvement plan will be developed to address the growing issue.

Analysis of the Root Cause

In Arnold Palmer Hospital for Children, one fine day, two pediatric patients named Julia and Jenny came for vaccination. Their identification bracelets were mistakenly swapped, and Julia received the vaccinations intended for Jenny and vice versa. The nurse administering the vaccinations detected the error when Julia’s medical history did not match the Electronic Health Records (EHR) information. The nurse realized the patient’s identification did not match the digital records, prompting further investigation. This misidentification of patients affected both patients as Julia received vaccines that were not suited to her medical condition and experienced some allergic reactions as adverse effects. Similarly, Jenny was at risk of contracting diseases due to missed vaccinations, which her health condition required. Additionally, this incident caused anxiety and distress for the families involved, eroding trust in healthcare systems.

The standard protocol for patient identification during vaccination needed to be followed. The nurse did not verify the patient’s identity by cross-checking identification bracelets and EHR data to execute the further vaccination procedure properly. Furthermore, there needed to be more communication between the administrative staff responsible for assigning patient identification bracelets and the nursing staff responsible for administering the vaccinations (Romano et al., 2021). Moreover, the hospital’s vaccination department’s high workload and fast-paced nature must have contributed to the oversight and resulted in this event. Lastly, the EHR system failed to raise an alert for a mismatch in patient identification, highlighting a potential flaw within the technology and requiring further upgrades and feature installation (Riplinger et al., 2020). Hence, the root-cause analysis indicates the procedural breakdowns, communication gap, human and environmental errors, and the need for an upgraded EHR system with better-aligned features.

Application of Evidence-Based Strategies

Patient identification errors impact patient safety and require implementing evidence-based strategies to ensure patient safety by delivering correct care treatments to the right patients. These strategies include using a Barcoding System to correctly identify the patients for medication administration and other therapies such as surgeries. The barcode system allows healthcare professionals to give a patient a specific barcode as an identifier in the form of a wristband and deliver care treatments based on the barcode allotted (Barakat & Franklin, 2020).

One example of this system is Barcode Medication Administration, in which the barcode of a patient’s wristband is matched with a barcode on the medication to administer the correct medication to the right patient without making an error in patient identification (Owens et al., 2020). Literature states that about 236 patient identification errors occurred when patients lost bracelet identifiers (Rahmawati et al., 2020). This required a robust identification system for patients, such as biometric systems such as iris biometric systems where iris scanning for each patient is conducted to store as a template. This scanned template matches the patient for routine care treatment deliveries (Anne et al., 2020).

NURS FPX 4020 Assessment 2 Root Cause Analysis and Safety Improvement Plan

Other strategies include developing and enforcing standardized protocols for patient identification, including using checklists for verification. Implementing these checklists during patient encounters will reduce the incidence of patient misidentification, particularly before administering medications or vaccines (Riplinger et al., 2020). Moreover, healthcare professionals must establish regular communication channels, such as huddles or briefings, to discuss patient identification protocols and address any concerns or challenges the healthcare team faces. Furthermore, healthcare professionals must be trained on the importance of patient identification and ways to mitigate human errors that lead to patient harm (Vaismoradi et al., 2020). By implementing these strategi