Factors That Influence Professional Adherence to Positive Patient Identification (PPID)

Getting the Right Patient: What do health care professionals perceive are factors that influence their adherence to Positive Patient Identification (PPID)?

Research Question

Getting the Right Patient: What do health care professionals perceive are factors that influence their adherence to Positive Patient Identification (PPID)?

Aims and Objectives of the study

 The aim of this study is to understand the experiences and perception of health care professionals undertaking positive patient identification and to explore their reasons for non-adherence to best practice PPID.

Objectives of the proposed research are:

• To understand whether health care professionals are aware of the need of PPID
• To understand health care professionals understanding of the process of PPID
• To explore why health care professionals do not undertake PPID consistently
• To understand  what would influence health care professionals to undertake correct  PPID consistently

Background

Positive patient identification (PPID) is a cornerstone of safety in health care. Ensuring the correct patient is going to benefit from an intervention is obviously of the utmost importance. Whilst it appears basic, getting it wrong can be easy in busy clinical environments.

The World Health Organisation (WHO) highlights that the failure to correctly identify patients leads to increase in morbidity, mortality and distress (World Health Organisation, 2007). It emphasises that it is the “primary responsibility of health-care workers to check the identity of patients and match the correct patients with the correct care (e.g. laboratory results, specimens, procedures) before that care is administered.” It however goes on to note that there may be difficulties in ensuring behavioural changes to comply with recommendations and best practice.

Despite the dangers associated with PPID incidents its incidence is poorly understood. The ECRI Institute undertook a broad literature review to understand the prevalence of patient mis-identification incidence internationally (The ECRI Insitute, 2016). This work brought to light a large number of peer reviewed studies internationally, highlighting high numbers of PPID incident from a broad range of healthcare settings. This work was followed up by a deep dive exercise by the ECRI institute. Within this work 181 healthcare organisations submitted 7613 events to be analysed by the patient safety organisation from a 32 month period January 2013-August2015. Following analysis it was apparent 9% of these incidents led to permanent harm, with 2 resulting in death. It is worthy of note that these submissions were voluntary and are likely to be only a small proportion of actual PPID incidents (The ECRI Institue PSO, 2016)

In the last 18 months within a large tertiary level university teaching hospital there have been a number of serious incidents which have resulted in patients receiving the incorrect treatment; these have all been due to non-compliance with the trusts PPID policy.  These incidents include

• Wrong patient received laser eye treatment
• Patient was cared for using electronic documentation for a different patient for 12 hours
• Endoscopy performed on the wrong patient
• Patient received another patients chemotherapy
• Patient had a CT scan rather than a chest X-ray
• Incorrect blood products administered
• Scoping X-ray given to the wrong patient

In addition to these serious incidents there are a number of other incidents where no harm has occurred which could have been avoided if proper PPID checks had occurred.

Lack of appropriate PPID appears to be widespread and its effects potentially serious, whilst its implementation and use straight forward. What leads health professionals to not undertake this vital patient safety process?

Literature review

It is vital before undertaking any form of research to ensure an overview of what is already understood, and what if any gaps there might be. The author used a number of online database to undertake the literature review, these were

• CINAHL-nursing and allied health care from North America and Europe
• OVID – is an online database that carries out a single search on a range of databases including MEDLINE, PreMEDLINE, EBM (Evidence Based Medicine) Reviews, Cochrane Database of Systematic Reviews, Cancerlit, CINAHL, and EMBASE.
• British Nursing Database-The British Nursing Database is a full-text resource supporting the practice, education, and research for nurses, midwives and healthcare professionals in the U.K. and the greater nursing community.

This range of databases will cover UK and international health related journals

The search terms used are in the table below

Through using these search terms it is the author’s intention to find any articles pertaining to studies which explore health professional’s adherence to best practice regarding positive patient identification.

Following review by the author, the literature considered appropriate in relating to the research question and explanation can be found in the bibliography. It is apparent  there is very little research specifically studying behavioural reasons for non-adherence or no-compliance has been undertaken.

The ECRI Institutes work (The ECRI Insitute, 2016), cited earlier, exploring the incidence of PPID internationally is a useful starting point in establishing the scale of the issue around PPID, and the potential impact that non-adherence can have for patients. It does not however explore why these incidents occur, although does highlight issues around behaviours of health professionals and organisational culture in these types of incidents. It does not elaborate on this, nor does it give means of improving either, instead concentrating on the use of technology in preventing PPID incidents.

It is apparent from much of the literature reviewed that errors around the identification of patients are associated with significant morbidity and mortality (Anders, et al., 2011; Higgins, et al., 2010), and distress to the health care professional involved (Stewart, et al., 2018). Much of the literature currently available centres on blood transfusion safety (Anders, et al., 2011; Kelly, 2016; Maskens, et al., 2014; Varey, et al., 2013), and issues associated with the incorrect patient receiving blood products. Whilst there is a range of research methods employed, much of the research and evidence associated with these issues revolves around technological solutions that can be instituted to resolve these major safety issues (Anders, et al., 2011; Stout & Joseph, 2016; Varey, et al., 2013) Whilst both of these issues are of the utmost importance specifically blood transfusion and wider laboratory medicine, the authors interest and research centres around the human factors of PPID, and the apparent decision of health care professionals to not undertake PPID.

