D221 Practice Improvement Plan Proposal

D221 Practice Improvement Plan Proposal

Student Name

Western Governors University

D221 Organizational Systems and Healthcare Transformation

Prof. Name:

Date

D221 Practice Improvement Plan Proposal

1. Describe a healthcare-related situation (S) prompting a systems-level patient safety concern that has the potential to impact multiple patients.

Accurate patient identification is critical in delivering safe and effective medical care, particularly for inpatient newborns. Misidentification in this vulnerable population can lead to serious errors such as conducting the wrong laboratory tests, performing unnecessary procedures, administering incorrect medications, or feeding the wrong breast milk. Newborns present unique identification challenges since many may share the same birthdate, have similar medical record numbers, or even the same last name—especially in the case of multiples (Redman et al., 2020). Unlike adults, newborns cannot communicate to verify their identity and often lack distinct physical features, increasing the risk of identification errors.

2. Analyze background (B) information about the concern

a. What data supports the need for change in newborn patient identification?

In 2022, approximately 3.66 million live births occurred in the United States (Hamilton et al., 2023). This newborn population is highly susceptible to misidentification errors because of their unique challenges. Research shows that around 10% of medical errors and 25% of serious medication errors in Neonatal Intensive Care Units (NICUs) result from patient misidentification. Notably, multiple-birth infants face nearly twice the risk of wrong-patient order errors compared to single-birth infants (Adelman et al., 2019).

A study at Beth Israel Deaconess Medical Center reported that 26% of NICU newborns daily were at risk of misidentification due to overlapping identifiers. Additionally, the Vermont Oxford Network documented that 11% of newborn errors over two years were linked to misidentification. Analysis of 1,234 newborn identification events reported to the Pennsylvania Patient Safety Authority between 2014 and 2015 revealed the following:

These statistics highlight the elevated risk newborns face from misidentification, which jeopardizes their safety and care quality (Wallace, 2016).

b. How do national patient safety standards apply to this issue?

The 2023 National Patient Safety Goals (NPSGs) by The Joint Commission directly address patient identification accuracy. Goal 1 (NPSG.01.01.01) mandates the use of at least two patient identifiers during care delivery, emphasizing the risks for newborns. It recommends distinct identification methods such as standardized naming conventions, banding processes, and communication tools to reduce errors (The Joint Commission, 2023).

Goal 3 focuses on medication safety, which is critically linked to proper patient identification. Though it does not exclusively target newborns, misidentification can lead to wrong medication administration in this population, underscoring the importance of accurate identification systems (The Joint Commission, 2023).

3. Assess (A) the impact of the safety concern on patients, staff, and the healthcare organization

Misidentification impacts both newborns and their families deeply. For instance, reported incidents include wrong X-rays due to mixed patient records, incorrect identification bands with inaccurate birthdates, infants being mistakenly breastfed by the wrong mother, and babies receiving breast milk intended for others (Wallace, 2016). Such errors not only pose direct harm to infants but also erode parental trust, which can have lasting consequences.

From the organizational perspective, these errors decrease patient satisfaction scores, damage the hospital’s reputation, and may deter families from returning. Nurses and staff involved in these incidents experience increased stress, lower job satisfaction, and decreased morale, which may contribute to further errors.

a. How does this safety concern affect value for patients and the healthcare setting?

Patients expect safe and reliable care. For parents of newborns, trust in healthcare providers is paramount. When identification errors occur, this trust diminishes, potentially influencing parents’ decisions on future care locations and negatively impacting patient satisfaction and revenue. Healthcare organizations strive to provide high-quality care, and errors like these challenge that commitment, undermining both clinical outcomes and institutional credibility.

4. Recommend (R) an evidence-based practice change to address the safety concern

An effective evidence-based solution is implementing distinct identification methods for newborns, such as a specific naming system on patient ID bands. One study demonstrated a 36% reduction in wrong-patient orders by using distinct naming compared to nondistinct methods (Adelman et al., 2019). The Joint Commission supports this approach as part of its safety goals for newborn identification.

a. How does this recommendation align with high-reliability organization principles?

Using a distinct newborn identification system promotes safety and accuracy, reducing errors such as incorrect lab tests, medication administration, or infant-to-parent mismatches. High-reliability organizations emphasize consistent quality and safety through vigilance and systems designed to prevent harm. Accurate identification supports this by minimizing risk and ensuring that families leave the hospital confident in the care provided.

b. What are two potential barriers to implementing this change?

c. What interventions can minimize these barriers?

d. What is the significance of shared decision-making in implementing this recommendation?

Involving all stakeholders—nurses, physicians, administrative staff, and parents—in the decision-making process encourages buy-in and facilitates practical solutions. Frontline staff can identify potential issues and contribute to effective protocols. Parents’ involvement ensures they are partners in safeguarding their newborn’s identity, enhancing both safety and satisfaction. Shared decision-making supports quality, safety, and cost-effectiveness.

e. What outcome measures can evaluate the recommendation’s effectiveness?

A primary measure would be the reduction in misidentification events, tracked through incident reports before and after implementing the change. These can be further categorized into procedural errors, medication errors, and breast milk administration errors. Additionally, staff surveys can assess attitudes towards the new process and suggest further improvements.

f. What care delivery model is currently used, and how would it be impacted by this change?

The NICU and postpartum floors use a total patient care model, where nurses are responsible for all aspects of newborn care. The recommended change would minimally impact this model, requiring only brief additional education for parents and a second nurse to verify identification band accuracy. This integration can be efficiently incorporated during admission and routine care activities.

References

Adelman, J. S., Applebaum, J. R., Southern, W. N., et al. (2019). Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems. JAMA Pediatrics, 173(10), 979–985. https://doi.org/10.1001/jamapediatrics.2019.2733

Hamilton, B. E., Martin, J. A., & Osterman, M. J. K. (2023). Vital Statistics Rapid Release. Births: Provisional Data for 2022 (Report No. 28). National Vital Statistics System, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. https://dx.doi.org/10.15620/cdc:127052

Redman, C. T., Reddy, P., Kneifati-Hayek, J. Z., Applebaum, J. R., Manzano, W., Goffman, D., & Adelman, J. S. (2020). Incident Reports of Naming Errors among Two Sets of Infant Twins. Pediatric Quality & Safety, 5(6), e356. https://doi.org/10.1097/pq9.0000000000000356

The Joint Commission. (2023). National patient safety goals. Hospital: 2023 national patient safety goals.

Wallace, S. C. (2016). Newborns pose unique identification challenges. PA Patient Safety Advisory, 13(2), 42-49.