Ensuring Patient Safety in the Infusion Center when Using Two Patient Identifiers While working as a recent graduate pre

Ensuring Patient Safety in the Infusion Center when Using Two Patient Identifiers

While working as a recent graduate preceptor in a local hospital’s infusion center, I undertook a near-miss event on the proper identification of patients as mandated by the Joint Commission’s National Patient Safety Goals. The attendance in the case entailed two patients of a similar first name and almost receiving the wrong treatment. Most dangers were shown in this case to explain why it was important to adhere to the two-patient identifier rule.

Incident Description

A patient came for a port flush and another patient with the same name was booked for both port flush and antibiotic administration at about the same time. Although the nursing staff was careful they nearly gave the wrong patient antibiotics; they had compounded the medication and were ready to infuse the intravenous fluid. However, when the nurse asked the patient the date of birth at the bedside she got two different people. Any dismissal without review of applicants’ portfolios would be a fatal mistake in this case, thus, it was a close-call type of situation. (Gorski et al. 2021).

Policy Relating to Identification of the Patient

The hospital where I worked has such a policy that all patients must be identified twice before treatment takes in a procedure. This typically includes some questions like the full name of the patient and the date of birth. The policy is consistent with The Joint Commission’s NPSGs in which the latter underscores that there is a need for several confirmations of a patient’s identity in order to administer the right treatment to that particular patient. In this case, the policy of the hospital proved effective since the error was detected when the nurse performing the action double-checked the identification of the date of birth in order to prevent the provision of improper treatment. There should be a policy requiring comparing at least two pieces of identification data, like name and date of birth, and recommending the use of supplementary measures, including barcode scanning technology. The Joint Commission insists that as application of these identifiers decreases the chances of mistakes and enhances the safety of patients as it guarantees the correct administration of therapies. (Murphy & APR 2012).

Causes of the Occurrence

There were two major causes for this near miss: The patients had the same name and had booked their appointments for the same time of the day. This is more especially so where staff executes the various procedural bureaucracies routinely and at such busy areas as infused centers. What this incident portrays is how a plan such as the two-patient identification process can easily go wrong if the staff involved pay little or no attention to it.

Outcome and Potential Risks

Luckily in this particular case, it was detected before any of the patients was harmed. But if the error was not noted then the wrong patient could have been given antibiotics when they do not need it, which would in turn cause an occurrence of an allergic reaction or any other complications. As well, getting the wrong patient would have meant that the right patient would have come at the wrong time without the antibiotics that they needed which could cause some harm to their health. (Erickson et al. 2003).

Measures to Minimize Mishaps in the Future

Particularly where there is confusion due to patients having similar names, or being admitted and discharged within a similar period, as an RN I would always make sure the two-part identifier is used strictly. I would also recommend extending bar coding scanning to every activity as a measure to counteract human errors. In the same respect, I would also want the staff not to be negligent, and ensure they cross-check the identifiers to ensure that they do not mistake any patient.

Therefore, it is important for obedience to patient safety measures, which include the use of two identifiers before disclosing a patient’s identity. By making sure that these procedures are adhered to within the letter of the law and backing up such processes with IT healthcare delivery systems are able to stop potential incidents from turning into actual ones thereby enhancing the safety profile.

Reference

Erickson, S. M., Wolcott, J., Corrigan, J. M., & Aspden, P. (Eds.). (2003). Patient safety: achieving a new standard for care.

Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., ... & Alexander, M. (2021). Infusion therapy standards of practice. Journal of infusion nursing, 44(1S), S1-S224.

Murphy, J., & APR, N. (2012). Joint Commission National Patient Safety Goals, 2012. Safety, 12(1).