Student Dissertation

Agency : Root Cause Analysis, Patient Identification, Failure Modes, Errors in Patient Identification, Failure Modes, Effects Analysis.

Objective : The objectives of the study were: • To review the patient identification process in a hospital • To identify step/point of errors in the patient identification process of hospital. • To analyze the patient identification process of the hospital and find out the challenges at each step of the process. • To suggest strategies to reduce the errors taking place in the process of patient identification, if required.

Background : Root cause analysis (RCA) is a method of problem solving that tries to identify the root causes of faults or problems. A root cause is a cause that once removed from the problem fault sequence, prevents the final undesirable event from recurring. Van Vuuren’s (1920) study of Intensive Care, Accident and Emergency and Anesthesia related incidents in UK hospitals found that poor communication was a major factor amongst the many organizational issues that contributed to adverse events. A recent investigation into the causes of near miss incidents in an Edinburgh Intensive Care Unit also focused on organizational factors, including poor communication between healthcare professionals (Busse and Johnson, 1999). This study was based on over ten years of incident data that was collected by a consultant, Dr David Wright. Root cause analysis is a valuable management tool that can be readily learned by managers as well as frontline personnel. It can be conducted at several levels of depth and complexity.

Methodology : Departmental process review was done for Radiology, Customer care and Wards for Observation of the common identification errors. Potential errors were analyzed after the departmental process review and physical observation. Study respondents were Nurse, customer care staff, duty doctors and staff of the radiology department. Methods of Data collection were Process mapping, Observation and Informal Interviews (Nurses, customer care in-charge, Duty Doctors and radiology technician) the Tools of data collection were Datasheet for RCA and FMEA data sheet.

Findings : RPN score (risk priority number) is calculated by scoring each failure mode for Severity, occurrence and detectability of the event and then multiplying these 3 scores with each other so that we get an RPN score for that failure mode. The failure modes with maximum RPN number are as follows: Potential causes RPN scores Bed number is easy to remember 100 UHID difficult to remember 80 Housekeeping involved in dispatch and receipt of X- ray film . 75 IPID too long and difficult to remember 64 Medication given keeping bed no. in mind 60 X-Ray misplaced 48 Above failure modes are the one with max. RPN score (risk priority number) calculated by scoring each failure mode for Severity, occurrence and detestability and then multiplying these 3 scores with each other so that we get an RPN score for that failure mode

Recommendations : The main suggestions given were: • Patient’s name must be checked before the administration of drugs. • ID band must be checked before the patient is admitted to the ward. • IP sticker must be placed on the vile before the collection of the blood sample. • The IP sticker should not be placed on the cassette of the X-ray film. This might lead to confusion among the films and wrong x-ray film could be given to other patient.