1. Running head: TAKE HOME PAPER 1
Take Home Paper
Katelyn Duncan
University of Wisconsin Eau Claire
NRSG 432

2. TAKE HOME PAPER 2
Introduction with Purpose Statement
In recent years the issue of medical safety and errors has become a large area of concern.
Ensuring patients are receiving the care and medications specific to themselves is vital. Through
clinical practice it has occurred to me just how simple it is to ensure proper identification of your
patients and how easy it can be as well to let it be forgotten. Because of this, I have become
extremely interested in researching ways to promote proper identification methods in patients,
especially those that are vulnerable and/or may be harder to properly identify. Therefore, the
purpose of my paper is to further examine issues of medical safety, errors, and patient
identification.
Current Issue in Nursing
In current nursing practice the failure to properly identify patients can result in several
medical errors that can be detrimental to a patient’s health. According to World Health
Organization (2007), “The major areas where patient misidentification can occur include drug
administration, phlebotomy, blood transfusions, and surgical interventions (p.1)”. When patient
misidentification occurs, often times it can be a result attributed to a healthcare professional’s
failure to ensure proper identification procedures required by their facility or the lack of adequate
identification procedures within a facility. This issue affects patients of all ages and health
backgrounds. Some of those most vulnerable patients of this issue, in my opinion, however are
children, those who are cognitively impaired, and older adults who may not know enough about
their cares to be able to know to inform their healthcare provider if something doesn’t measure
up with potential wrong cares/medications they are being given.
History of Issue (Past and Current)

3. TAKE HOME PAPER 3
According to Ballard (2003), “28% of adverse reactions to medications and 42%
of life-threatening events in health care are preventable (p.1)”. This means that
somewhere in the line of care, healthcare professionals such as nurses take some part in
being able to reduce the occurrence of medical errors. Although there is no current
research showing exactly how many medication errors are directly related to patient
misidentification issues, Mayo & Duncan (2004), explain that patient misidentifications
play a large role in these errors.
The issue of patient safety has been an area of concern for years.
“In 1999, the Institute of Medicine (IOM) described the nation’s health care
system as fractured, prone to errors, and detrimental to safe patient care. It defined
patient safety as freedom from accidental injury and further stated that ensuring
patient safety involves the establishment of operational systems and processes that
minimize the likelihood of errors and maximize the likelihood of intercepting
them when they occur (Ballard, 2003, p.1)”.
Ballard (2003) also explains that in past years patients have been passive while receiving
nursing care. Often times they were not informed of what procedures were being done, what
medications they were taking, and what they were supposed to do to comply with their illnesses.
However, in more recent years, patients have become more active in there cares and the
knowledge of their cares has helped to decrease medical errors, ensuring that they are the correct
individual to receive the care, treatment, or medication. Currently, hospital safety committees
have been advocating for healthcare teams to properly inform and educate patients and their
families of the cares/medications/treatments they are receiving to help minimize medication
errors attributes to misidentification gaps and issues that lead to medical errors. Safety

4. TAKE HOME PAPER 4
committees continue to address this issue as they research new information regarding better
patient identification procedures.
Importance of Issue
The issues of patient misidentification are vastly impacting, especially when it causes any
type of medication error. “Medication errors strike at the heart of being a nurse- the
responsibility to do good and avoid harm (Mayo & Duncan, 2004, p.1)”. It is the duty of all
healthcare providers who are stakeholders in a patient’s care to ensure that they are properly
identifying patients to avoid any harmful consequences. According to Pham, J., Aswani, M.,
Rosen, M., Lee, H., Huddle, M., Weeks, K., & Pronovost, P (2012), “Medical errors account for
~98,000 deaths per year in the United States. They increase disability and costs and decrease
confident in the health care system (p.447)”.
Suggested Changes
When I was observing a surgery one day in my clinical course it was procedure to hang a
piece of paper on the end of each patient’s bed including all medications and there conversions of
dosages according to the patients weight upon going to surgery. The professionals were going
through all there identification procedures however while observing the room I noticed that the
name on the end of my patient’s bed did not match up with the name on the surgery board. I
immediately told the nurse monitoring the surgery and she instantly stopped the surgery to check
that we in fact had the correct person. Fortunately, they were operating on the correct patient,
however someone had accidentally placed the wrong medical sheet on the patient’s cart. This goes
to show just how easy it can be to have an error due to one improper check.

5. TAKE HOME PAPER 5
I believe that medical errors within healthcare would decrease more if all healthcare
providers were required to get yearly education about strategies including proper patient
identification methods and other interventions that help to reduce errors. According to the Joint
Commission (2014), recommended protocol includes using at least two patient identifiers when
giving cares, treatments, or services. This may include “the individual’s name, an assigned
identification number, telephone number, or other person-specific identifier (Joint Commission,
2014)”. Checking such identifiers to properly match patient with the correct treatment can be
highly beneficial. “The use of bar-coding systems, which utilize patient arm bands for name,
birthdate, and ID as their two patient identifiers, have been associated with eliminating
transcription errors and reducing 50.8% of potential ADEs” or adverse errors (Pham et al., 2012,
p. 449). Lastly I believe that within these educational sessions for patient safety strategies, health
employees should go through routine teamwork simulations. Studies show that common safety
culture relationships associated with patient safety include quality handoffs and transitions, and
teamwork across and within units (p. 451)”.
Conclusion
Hopefully, by implementing some of these interventions and diligently continuing to
practice each of them on a daily basis, medical errors will begin to decrease more rapidly. As
technology and research continue to expand I am excited to see what will be available to
healthcare providers in the near future to more properly identify our patients and what ways we
will be able to strategize to continue to protect or patient’s health and ensure orchestrating safer
cares.

6. TAKE HOME PAPER 6
References
Ballard, A. (2003). Patient safety: A shared responsibility. Online Journal of Issues in Nursing,
8(3).
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/T
ableofContents/Volume82003/No3Sept2003/PatientSafety.aspx
Joint Commission. (2014, Jan 1). Patient safety goals. Retrieved from jointcommission.org
Mayo, A.M., Duncan D. (2004). Nurse perceptions of medication errors: What we need to know
for patient safety. Journal of Nursing Care Quality. 19(3), 209-217.
Pham, J., Aswani, M., Rosen, M., Lee, H., Huddle, M., Weeks, K., Pronovost, P. (2012).
Reducing medical errors and adverse events. Annual Review of Medicine, 63, 447-463.
World Health Organization. (2007). Patient safety solutions. WHO Collaborating Centre for
Patient Safety, 1, 1-4