The outcome of much of the current research around misidentification of patients highlights poor compliance with PPID as a root cause of errors (Cottrell & Davidson, 2013; De Biaso, 2016; Tase, et al., 2018). All of these studies highlight the importance of this process, with Cottrell & Davidson (2013) and De Biaso (2016) exploring systematic issues with PPID such as patients with similar sounding names and incorrect names input in to electronic patient records. There remains however a lack of information about the decision not to undertake PPID or to not undertake it fully. The work undertaken by De Biaso (2016) also highlights how busy health professionals are as an issue with adherence to PPID but does not go in to any detail as to how this assertion has been proven.

There is one piece of evidence found in the literature that explores an aspect of the behaviour of health professionals and their approach to PPID (Campbell, et al., 2015). This work is relevant to the author’s research as it is one of the few pieces of evidence that points to reasons that healthcare workers do not adhere to best practice in this field. This qualitative, observational study of PPID practice in a Canadian peri-operative care centre found that 90% (n=55) of PPID practice did not match policy. It goes on to hypothesise that a lack of knowledge on the part of the health professional around policy and best practice in PPID may lead to this finding. This information is vital, as one of the few studies truly applicable to the author’s research, and will advise of an area of questioning in the semi structured interviews that will be carried out.

It is felt that there is a clear gap in the literature around health care professional’s behaviour, their perception of PPID and the policies that support it. Broader investigation in to the health care professional’s perception of, and adherence to best practice relating to PPID is required. Through examining the human factors associated with PPID there are clear implications for future practice. Through a more thorough understanding of why health care professionals do not adhere to basic PPID, patient safety could be improved drastically.

Methodology

For this study in the researcher plans to carry out a study which explores the perceptions of health care professionals regarding positive patient identification (PPID). A qualitative approach to this study is to be used to explore thoughts, behaviours and experiences of health care professionals in their adherence, or not to PPID practice.

In order to answer the research question fully it is vital to construct a deeper understanding of the human experience regarding PPID, so issues and themes surrounding it can be established. It is argued that it is qualitative research that can build a richness of information regarding the human experience (Bryman, 2012) unlike other means of research. It will allow the researcher to view the issue through the experiences of others rather than their own. A qualitative method will allow the researcher to understand why health professionals do not undertake the PPID process rather than establishing prevalence or impact.

There has been a widely held view that qualitative research does not benefit from the rigour of quantitative research and lacks validity due to the inability of replication (Bryman, 2012). This view is now widely held as out of date (Silverman, 2001). It is becoming more widely accepted that qualitative research, with its emphasis on the exploration of narrative which can be used to create theory and promote understanding (Polit & Beck, 2006) adds richness to the world of research and evidence in a way quantitative methods cannot. Whilst this debate continues, Silverman(2013) feels that the suggestion that one method is better than the other is not helpful. The method which is best suited to answer the research question should be employed

A quantitative method would not be suitable for this type of research as these approaches rely on the formation of a hypothesis, which the research then tests, to establish cause and effect (Polit & Beck, 2018). The author has no hypothesis to test, this research is to establish the behaviours and emotions of participants regarding the approach to PPID, and this may lead to the generation of a hypothesis which then can be tested using a quantitative method of research. The lack of research in the area of human behaviour in approaching PPID means a qualitative approach is ideal.

Methods

Data collection for this study is semi structured face to face interviews using open questions. This method ensures the description and exploration of issues from the perception of participants with the added benefit of the ability to interpret emotions due to this being undertaken face to face. A fully structured interview would not allow participants to fully explore and discuss their perception; nor would the use of questionnaires.

Interviews are not without their issues, particularly when asking participants to recall a process they have undertaken as part of their everyday working life. It is noted that participants, when asked to recall a routine task may often not recall or forget parts of that task, and they may seem too obvious or nuanced (Blandford & Rugg, 2002). This is of obvious relevance to this study, and the interview would be designed in a manner which takes this in to account.

Within semi structured interviews it is vital that the interview and interviewee form a relationship that leads to the participant feeling at ease and able to be relaxed enough to be open and frank in their responses to the themes being explored. The researcher must feel at ease in speaking with the interviewee, and be able to receive the thoughts and perception of the interviewee without feeling the need to impart their own knowledge of the subject on the interview (Legard, et al., 2003).

Preparation is key in making these interviews feel natural and open, rather than a more closed interview technique. With this in mind the author plans to use a “topic guide” as advised by Arthur & Nazroo(2003). With the researcher using these topics to pose questions in a non-verbatim manner leading to a more natural conversational approach to the interview.

