Issue Analysis and Leadership Action Plan

Issue Summary

Two patients, both males aged 23 and 24 years old, were brought to the hospital on Monday morning. Since their conditions seemed to be worsening each minute, they were briefly taken through the emergency department (ED) for examinations of their identification. One of them was vomiting and complaining of a stomachache, while the other had diarrhea and still complaining of a stomachache. However, they were both stabilized while their samples were collected and taken to the laboratory for further examination. The two patients were admitted to two neighboring rooms while awaiting for the laboratory results and further medical procedures. The laboratory technician carried out the laboratory sample tests and indicated the results on the charts as per their room numbers as had been indicated on the samples. The patient who had been vomiting was having chronic ulcers whereas the other was suffering from food poisoning. The same doctor attended the two patients separately. However, while attending to the second patient, she realized that the name of the patient in the file did not match the name on his wristband. That means she had administered the wrong procedure and medication to the patients unknowingly. On checking the first patient's identification, she realized that the names on wristbands had been alternated in the emergency room. Possibly the clinical officer in the emergency room had been solely on duty overnight. Therefore, there were chances that he was exhausted and gave the wrong identification of the patients on their wristbands coupled with the fact that both patients were complaining of stomachaches, the same gender and age set.

IHI Triple Aim

The Institute of Healthcare Improvement (IHI) Triple Aim is a framework developed by John Whittington and Ton Nolan, which provides an incentive for performance improvement in the health system (Whittington et al., 2015). This approach comprises three major dimensions; hence triple aim. Improve the patient experience of care, reduce the per capita cost of health care, and improve populations' health. The rate at which patient Identification has risen surpasses detection due to the varying nature of results. However, there have been attempts to quantify the occurrences of such incidences. As a way of curbing this issue from future occurrences, an Individual Health identifier (IHI) has been devised, and it being a number, can be easily used to safely identify an individual and their health information while using a health care service (Clavel et al, 2019). The primary importance of having an IHI is to ensure patient safety. However, IHI can achieve this in several ways:  Identification of the patient, identification of the patient's records, availing a mechanism that provides current and past health information to help make relevant clinical decisions, and ensuring the safe transfer of patient's records as they transfer across private and public health care centers. Generally, IHI has been crucial in tracking patients' essentiality with health services, thus enabling the identification of flows and developing necessary patient care to follow-up. IHI has also allowed the collecting of health data that the research team can eventually use to create better treatments and offer better health needs (Whittington et al, 2015). In terms of the efficiency of Health Services, IHI is relevant in the tracking of patients across health services in the following manner:

They collect more accurate information, such as identifying any form of misidentification of patients waiting for bays to receive a similar consultancy, treatment practice, or service. IHI also identifies how and where it can achieve effectiveness and accuracy by focusing on highly demanded services and planning such strategies to meet the requirement. IHI ensures patients' privacy by acting as a medium for logging and identification of access to patient records and limiting the access of patient data to only the relevant Health service providers. IHI also offers aid for the provision of electronic health systems, which are essential in identifying individual health records of patients in health care algorithms (Merry et al., 2017). Recording of patients electronically, transferring, and referring. Within the health programs, all health servers include disease registers, acute, community, national, and international public and private.

It also provides a linkage of health records across systems for presentation to patients' health care services, supporting audit requirements on health record access logs while complying with GDPR. The issue that gave rise to this case had emerged from the emergency department. Now, similar errors of patient mistaken identification that may occur in various circumstances have been illustrated. For instance, typical names of patients can increase the chances of patients being mistakenly identified. However, a case study by the New York-Presbyterian Hospital of wrong-patient electronic records revealed that only 3% of errors resulted from patients with the same identifiers. A similar case study instead pointed out that one staff member handles too many patients and several distractions while providing services to the patients.

Culture

Culture, for the most part, is the conduct developed that is primarily personally learned. A Culture of Health is extensively characterized as a culture through which great well-being and prosperity flourish across all regions, including the geographic, segment, and social areas, such as those that cultivate solid fair network aides and public and private dynamics. This guarantees that everybody is qualified to settle on decisions that can result in a solid living. A patient security culture dependent on the sociotechnical structure has seven essential qualities. It supports both qualitative and quantitative data. The well-being frameworks require personal information, for example, center gatherings, to decide if a culture of security exists among colleagues or if they have a significant comprehension of patient security standards and are rehearsing them. This is because highly quantitative social results at a given level don't show whether an association is utilizing medical care IT securely or that it is medical care IT frameworks are protected.

It does not entirely depend on HIMSS Stage Levels to affirm total security. Clinical units can achieve a HIMSS stage five or higher. However, as indicated by subjective criticism from bleeding-edge staff, can, in any case, encounter security issues. Be that as it may, HIMSS levels don't quantify patient well-being and culture of security issues. The HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM) subsequently exhibits well-being frameworks on their EMR limits, although these scores may not match clinical security. It gives Frontline Clinical officials a strength in the making by strengthening bleeding-edge clinicians and other specialist co-ops with patient-explicit wellbeing well-being examination giving room for guaranteed clinical dynamics to alleviate any harm. When dynamic designated and degenerated at medical care IT higher administration levels, specialist organizations at forefront levels are less ready to follow up on security issues they have recognized rapidly. Forefront clinicians can address potential mischief quickly with the utilization of neighborhood oversight (Gray & Jani, 2016). It makes IT solutions accessible to non-technical users

Forefront clinicians should have the option to effortlessly access and use well-being investigation answers to settle on ideal security-related choices. Shortcomings with innovation, not just deferral tending to well-being issues and expanding hazards, but besides putting pressure on clients, build the danger of labor force burnout. Associations can make productive patient well-being arrangements open to bleeding-edge clinicians with a protected, cloud-based programming module. The Surveillance Module recognizes, screens, and forestalls patient security occasions and robotizes answering to give prescient information and all-hurt distinguishing proof and investigation.

