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Introduction Summary

This online resource toolkit comprises 12 annotated resources deemed crucial for enhancing patient safety in hospital settings as part of a positive improvement initiative. These resources facilitate nurses and other professionals in implementing and upholding safety enhancements through evidence-based practices that yield measurable and quantitative outcomes.

Arsyawina, A., Hilda, H., Supriadi, S., Widiastuti, H. P., Syaputri, A., & Pramono, J. S. (2023). Relationship between nurses knowledge level and workload about implementation of patient identification. Healthcare in Low-resource Settings. https://doi.org/10.4081/hls.2023.11756

• The study results indicate that there is no significant correlation between nurse workload and the implementation of patient identification protocols. This is evident in the vicariate analysis findings, where 62 out of 93 nurses with heavy workloads demonstrate good patient identification practices. Moreover, responses to the patient identification questionnaire reveal that most nurses frequently or always adhere to hospital protocols mandating patient identification.

Aseem, S., Ratrout, B. M., Litin, S. C., Ganesh, R., Croghan, I. T., Salerno, M. S., Majka, A. J., Chutka, D. S., Hurt, R. T., Lebdeh, H. S. A., Vincent, A., & Nanda, S. (2020). A process of acceptance of patient photographs in electronic medical records to confirm patient identification. Mayo Clinic Proceedings. Innovations, Quality & Outcomes, 4(1), 99–104. https://doi.org/10.1016/j.mayocpiqo.2019.10.002

• Accurate patient identification plays a pivotal role in ensuring safe healthcare delivery. The increasing utilization of electronic medical records (EMRs) has led to a rise in errors related to test ordering and documentation. Incorporating patient photographs into EMRs has proven to be an effective strategy in reducing error rates and enhancing healthcare provision by simplifying patient identification for medical personnel. Errors in patient identification can lead to treatment mistakes, incorrect procedures, privacy breaches, billing inaccuracies, insurance fraud, and even identity theft. Many healthcare institutions primarily rely on names and birthdates for EMR chart identification, which can result in mix-ups when multiple patients share the same personal information within the facility. Studies have shown that a significant percentage of errors stem from placing electronic orders in the wrong patient’s chart, highlighting the need for accurate patient verification procedures before documenting or ordering treatments in medical records.

Heck, J., Groh, A., Stichtenoth, D. O., & Bleich, S. (2020). Look‐alikes, sound‐alikes: Three cases of insidious medication errors. Clinical Case Reports, 8(12), 3283–3286. https://doi.org/10.1002/ccr3.3409

• Medication errors pose a significant risk to patient safety, encompassing instances such as administering a medication to the incorrect patient, selecting the wrong route of administration, administering a drug at an incorrect time, and giving the wrong medication. Errors involving the administration of the wrong drug can often stem from confusion between drug names that closely resemble each other, like hydroxyzine and hydralazine. This article delves into three cases where the mix-up of look-alike/sound-alike drug names resulted in medication errors with varying consequences.

Hsieh, M., Chiang, P., Lee, Y., Wang, E. M., Kung, W., Hu, Y., Huang, M., & Hsieh, H. (2021). An investigation of human errors in medication adverse event improvement priority using a hybrid approach. Healthcare, 9(4), 442. https://doi.org/10.3390/healthcare9040442

• The objective of this study was to conduct a detailed analysis and identify key priorities for enhancing medication safety by addressing adverse events. To achieve this, the Human Factor Analysis and Classification System, along with its subfactors, were employed to scrutinize these events. Subsequently, a hybrid approach combining the Analytical Hierarchy Process and the fuzzy Technique for Order of Preference by Similarity to Ideal Solution was utilized to determine improvement priorities for the identified subfactors. Out of 157 medical adverse events retrieved from the Taiwan Patient-safety Reporting system, 25 cases were classified as medication-related incidents. Utilizing the Human Factor Analysis and Classification System and root cause analysis, error factors and subfactors within medication adverse events were examined. The findings revealed that decision errors, crew resource management, inadequate supervision, and organizational climate encompassed a broader range of subfactors compared to other error factors within each category. Through this analysis, 16 improvement priorities were delineated. These priorities aim to guide healthcare professionals, researchers, and policymakers in efficiently addressing deficiencies in medication processes.

Mardawi, G. H. A., Rajendram, R., Alowesie, S. M., & Alkatheri, M. (2021). Reducing Nonsentinel Harm Events due to Medication Errors by Using Mini–Root Cause Analysis and Action. Global Journal on Quality and Safety in Healthcare, 4(1), 27–43. https://doi.org/10.36401/jqsh-20-25

• Implementing mini-RCA for medication error reviews introduces a systematic approach to handling reported incidents, tracking recommendation implementations, and evaluating the impact of corrective measures. Employing this expedited method to scrutinize non-sentinel events resulting in harm minimized the likelihood of recurrent medication errors. While this intervention entails notable time and cost investments, the overall advantages in terms of patient safety, staff welfare, and organizational outcomes outweigh the associated resources.

Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review. Medical Principles and Practice, 29(6), 524–531. https://doi.org/10.1159/000508677

• This article demonstrates the implementation of a collaborative nurse-led project to enhance collaboration, interdisciplinary teamwork, and the delivery of healthcare services. It is recommended for nurses seeking strategies and models for building and engaging in interdisciplinary teams rather than focusing solely on fall-prevention strategies. Prior to establishing an interdisciplinary team for a collaborative healthcare project, reviewing this resource is advised.

