Assessment 2 Instructions: Root-Cause Analysis and Safety Improvement Plan
The provision of safe healthcare relies on the accuracy of patient identification. Serious injury, extended recovery time, or death might occur as a consequence of patient identification mistakes. In addition to the obvious repercussions, patients lose faith in the healthcare system as a whole, which makes them less likely to seek treatment and more likely to disregard doctors' orders. To address the devastating impact of patient identification mistakes on individuals' well- being and healthcare trust as a whole, a thorough strategy is required, one that includes root- cause investigation and safety improvement initiatives. Analysis of the Root Cause The identification of patients inside healthcare systems is a major problem that necessitates rigorous consideration in the field of patient safety. A complete root-cause investigation and safety improvement strategy must be put in place since patient identification errors might have serious repercussions. John, a middle-aged man, is hospitalized to a bustling metropolitan hospital for a standard surgical operation. A number of mistakes in identification do happen, regrettably, while the admission procedure is underway. Clerical error has resulted in the patient's wristband being incorrectly tagged with the details of another patient. Consequently, this sets in motion a series of events that result in several significant consequences. The immediate danger to the patient's safety and well-being is the primary worry when it comes to patient identification mistakes. Medication meant for another patient with a different medical history and condition was administered to John as a result of the misidentification. Adverse medication responses, worsened health problems, and an increased risk of
3 complications before and after surgery may occur when the therapy does not fit the patient profile. Patients and their loved ones endure severe mental and emotional distress in addition to the physical injury. A family may feel betrayed and lose faith in the healthcare system after learning that a loved one has been the recipient of medicine or surgery that was intended for another person. If John's loved ones don't know about the mistake in diagnosis, they may see worrying changes in his health without knowing why. This might force them to wait to intervene, which could have permanent effects. A further important outcome is a decline in faith in the healthcare system. After hearing about the mistake in identification, John's family no longer has faith in the hospital's capacity to provide dependable treatment. Future healthcare choices are influenced by this distrust, which goes beyond the present occurrence. In the aftermath of such mistakes, patients and their loved ones may be afraid to seek medical attention or adhere to treatment plans for fear of further harm to their health. In order to get to the bottom of this patient safety problem, we need to look at the different steps in the identifying process. This involves checking the current systems for admissions, labeling methods for wristbands, and cross-checking. In order to create a successful strategy for improving safety, it is essential to determine exactly whether communication, training, or technological failure enabled the mistake to spread. Policy, procedure, and training program revisions should all be part of a comprehensive strategy to enhance safety. Implementing multiple verification stages, improving staff training on the necessity of precise identification, and introducing barcode technologies for patient
4 identification may considerably decrease the likelihood of mistakes. The implementation of new procedures necessitates the establishment of regular audits and feedback systems to track compliance and pinpoint improvement opportunities. Healthcare providers should be aware that patient identification mistakes are a major risk to their patients' security, confidence, and health. Healthcare companies may strengthen their systems to prevent these types of mistakes by conducting thorough root-cause analyses and implementing rigorous safety improvement plans. The hypothetical situation involving John highlights the need of precise patient identification in guaranteeing the provision of trustworthy healthcare services. Application of Evidence-Based Strategies A thorough root-cause analysis and safety improvement strategy are necessary to resolve patient identification problems and improve patient safety. It is essential to implement measures that are based on facts and best practices in order to reduce the risks of identification mistakes (Tilly et al., 2022). To do this, a combination of methods is required, one of which is the use of cutting-edge technology like biometric verification systems and barcode scanning. Additional precautions may be implemented by standard
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