Problem Statement

Patient identification is the very first activity health care workers perform to advocate for patient safety. It guarantees proper care, reduces errors, and damage if done correctly. Patient identification errors occur from admission to discharge stemming from different factors that relate to the patient, or the work environment for example busy and under-resourced healthcare facilities (Alves et al., 2018). Nurses are frontline care workers who interact with patients daily; hence more likely to witness or get involved in clinical practice errors resulting from misidentification. Plastic wrist bands are the standard way of identifying patients. In addition to the bands, nurses are required to conform to patients’ details verbally before attending to them.

There are various situations during patient care when patient identification errors may occur, these include patient transfer, sample collection, medication management, and surgical procedures. Healthcare facilities also tend to have a shortage for clinical team members, which further leads to an increased number of patients to healthcare workers (Alves et al., 2018). This increases the likelihood of handover and communication errors. While wristbands are a common technique used to identify patients, incorrect information on the wristbands or missing bands increases the risk of misidentification. The lack of standardized coding systems also leads to errors and healthcare workers who work across various facilities (Ferguson et al., 2016).

There are also various patient-level factors that increase the risk of patient identification errors. Among these factors include patients being in critical conditions such as comas or dementia, where patients’ abilities to communicate are undermined. During such conditions, patients cannot advocate for their needs and are therefore vulnerable to misidentification (Alves et al., 2018).

Implications of Patient Identification Errors on Nursing Practice.

The consequences of patient misidentification run from no notable effects to death. In some cases, patient identification errors might lead to new healthcare problems which are either temporary or permanent. These errors affect at least two people: the one who was given someone else’s treatment and the one who missed their treatment. Medication errors resulting from patient misidentification may lead to severe healthcare problems and even death. (Alves et al., 2018).

Nurses who misidentify patients or experience a near miss suffer self-doubt and guilt. This leads to the second victim condition, which can be threatening to nurses. There have been situations where nurses have committed suicide due to guilt. The embarrassment that comes with the misidentification of patients also deters nurses from reporting their mistakes. This further hinders the possibility of personal reconciliation with patients and closure of such errors. It also prevents the possibility of review and change of the systems that led to the misidentification of patients. It is also common for patients or their next of kin to pursue lawsuits against nurses for negligence. This further affects nurses’ career advancement plans, and at times their licenses are revoked (Bártlová et al., 2015). Litigation further imposes an emotional toll on healthcare practitioners in addition to the stress from misidentification of patients.

Need for Nurse Leadership intervention

Effective leadership has proven to foster a work environment that is safe and of high quality. The delivery of care to patients is a team effort therefore it is essential for nurse leaders to always provide appropriate guidelines and supervision to ensure that patients receive the best possible care (Sfantou et al, 2017).

Nurse leaders should ensure that the units have sufficient staff and participate in recruiting competent team members. This can be achieved by ensuring that all nurses meet the set educational standards and competence in practice. Nurse leaders needs to establish transparent and just ways of dealing with nurses who misidentify patients. It is crucial to understand that such errors create opportunities for improvement, and lessons learned from these errors should be shared. Nurse leaders support to their staff improve trust among the staff reduces medication errors to improve both patient safety and quality of care (Nurmeksela et al., 2021).

References

Alves, K. Y. A., de Oliveira, P.,Tuani Candido, Chiavone, F. B. T., Barbosa, M. L., Saraiva,Cecília Olívia Paraguai de Oliveira, Martins, C. C. F., & dos Santos, Viviane Euzébia Pereira. (2018). Patient identifi cation in the records of health professionals. Acta Paulista De Enfermagem, 31(1), 79-86. http://dx.doi.org.auth.lib.niu.edu/10.1590/1982-0194201800012

Bártlová, S., Hajduchová, H., Brabcová, I., & Tóthová, V. (2015). Patient misidentification in nursing care. Neuro Endocrinol Letter. 36, 17-22.

Ferguson, C., Hickman, L., Macbean, C., & Jackson, D. (2019). The wicked problem of patient misidentification: How could the technological revolution help address patient safety?. Journal of clinical nursing.

Nurmeksela, A., Mikkonen, S., Kinnunen, J., & Kvist, T. (2021). Relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: a correlational study. BMC Health Services Research, 21(1), 1–13. https://doi-org.auth.lib.niu.edu/10.1186/s12913-021-06288-5

Sfantou, D. F., Laliotis, A., Patelarou, A. E., Dimitra Sifaki- Pistolla, Matalliotakis, M., & Patelarou, E. (2017). Importance of Leadership Style towards Quality of Care Measures in Healthcare Settings: A Systematic Review. Healthcare, 5(4), 73. http://dx.doi.org.auth.lib.niu.edu/10.3390/healthcare5040073

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