Mekonnen, M., & Bayissa, Z. (2023). The effect of transformational and transactional leadership styles on organizational readiness for change among health professionals. SAGE Open Nursing, 9. https://doi.org/10.1177/23779608231185923

• This research aimed to evaluate how transactional and transformational leadership styles influence healthcare professionals’ readiness for organizational change. The study revealed that the extent of organizational change readiness is significantly impacted by two key factors: transformational and transactional leadership behaviors. The implications of this study are crucial for managers, leaders, and organizations navigating organizational transformations, particularly in challenging times such as during a healthcare pandemic. Effective leaders should lead by example, earning reverence, respect, and trust from their followers. They should foster a culture of creativity, innovation, and critical thinking, encouraging individuals to challenge prevailing norms and values to facilitate the shift away from outdated practices. To prepare organizations for change, management could consider implementing strategies to mitigate the negative repercussions associated with change initiatives. Additionally, leaders must ensure clarity, effectively communicate change objectives, and promote active participation and engagement during the change process. Furthermore, to enhance the efficacy of change initiatives, managers might explore integrating concepts like contingent rewards and active management by exceptions into leadership development programs.

Miles, M. C., Richardson, K. M., Wolfe, R., Hairston, K., Cleveland, M., Kelly, C., Lippert, J., Mastandrea, N., & Pruitt, Z. (2023). Using Kotter’s change management framework to redesign departmental GME recruitment. Journal of Graduate Medical Education, 15(1), 98–104. https://doi.org/10.4300/jgme-d-22-00191.1

• Kotter’s eight-step model demonstrates that implementing changes in management and organizational administration frameworks can significantly improve patient safety. This underscores the pivotal role that nurses play in reducing medication administration errors when empowered to collaborate within interdisciplinary teams comprising various healthcare professionals like physicians and pharmacists. Ultimately, this approach enhances patient safety, diminishes the expenses associated with corrective measures for medication errors, and betters overall therapeutic outcomes in hospital settings.

Morris, M. E., Webster, K., Jones, C., Hill, A., Haines, T., McPhail, S., Kiegaldie, D., Slade, S., Jazayeri, D., Heng, H., Shorr, R., Carey, L., Barker, A., & Cameron, I. (2022). Interventions to reduce falls in hospitals: a systematic review and meta-analysis. Age And Ageing, 51(5). https://doi.org/10.1093/ageing/afac077

• In this article falls continue to present a prevalent and consequential challenge in hospitals globally. This study aimed to explore the impact of falls prevention strategies on the rates of falls and the likelihood of falling while in a hospital setting; fall prevention tactics encompassed educational initiatives for patients and staff, environmental enhancements, assistive devices, policy implementations, rehabilitation programs, medication oversight, and strategies for managing cognitive impairment. The study encompassed the assessment of both singular and multifaceted approaches.The research suggests that educational interventions for patients and staff can effectively reduce instances of falls within hospital settings. Multi-faceted approaches displayed a promising trend towards yielding positive outcomes. Notably, the utilization of chair alarms, bed alarms, wearable sensors, and the use of risk assessment tools did not show significant associations with notable reductions in fall rates.

Schroers, G., & O’Rourke, J. (2023). Nursing Students’ medication administration: a focus on hand hygiene and patient identification. Journal of Nursing Education/˜the œJournal of Nursing Education, 62(7), 403–407. https://doi.org/10.3928/01484834-20230614-01

• This highlights the need for a shift in teaching methods as nursing school students frequently struggle to adhere to medication safety protocols. Nursing curriculums should adjust their approach to educating students on safe medication administration to better equip them with this essential competency.

Sheedy, C., & Richard, S. (2020, March 1). Patient identification errors in the operating room. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK555511

• It is crucial for protocols to align with suitable information technology, for procedures to be integrated with initiatives that persuade and instruct healthcare providers on the importance and proper utilization of protocols or checklists, and for participatory planning to accompany checklist use. Although enhancing individual patient identification processes could optimize specific procedures and possibly reduce instances of identification errors, a solitary modification is inadequate to eradicate errors entirely.

Trakulsunti, Y., Antony, J., Dempsey, M., & Brennan, A. (2020). Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study. International Journal of Quality and Reliability Management/International Journal of Quality & Reliability Management, 38(1), 339–362. https://doi.org/10.1108/ijqrm-10-2019-0334

• This data illustrates that Global errors represent a concern. During the period from April 2018 to August 2019, dispensing errors decreased from 6 to 2 instances per 20,000 inpatient days each month, reflecting a 66.66% decrease. The implementation of this initiative has bolstered the efficiency of the dispensing process, resulting in fewer errors and an increased focus on patient safety. Additionally, there have been improvements in communication channels between the hospital pharmacy and pharmacy technicians with nurses in the forefront to protect the safety of the patients.

Conclusion

Effectively utilizing annotated bibliographies as part of the writes tool kit in research is crucial for acquiring precise and trustworthy resources. Constructing annotated bibliographies not only boosts the credibility of research tasks but also provides a well-organized method and layout for readers to comprehend additional information efficiently.