The operational structure in health facilities remains a complicated and stressful environment of work. Studies have continued to show how lapses in judgment and system errors have led to fatal clinical outcomes. However, a number of these errors, with the majority being considered malpractices have gone unrecorded. The lack of statistical information has further compromised the efforts to have such cases reported and addressed as institutions and stakeholders within the healthcare sector have chosen to leave the issues unperturbed (Sheedy & Richard, 2020). The discussion herein provides a review of the patient misidentification as a leading cause of fatal medical errors that remain mostly unreported. The paper outlines how data analysis tools can help isolate and eliminate such latent medical errors in health facilities. The evaluation is pegged on a 67-year old Joan Morrison, who was misidentified by clinicians leading to a performed intrusive surgical procedure that was wrongful and against her consent.
The Significance of Data Analysis in Evaluation/Measurement of the Chronology
The application of data analytical tools remains critical in the healthcare setting, considering their potential in transforming outcomes across health system anchors on the ability and willingness of practitioners' to deploy data use. Various data analytical tools exist at the disposal of clinicians, including charts, interactive healthcare information systems, and digitized registries. Relying on such breadth of information sources has the potential to arrest possible medical errors currently unrecorded across different healthcare (Sheedy & Richard, 2020). The case of misidentification herein proves the vulnerability of assuming clinicians can manage patient-centered care without relying on data-based support systems. The failure of RN1 and RN2 to anchor their decisions on data charts, and other information assisting tools at their disposal can be the best attribute for the failure of all medical interventions (Chassin & Becher, 2002). The incident well qualifies for a malpractice case on the part of the practitioners as well as the institution.
Delegate your assignment to our experts and they will do the rest.
Steps That Could Help Avoid Latent Errors
The consequences of patient misidentification, as elaborated herein, remain adverse upon litigation on medical practice and malpractice basis. Objectively, institutions and leading medical practitioners have the responsibility to guarantee their patients safe and quality care. The unfortunate incident involving Joan Morrison remains an example of such incidents where negligence following the failure of practitioners employing the appropriate tools of work has risked their patient's life. Avoiding such events would call on practitioners' dedication to various procedures aligned to data-aided practice. The identified potential errors would have been avoided by observing the steps below.
Using two patient identifiers at the beginning of the procedure
The use of two visual identifiers would have enabled the nurses to differentiate Joan Morrison from Jane Morrison. Based on the discussion by Chassin & Becher (2002), despite employing the concept in her conversation and engaging RN3 over a call, the nurse could not identify the patient over the phone hence further misleading RN1 in her efforts to identify the patient.
Considering informed consent from a patient perspective
The case of informed consent before any procedure conducted on patients should be a primary cause of action. According to Chassin & Becher (2002), clinicians performed a procedure on a patient who had not consented to the process after adequately being informed. In her case, Ms. Morrison agreed to the procedure but was unaware of the particulars.
Have protocols for patients with similar names
Having protocols for patients with similar names would mean that Joan and Jane Morrison would have been provided with patient-specific identifiers. In this case, it would have helped to inform RN1 of the fresh groin would that Joan Morrison had as opposed to Jane Morrison. Such identifies when employed as protocols create a more natural path to differentiating patients.
The identification process should engage patients
Finally, the patient identification process ought to be engaging. The nurses would have better engaged their patients to interrogate her condition and understand her medical state. Such engagements allow nurses to establish patient history before committing them to any procedure.
Reference
Chassin, M. R., & Becher, E. C. (2002). The wrong patient. Annals of internal medicine , 136 (11), 826-833.
Sheedy, C., & Richard, S. (2020). Patient Identification Errors in the Operating Room. In Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices . Agency for Healthcare Research and Quality (US).
