Root-Cause Analysis and Safety Improvement Plan
Capella University
NURS-FPX4020: Improving Quality Care and Patient Safety
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Dr. Tom Dalesandro
January 2024
Root-Cause Analysis and Safety Improvement Plan
Introduction
Root cause analysis refers to a structured process for understanding the major causes of
certain issues within an organization or system. Root cause analysis aims to evaluate what
occurred, the reasons, and how the problem can be stopped (Okes, 2019). This root cause
analysis was done in a healthcare setting with many patients. The paper explores the root causes
of patient identification errors at Palmcare Healthcare and provides a safety enhancement
strategy to resolve the issue and prevent them in the future. The problem of patient identification
errors can lead to major impacts such as poor patient safety and possible legal action against the
facility. The analysis tries to offer a definite understanding of what happened, the victims, and
how the root causes led to the problem.
Root Causes Analysis of Patient Identification Errors at Palmcare Healthcare
The patient identification error at Palmcare Healthcare included the failure of healthcare
providers in the registration and admission department to correctly identify some patients
admitted during different points of care within the facility. The problem affected the healthcare
workers and patients with cases of wrong medications reported. It caused serious medical errors
and reduced the safety of the affected patients. The analysis was done through the utilization of
different methodologies such as examination of records and documentation, incident reports, and
interviews.
The first stage of the analysis was based on understanding events contributing to the
errors. It comprised understanding the errors and possible outcomes for workers and patients.
Secondly, a comprehensive survey of the patient identification activities across various
departments was done. It comprised finding out the major areas like registration and admission,
medication administration, and transfers where identification is supposed to take place. The aim
was to understand the course of patient identification and point out places where issues were
experienced (Okes, 2019). Thirdly, the analysis tried to evaluate what was expected to be done
during patient identification. Divergence from standard procedures was noted and studied to get
reasons for the failure to follow protocol. The analysis explored possible environmental aspects
that may have caused patient identification errors. They comprised the healthcare facility’s
layout, lighting, and the degree of noise that can cause distraction during patient data entry and
capture. There was also a thorough evaluation of human-related factors like fatigue,
distractions, and overload. The analysis focused on how human factors might have led to patient
identification errors. Communication problems were also examined. Lack of effective
communication among healthcare providers in the organization was determined (Rodziewicz &
Hipskind, 2020). The process included the evaluation of communication during different
sessions including handoffs, care transitions, and interactions among various teams
concerning the identification of patients.
Finally, the analysis showed a uniform trend across various departments of the
organization. There were no standardized procedures for proper identification of patients.
Discrepancies in practices and procedures across different healthcare departments laid a
suitable foundation for patient identification errors (Okes, 2019). Without definite and
consistent protocols for patient identification, massive divergence from the routine procedures
and intensified possibility of errors were witnessed.
Application of Evidence-Based Strategies
Piera-Jiménez et al. (2020) conducted a study to identify modern patient identification
techniques and approaches utilized across the world. Through a review of the literature, various
strategies that can inform the reduction and avoidance of patient identification errors can be
understood. Guaranteed quality health information is getting hard with the use of new data
sources and electronic sharing of data. Various literature such as Piera-Jiménez et al. (2020)
encourages the idea that standardizing patient identification operations is critical in limiting
errors in the healthcare setting. The use of evidence-based approaches to solve patient
identification errors includes the application of best practices that have been shown to help
improve reliability, safety, and accuracy.
Strategies like unique patient identifiers are commonly used best practices during the
identification of patients in healthcare organizations. It is a process that includes giving patients
specific identification codes that are uniformly used at different points of care. The unique
identifiers reduce confusion while ensuring that the right patient gets matched with the right
medical records and documentation. Another strategy is a standardization of patient
identification protocols. At every point of patient care, patient identification should be
standardized through clear and uniform definitions of patient identification verification during
patient admission, administration of medication, diagnosis, and transfer. Moreover, it is
important to consider technologies such as electronic health records (EHR) to improve
identification efficiency and offer reliable validation (Gibney et al., 2020).
Improvement Plan for Patient Identification
The improvement plan involves creating standardized patient identification procedures
and unique patient identifiers. For the standardized patient identification process, the actions
include a dedicated collaboration with the interdisciplinary teams to develop the protocols. The
protocols will focus on different points of engagement within the organization, a situation that
will reduce the inconsistency that has been highlighted in the root cause analysis. According to
Gal & Rubinfeld (2019), standardization facilitates and improves data use when data portability
and interoperability are necessary not only in healthcare organizations but across various sectors
that utilize data and information. The aim is to create consistent operations for patient
identification during admission, medication, and transfer. The draft protocols will be developed
within the initial 3 months and implementation undertaken within 6 months.
Based on Piera-Jiménez et al’s. (2020) research which argues that unique patient
identifiers (UPIs) were successfully implemented in Europe to develop effective and uniform
identification strategies, this plan will also implement the UPIs approach. The aim is to limit
dependency on patient traits, something that will lead to a reduction in patient identification
errors. The timeline consists of 6 months for the initialization of the pilot stage. The
determination of results and a map for general implementation will take place within 1 year.
Existing Organizational Resources
Some of the resources that will be relied on to ensure successful implementation of the
plan include healthcare providers in the organization. Healthcare providers like nurses,
pharmacists, and physicians among others will be engaged during the development, training, and
implementation stage of the identified standardization strategies and protocols. The practitioners
are important for protocol adjustment and practical implementation.
The information technology department will be dependent on for the successful
implementation of the unique patient identifiers (UPIs). The skills of IT specialists are important
for the smooth incorporation of modern methods of identification. Moreover, the organization’s
IT resources will be used to facilitate the management of data, updates, and improvements for
the UPIs approach.
Conclusion
The root cause analysis is a reliable process of understanding the underlying problems in
an organization. Through the root cause analysis, the significant patient safety issues, specifically
identification errors within Palmcare Healthcare have been understood. Moreover, a workable
improvement plan has also been drawn out to resolve the identified problem. Utilizing precise
evaluation of occurrences and associated factors, the analysis has helped to single out the failure
to standardize patient identification procedures as the root cause of patient identification errors.
The improvement plan created and informed by evidence-based approaches helps resolve
the problem. The developed plan involves a diversified strategy that focuses on the creation and
effective implementation of standardized patient identification procedures, the experimentation
of UPIs, and the training of employees. The identified actions aim at finding solutions to the
given root cause and an enhancement of an organized and effective strategy that improves patient
identification.
References
Gal, M. S., & Rubinfeld, D. L. (2019). Data standardization. NYUL Rev., 94, 737.
Gibney, B., Ryan, J. W., MacMahon, P. J., O’Connor, G. S., & Bolster, F. (2020). Assessment of
RAdiopaque Patient Identification Stickers (RAPIDS) for patient-scan correlation in a
mass casualty incident. Emergency Radiology, 27, 293-301.
Okes, D. (2019). Root cause analysis: The core of problem-solving and corrective action.
Quality Press.
Piera-Jiménez, J., Dooling, J., Ranade-Kharkar, P., Pollock, S., Mann, D., Thornton, S., ... & Rai,
A. (2020). Patient identification techniques–approaches, implications, and
findings. Yearbook of medical informatics, 29(01), 081-086.
Rodziewicz, T. L., & Hipskind, J. E. (2020). Medical error prevention. StatPearls. Treasure
Island (FL): StatPearls Publishing.