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Problem Statement

The patient safety nurse has identified recurring patient identification errors at the hospital, including registering the wrong patient information. An investigation found the medical records system does not highlight similar patient names and dates of birth well. This leads to safety risks from misidentifying patients, which could cause medical errors. A comprehensive review is needed to improve patient identification processes and ensure safety.

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117 views

Problem Statement

The patient safety nurse has identified recurring patient identification errors at the hospital, including registering the wrong patient information. An investigation found the medical records system does not highlight similar patient names and dates of birth well. This leads to safety risks from misidentifying patients, which could cause medical errors. A comprehensive review is needed to improve patient identification processes and ensure safety.

Uploaded by

9cwkwgccdj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Problem Statement

Overview:
Patient Safety Nurse in the Quality Group is confronted with a critical issue regarding an
ongoing series of patient identification errors, as highlighted in recent Hero reports. While a prior
investigation employing the Learning From Defects (LFD) tool has led to some noticeable
improvements, there is an essential need for a comprehensive and in-depth examination of the
matter, as requested by the leadership team.

One significant patient identification error recorded during the LFD investigation involved
the accidental registration of Sandra Johnson, with a date of birth of 10/31/56, under the name
"SandyJohnson" with a date of birth of 10/13/66. Fortunately, the error was identified when
applying the patient's identification armband, as the patient informed the staff that her date of
birth was incorrect. This incident underscores the vital importance of adhering to the practice of
verifying two patient identifiers during registration.

Moreover, the LFD investigation has indicated that the medical record system does not
effectively highlight patients with similar names and dates of birth, potentially contributing to the
recurring patient identification errors. These findings raise concerns about the effectiveness of
our current patient identification processes and emphasize the pressing need for a structured
investigation and solution.

Current Situation:
The overarching problem is the recurrent patient identification errors, with a specific
focus on the inadequate identification of similar patient names and dates of birth in the medical
record system. This problem presents a significant patient safety risk and demands an in-depth
analysis and corrective measures to ensure the highest standard of patient care and safety.

In addition to the previously highlighted patient identification error involving the


registration of Sandra Johnson, the Quality Group faces a broader challenge encompassing
various patient identification situations. These issues underscore a critical need for a
comprehensive evaluation and improvement of the existing patient identification processes to
ensure the highest level of patient safety and care.

The reported patient identification issues include:


 Same patient, same DOB, but under different names (e.g. Robert Jr., Rob, Bob).
 Different patients with the same name and the same DOB.
 Smudged bar codes on Patient ID or medication.
 Broken or unavailable servers, computer or scanning equipment to verify patients.

Negative Outcomes of Current Situations:


 Multiple Names for a Single Patient with the Same Date of Birth: Instances where
the same patient is registered under different names, such as "Robert Jr.," "Rob," and
"Bob," while having the same date of birth. These discrepancies pose a significant risk to
patient safety and data accuracy, potentially leading to medical errors.

 Multiple Patients with Identical Names and Date of Birth: Cases where different
patients share identical names and the same date of birth in the healthcare facility's
records. This situation can lead to misidentification, incorrect treatment, and breaches of
patient confidentiality, underscoring the necessity for a robust patient identification
system.

 Smudged Bar Codes on Patient ID or Medication: Occurrences of smudged or


illegible barcodes on patient identification bracelets or medication packaging. This can
hinder the accurate matching of patients with their medications, potentially causing
medication errors and adverse effects.

 Issues with Server, Computer, or Scanning Equipment: Instances where the servers,
computers, or scanning equipment used for patient identification verification are broken,
unavailable, or malfunctioning. These technical challenges disrupt the efficient and
reliable verification of patient identity, increasing the risk of errors and jeopardizing
patient safety.

Follow-on or Downstream Impact of the Problem


The collective impact of these patient identification situations poses a grave concern for
patient safety and healthcare quality. Addressing these issues is essential to prevent medical
errors, safeguard patient information, and maintain the highest standards of patient care and
safety. The problem at hand encompasses a multifaceted challenge in patient identification,
necessitating a comprehensive approach to address each of these identified issues effectively.

Property of Miguel Carlo Y. Panganiban

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