A mutually agreeable time would be found in a comfortable area to undertake the interview. It is key that the interviewee feels relaxed and able to be honest and open about their experiences relating to PPID in order to build a rich dataset

Ethics

The Department of Health states that”the dignity, rights, safety and wellbeing of participants must be the primary concern in any research study”. In addition to this the NHS Health Research Authority (HRA), declares that “  Scientific and Ethical Conduct” is one of its 15 guiding principles which serve as a benchmark for health and social care research in the UK to ensure good practice in its management and conduct (NHS Health Research Authority, 2017). The author will ensure that the research adheres to all 15 principles outlined in the HRA UK policy framework (2015).

It is therefore vital to consider the ethical considerations of the research to be undertaken before doing so; indeed ethical approval will be required from the academic institution and the health care organisation where the research is to be taking place, the ethics committee within the health care organisation will be bound by the principles of the HRA.

Informed consent is a vital when considering the ethics of this piece of research. Information sheets will be produced outlining the aims of the study, and the types of subjects that will be broached in the interview, the information available to participants will make it clear they are able to withdraw from the study at any time. The consent process will also ensure that participants are aware that their responses will remain anonymous. It will also outline the fact that whilst anonymised, that interviews will be transcribed verbatim, and may be used as such in the final write up. Whilst transcripts can be made anonymised they cannot be classified or not in the public domain as the research will be public, those that participate in the research are informed and will understand this (Houghton, et al., 2010)

Whilst the research is unlikely to directly benefit the participants of the study, there are clear benefits in terms of safety for patients of the healthcare organisation in question due to the potential of introducing changes, advised by the outcome of the research which may reduce errors.

As a qualitative piece of research the study will certainly not cause harm to patients or study participators, consideration however will need to be given if participants in the research have been affected by an adverse incident associated with PPID. As part of the informed consent process clarity will be given around the subject of the study and the types of questions that will be used, this will ensure potential participants are able to make an informed decision over their inclusion in light of any previous experience they may have had with incidents associated with PPID.

Due to the participants being asked to comment on issues within the organisation in which they work, this may lead to them not feeling able to be open and honest regarding the answers they give. Ensuring complete anonymity through only collecting details regarding their professional background and age will be vital. More will be covered during the net section on sampling; however it is worth noting through use of purposive sampling the author will ensure that participants will not work directly with the researcher.

Sample

The approach to sampling is key in ensuring the desired research outcome. It is important that the goals of the research are held central when selecting the sample. With this in mind a purposive sample will be undertaken. Participants in the study will be health care professionals of a variety of professional backgrounds for whom PPID should be a central part of their day to day practice. Purposive sampling produces a sample which is representative of the population that is being researched (Lavrakas, 2008) and is a type of non-probability sampling. It is the intention of the researcher to use a type of sampling known as typical case sampling. Typical case sampling is a method of sampling that ensures participants are the norm and typical (Palinkas, et al., 2015). This will ensure samples can compared to one another to produce themes, although this cannot be then used to make generalisations to the population, but the sample could be illustrative of others. Due to the widespread use of PPID in health care settings it is unlikely that the research will be impacted by researcher bias-a disadvantage of this type of sampling technique (Laerd Dissertation, 2012)

Data Analysis

Interviews will be recorded and then transcribed to text. This will allow the researcher to examine the transcripts to identify sections which provide meaning to the area being researched. Through grouping these emergent themes it will allow the researcher to identify interconnecting concepts. It is felt that limiting these themes to around 5-7 key areas is best for this types of research (Creswell, 2014). Creswell (2014) goes on to describe the process of ‘coding’ attributing a word for the categories arising in the transcripts of the interviews. These codes fall in to 3 broad themes

• Codes that are based on themes you would expect to find in the research
• Codes that are surprising and were not anticipated
• Codes that are unusual and may be of interest to the reader.

Resources

The author has no funding for this study, although the research will need little resource apart from time. The author will ensure the interviews take place in participants work time. The small amount of financial resource required for stationary will be funded by the author.

Whilst an inexperienced researcher the MSc pathway the author is undertaking has taught them basic research methods and techniques, therefore no further training is required and will not add extra resource to the project

Limitations

As an inexperienced researcher it is vital the author practices good self reflexivity to ensure high quality results and reduce the risk of bias in the study (Attia & Edge, 2017). The author will strive to maintain contact and a good relationship with their educational supervisor to ensure dialogue and feedback as the study develops.

The studies sample will be small, and from a single organisation, which will be useful in understanding the issues around PPID in that specific healthcare environment, but the method of sampling will mean it is impossible to relate this research to other health care settings

Project Plan

A Gantt chart will be used to organise the project timescale (appendix 1). A contingency of 4 weeks will be built in to this plan

Letters will be sent to health care professionals for whom PPID is a part of their role as per the section on sampling earlier in the document). This documentation will include a letter outlining the study, a consent form and a stamp addressed envelope. All those that respond yes will be approached and invited, at a convention time to join the researcher for an hour long interview. It is in this time a face to face semi structured interview will take place with full consent being obtained prior to the interview taking place

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