Joint Commission Safety/Performance Improvement & Change Theory

NUR 490: Nurse Leadership

Phlebotomy and Patient Identification Group Paper

Purpose of the Assignment

To identify a safety issue within a health care organization that needs to change in order
to promote better delivery of patient care; to demonstrate an ability to collaboratively
problem-solve in an interdisciplinary environment while working towards resolution of a
common problem.
Approach to the Assignment
The Joint Commissions (TJC) establishes yearly patient safety goals to address
discrepancies in providing safe care to patients. Safety goal NPS.01.01.01 establishes the
need to identify patients correctly. This focus of this paper was to examine the
qualitative and quantitative data that leads to identification errors. The paper also uses
data analysis to find possible solutions to prevent identification errors.
Reason for Inclusion
This assignment was important in understanding the contributing factors that leads to
identification errors. Patient safety is the single most important component of patient care
and all interventions and interactions should be centered on it.
Nursing Practice

Performs direct and indirect therapeutic interventions that incorporate principles of

quality management and proper safety techniques based upon assessment findings.

This assignment necessitated performing an assessment of qualitative and quantitative

data that contributed to a breakdown in patient identification, and specifically during
phlebotomy. Most hospitals have policies and procedures in place guided by the Joint
Commission to ensure proper identification of patients. This assignment suggested
strategies to improve patient identification based on our assessment findings.

Establishes and/or utilizes outcome measures to evaluate the effectiveness of care.

This assignment established four ways to measure effectiveness of care: the trainee's
reaction to the training can be evaluated; the amount of learning can be assessed with a
questionnaire, at least twenty-four hours after the education occurred; evaluating
behavioral change; and assessment of the organizational impact of the education
including cost-effectiveness.
Research

Evaluates research that focuses on the efficacy and effectiveness of nursing

interventions.

This assignment proposed audits and data collection on patient identification and wrongpatient phlebotomy errors to monitor success in proposed outcome measures.

Share research findings with colleagues.

This assignment was a group project that required sharing and compilation of information to
complete the paper.
Leadership

Delegates and supervises the nursing care given by others while retaining the
accountability for the quality of care given to the patient.

This assignment specifically recognizes that leadership plays an important role in the
success of the performance improvement strategies for safe patient care and in reaching
the end goal of providing the highest quality of comprehensive patient care.
Professionalism

Differentiates between general, institutional, and specialty-specific standards of

practice to guide nursing care.

This assignment references hospital-based policies and Joint Commission policies of

healthcare. The Joint Commission is the regulatory and compliance organization that
regulates the general guidelines a hospital must maintain. The hospital must then define
their policies and protocols, and in this assignment the use of patient identifiers when
drawing blood.