It urges Frontline Clinicians to report on safety and quality issues regularly. With a traditional culture wherein cutting-edge staff is open to revealing any security or quality concerns, well-being frameworks can precisely measure security issues (a fundamental advance in lessening hazards). To guarantee that staff is happy with shouting out, the administration should maintain a climate of non-debatable shared regard for all colleagues (Smagus, 2019). Culture undergoes necessary assessment before carrying out tasks. For wellbeing frameworks to completely use IT answers to improve patient security, they should perform careful due diligence before going live with the devices. Associations hazard wrecking innovation and improvement objectives when they dispatch instruments before giving a test for even fundamental usefulness such as signing on to mind modules. Treats a safety issue in one area as a potential system-wide risk. IT-related well-being issues in one segment of a well-being framework can show hazards throughout the framework.

Collaboration

According to Custonguay and Muran (2019), the well-being of patients is a principal and fundamental fragment of significant nursing care. In any case, the country's clinical consideration system is slanted to botches and can be unfriendly to safe patient thought on account of essential structure blemishes. A grouping of accomplices (society with everything taken into account; patients; solitary clinical overseers; nursing educators, heads, and researchers; specialists; governments and definitive bodies; capable affiliations; and affirming associations) are needed so that patients' demands are met and are securely communicated. These specialists are perceived by a combination of administrative titles that change starting with one affiliation and then onto the next anyway that fuse titles like supervisor clinical authority (CMO), VP for clinical issues, negative behavior pattern senior part for clinical cases, clinical boss, or head of staff.

Leadership

The frontline leaders include the senior nursing officer, the senior medical officer, the patient safety officer, doctors, nurses, laboratory technicians, and radiology technicians in various healthcare facilities. Leaders' role in correcting the issue of patient misidentification and quality improvement forms the foundation of any improvement plan leaders provide the strength of purpose and develop the organization's framework (Smigus, 2019). Therefore, the responsibility of leaders includes the creation and maintenance of the internal environment. It is in this environment that employees are entirely involved in meeting the organization's goals and objectives. Good leadership is necessary to promote quality across the organizational departments, as the frontline team sets objectives and enables the workers to carry out the proposed strategies.

Leadership Action Plan

Guarantee that medical care associations have frameworks in place that underline the essential duty of medical services clinicians to check the privacy of patients and match the suitable patients with the correct identification (for example, laboratory results, models, and systems) treatment procedures are administered Support the utilization of in any event two identifiers (for example, name ). Individual identification should not be the room number of the patient (Thomas, 2019). There is also a need to normalize the ways to deal with patient recognizable proof across various departments inside a medical facility. Incorporate preparing methods for checking/ confirming a patient's personality into the direction and proceeding with proficient improvement for medical care workers (Thomas, 2018). Educate all stakeholders about understanding recognizable proof positively which also involves worries for privacy.

Conclusion

The major areas where patient misidentification may occur include theatres, emergency departments, phlebotomy, blood transfusion, and careful intercessions. The strategy aimed at limiting working duration for the clinical workers prompts an increased number of workers focusing on every understanding, improving the probability of hand-over and other correspondence problems. While in certain nations, wristbands are customarily utilized to distinguish hospitalized patients, missing groups, or incorrect data limit this framework's adequacy. The use of wristbands encourages fast visual acknowledgment of explicit issues. Yet, the absence of a normalized coding framework has led to staff mistakes who give care at various offices. Many modern innovations may improve patient identification. i.e., barcoding. A portion of these has ended up being applicable. Regardless of the invention or approach utilized for accurately distinguishing patients, cautious making preparations for the cycles of care will guarantee a reliable patient identifier preceding any clinical intercession and give much safer consideration, essentially reducing the number of errors.

References

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Fernandes, L. M., Burke, J., & O'Connor, M. (2017). Applying innovation to the patient identification challenge. Journal of AHIMA, 88(8), 26-29.

Goeckenjan, G., Sitter, H., Thomas, M., Branscheid, D., Flentje, M., Griesinger, F., ... & Wolf, J. (2011). PubMed Results. Pneumologie, 65(8), e51-e75.

Gray, M., & Jani, A. (2016). Promoting Triple Value Healthcare in Countries with Universal Healthcare. HealthcarePapers, 15(3), 42-48.

Mery, G., Majumder, S., Brown, A., & Dobrow, M. J. (2017). What do we mean when we talk about the Triple Aim? A systematic review of evolving definitions and adaptations of the framework at the health system level. Health Policy, 121(6), 629-636.

Smaggus, A. (2019). Safety-I, Safety-II, and burnout: how complexity science can help clinician wellness. BMJ quality & safety, 28(8), 667-671.

Thomas, P., & Evans, C. (2004). An identity crisis? Aspects of patient misidentification. Clinical Risk, 10(1), 18-22.

Whittington, J. W., Nolan, K., Lewis, N., & Torres, T. (2015). Pursuing the triple aim: the first 7 years. The Milbank Quarterly, 93(2), 263-300.