Patient Safety and Communication

Patient Identification Errors

• Patient identification errors are a significant safety risk in healthcare, causing harm to patients and compromising care quality.
• Wrong-patient incidents occur frequently during medication administration, with studies indicating that these errors can be reduced through proper patient identification procedures.

Effective Communication

• Effective handoff communication from hospital to home can be improved through the development and implementation of personalized patient discharge letters.
• Patient portals can be improved by:
  • Ensuring accessibility on various devices
  • Providing real-time clinical notes and diagnostic testing results
  • Explaining test results directly in the portal
  • Offering easy access to support services
  • Providing personalized or contextual information to help patients understand test results
  • Establishing consensus and standards for releasing normal and abnormal test results

Diagnostic Errors

• Areas of focus for diagnostic errors include:
  • Screening and diagnostic radiology
  • Pathology
  • Laboratory testing (infectious disease/microbiology, newborn disease screenings, and results indicative of disease processes)
  • Care coordination (delayed communication, patient return after being seen, and patient appointments)

Measurable Elements of IPSG

• Patient participation may not be possible in certain situations, such as:
  • Patients who are not competent to make healthcare decisions
  • Children
  • Patients requiring emergent surgery
• The hospital should have a procedure for identifying the correct site in cases where site marking may cause harm or when a patient refuses site marking.

Preoperative Verification Process

• The hospital should implement a preoperative verification process using a checklist or other mechanism to document:
  • Verification of informed consent
  • Correct patient, procedure, and site
  • Presence of required documents, blood products, medical equipment, and implantable medical devices
• The hospital should use an instantly recognizable and unambiguous mark for identifying the surgical/invasive site.

Surgical/Invasive Site Marking Process

• The surgical/invasive site marking process should:
  • Be performed by the person performing the procedure
  • Involve the patient in the marking process
  • Have alternative site-marking processes for cases where marking may result in harm
  • Have alternative site-identification processes for patients who refuse site-marking
  • Define alternative site marking techniques for situations where routine site-marking is not possible