Summary
Reducing medical errors is one of the key concerns within the healthcare industry. The issue that has been reported at Vila Health is the placement of two patients with similar names and identical birthdays in two rooms in close proximity. B. Moore and B.R. Moore have been put in danger on multiple levels due to the possible mistakes that may have occurred because of the medical staff’s misunderstanding. Patient identification is a vital step covering the match between the patient, the medical problems to be addressed, and the measures taken to provide healthcare services and minimize risks.
There are several implications that may have a damaging effect on the patients and the medical facility if the threat is not addressed. First, there may be issues related to medication, which is a standard medical error that often causes the patient’s safety to be in danger. The issue becomes even more critical since the medication packaging are often identical, which is emphasized more if names and birthdays are similar (Shao et al., 2018). Thus, a patient whose medical history includes information about being prescribed fluoxetine can mistakenly be provided with phenelzine and experience damaging health effects, both mental and physical. Moreover, the nurses attending the patients may mistakenly provide certain services and attend to patients without considering their conditions and needs. Thus, a patient at risk of having bedsores will be visited less frequently, yet the other individual with no risk for such conditions will receive more visits from nurses. Needless to say, more advanced medical procedures such as surgeries or blood transfusions can also be performed on the wrong individual if the similarity in names and the close proximity of rooms is not attested. In this case, transfusing a blood type that is different from that of the patient may lead to severe consequences, including death.
Risks
It is certain that the situation in which two patients with similar names are given two rooms in close proximity of each other is potentially dangerous. Based on the premise of healthcare safety, the environment is to be transparent, which is the first step to ensuring safe and effective medical care (Leape et al., 2009). However, the situation in which nurses do not communicate with each other and other hospital staff has led to the issue remaining unresolved. Transparency, as highlighted in the health care safety imperative, applies through the openness of the staff in relation to the similarities in name, which should have been reported, and the individuals would have been placed in different rooms. Since the error has to do with safety within the healthcare area, the entity that has oversight is the Agency for Healthcare Research and Quality. Thus, the goals of the agencies are assessing current safety measures and findings ways to minimize risks in the future.
Another organization with a significant role in the domain of patient safety is the Joint Commission, which accredits hospitals and other medical facilities based on their performances in ensuring secure and productive services (Leape et al., 2009). Thus, the agencies are to make sure the patients receive the right medication, are not exposed to unsanitary conditions, or, as in this case, are vulnerable to being mistaken for another person with a different condition. Moreover, employees and organizations that implement safety measures implied by the agencies are less likely to misdiagnose, contribute to errors in test results, and put people in danger in any way. Besides the human factor, organizations and employees with high safety standards will not face legal consequences as a result of medical errors.
Regulatory Agency Impact
The Joint Commission has a specific set of National Patient Safety Goals (NPSG). One of the goals is to identify a patient both by using the name and the date of birth to avoid errors (National Patient Safety Goals, 2022). Such regulatory agencies as the Joint Commission have a critical impact on how hospitals approach safety. The main impact is linked to the accreditation of the facility, followed by goals such as the NPSGs, which are implemented by the facilities based on the evidence for the need for improvement provided by the organization. Thus, the guidance is incorporated through the implementation of specific rules and regulations within the facility itself. Training employees, informing safety officers of new regulations, and investing in the measures are among the efforts that the agencies intend to see from hospitals. Otherwise, the potential consequences can be devastating for the general population and the organizations providing the care. Some examples include mistakes in medications, blood transfusions, surgical procedures, and other services. The hospitals themselves and their employees are at risk of facing health hazards, financial issues, and legal problems without following the guidance.
Safety Officer’s Role
The safety officer is one of the leading figures in ensuring the hospital’s regulatory measures for ensuring patient safety. Researchers mention that some of the key responsibilities include setting and planning safety goals, applying evidence-based measures to minimize medical errors, and conducting frequent interviews and surveys with staff members and patients in regard to the current situation within the facility (Campione & Famolaro, 2018). In this particular instance, my responsibility is implementing guidelines in regard to patients with similar names in terms of avoiding misunderstandings. Moreover, having frequent conversations with staff members, ensuring all the nurses and doctors within the unit are aware of the situation, and monitoring the healthcare process throughout the patients’ stay.
Recommendations
Several measures can be implemented to minimize the possible risks by addressing the issue of patient identification. First, the initial identification of such problems requires the immediate response of distancing the two individuals with similar names. The rooms cannot be in close proximity due to the increasing challenge of differentiating the two. Moreover, another possible implementation can be giving the patients different color bands and board names since researchers mention this technique being favorable for the medical staff in terms of identification (Ip & Chan, 2021). Another measure can be the implementation of a protocol on the subject that includes sharing information about the situation among nurses to increase awareness. Furthermore, researchers advise the enactment of barcodes for blood tests and similar procedures to ensure the samples belong to the right individual (Kaufman et al., 2018). Last but not least, the safety committee is to monitor the patient at risk for experiencing medical errors throughout the hospital stay to decrease the potential challenges. These measures are based on the goals recommended by medical agencies and can help create an environment in which patient identification is properly addressed, and the hospital staff makes sure that such circumstances do not compromise the high level of care.
References
Campione, J., & Famolaro, T. (2018). Promising practices for improving hospital patient safety culture. The Joint Commission Journal on Quality and Patient Safety, 44(1), 23–32. Web.
Ip, K. H. K., & Chan, B. C. Y. (2021). How we do it: Color-coded patient labels for enhanced surgical instrument identification during Mohs micrographic surgery. Dermatologic Surgery, 47(8), 1122–1123. Web.
Kaufman, R. M., Dinh, A., Cohn, C. S., Fung, M. K., Gorlin, J., Melanson, S., Murphy, M. F., Ziman, A., Elahie, A. L., Chasse, D., Degree, L., Dunbar, N. M., Dzik, W. H., Flanagan, P., Gabert, K., Ipe, T. S., Jackson, B., Lane, D., Raspollini, E., … Yazer, M. (2018). Electronic patient identification for sample labeling reduces wrong blood-in-tube errors. Transfusion. Web.
Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., Lawrence, D., Morath, J., O’Leary, D., O’Neill, P., Pinakiewicz, D., & Isaac, T. (2009). Transforming healthcare: A safety imperative. Quality and Safety in Health Care, 18(6), 424–428. Web.
National Patient Safety Goals. Joint Comission. (2022). Web.
Shao, S.-C., Lai, E. C.-C., Owang, K. L., Chen, H.-Y., & Chan, Y.-Y. (2018). Look-alike medication packages and patient safety. Journal of Patient Safety, 14(3). Web.