Process For Alerting Staff Members of Potential Safety Errors

Process For Alerting Staff Members of Potential Safety Errors

Instructions/Descriptions

Process For Alerting Staff Members of Potential Safety Errors

Introduction
Independence Medical Center is a rural referral hospital with 115 beds in Independence, Iowa. Like all hospitals, administrators and providers try to avoid errors, and it’s the patient safety officer’s role to monitor the hospital’s safety posture and recommend better practices. But what happens when a mistake leads to a medication error? Patient Identification
At Independence Medical Center, the patient safety officer conducts daily safety rounds. Today, she’s rounding at the pediatric unit on the eighth floor. Kyra Dilley and Virginia Anderson

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Kyra Dilley: Hi, where’s the charge nurse? Virginia Anderson: That’s me. What’s up? Kyra Dilley: Well, I’m doing my safety rounds and I noticed that there are two patients on this floor in rooms directly across from each other: B. Moore and B.R. Moore. Virginia Anderson: That’s not all — they have really similar birthdates! B. Moore was born on 8/11/05 and B. R. on 11/8/05.Kyra Dilley: Okay, that’s even more concerning. How are you making sure not to confuse those patients? Virginia Anderson: It’s not a problem. We’re making sure that the two patients always have different nurses. Kyra Dilley: Well, that’s good, but I have to warn you that this is a troubling situation. Are all shifts aware of the need to schedule nurses around this? Virginia Anderson: There are notes in both charts. We had to do that; we’ve been short staffed this week and there’s been a lot of shifting around. Now that you’ve spoken with some clinical stakeholders, answer the following questions:
Question 1: If the PSO determines this is a trending issue on this unit, which step should she include in the corrective action?Your response:Incorrect.
Correct Answer: In-service education for the entire unit on which the errors continue to trend.Education for the entire facility is not warranted at this time, given that the error is trending only on one specific unit.Incorrect.

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Correct Answer: In-service education for the entire unit on which the errors continue to trend.Using only one identifier does not meet regulatory standards.Correct Answer: In-service education for the entire unit on which the errors continue to trend.Given that the errors are trending on the unit, all staff on the unit should attend in-service education on this issue.Correct!
Providing in-service education to the entire staff on the unit on which the error is trending is important. While only two nurses were involved in this error, the next error could occur with different staff. In addition, re-educating the entire unit is beneficial, as fellow staff members often catch errors that others do not see.Question 2: Which operational consideration is NOT a priority in terms of reducing patient identification errors?Your response:Incorrect.
Correct Answer: Reason for admission to the unit.The room assignment process is an important item to consider, as no process may be in place to strategically put patients on the unit when an error may occur due to identification or other similar factor. The PSO may want to revise the current process or create one if one doesn’t exist. This is a potential re-education topic if a room assignment process does exist but staff members do not adhere to it, or if the process is revised and staff members require education about the revised process.Incorrect.
Correct Answer: Reason for admission to the unit.Reviewing the process for alerting staff members of potential safety errors due to patient identification is important to consider. The patient safety officer may want to revise the current process or create one if one doesn’t exist. This is a potential re-education topic within the organization if a process for alerting staff members of potential safety errors due to patient identification exists but staff members do not adhere to it, or if the process is revised and staff members require education about it.Incorrect.
Correct Answer: Reason for admission to the unit.Reviewing the floor census is an important consideration in this case. The patient safety officer will want to determine working conditions at the time the error occurred. For example, was the unit short-staffed at the time of the error? Was there an emergency in the unit at the time the error occurred, distracting staff members?Correct!
At this time, knowing the reason for admission to the unit is not a priority, because the issue involves patient identification. Diagnosis is not an element used in patient identification.Question 3: What potential next steps might a patient safety officer take?Your response:Expert Response: Health care experts in patient safety and quality improvement identified the following as important next steps when a patient identification issue arises:

Review any existing room assignment policies and procedures.

Interview staff members assigned to each patient to determine their process for proper patient identification to ensure mix-ups are avoided.

Notify the risk manager of the potential patient safety error.

Educate the family about the importance of active involvement in their child’s care and about the organization’s patient identification process.

Question 4:
True or false: Regulatory agencies require the use of three patient identifiers (such as name, DOB, or address) to identify patients.Your response:Incorrect.
Correct Answer: False.The Joint Commission requires health care organizations to use two patient identifiers.Correct!
The Joint Commission requires health care organizations to use two patient identifiers, not three.Question 5: What are the potential implications for a health care organization if a mistake or an adverse event occurs as the result of a patient identification error?Your response:Expert Response: Health care experts in patient safety and quality improvement cited the following as potential implications for the organization if a mistake or adverse event occurs as the result of a patient identification error:

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Continued medication, blood transfusion, and procedural errors.

Increased costs to the organization.

Adverse effects on patient health.

Increased regulatory oversight, which could lead to fines, penalties, or loss of accreditation.

Question 6: What are the potential implications for the patient if a mistake or an adverse event occurs as the result of a patient identification error?Your response:Expert Response: Health care experts in patient safety and quality improvement cited the following as potential implications for the patient if a mistake or an adverse event occurs as the result of a patient identification error:

Prolonged admission, resulting in increased costs and diminished patient satisfaction.

Disability or death.

Process For Alerting Staff Members of Potential Safety Errors

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