Change and Look at Patient Safety

Abstract Description

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Authors (including presenting author) :

Chan PF, Wong YY, Fung MC, Tsang SY, Lee KY

Affiliation :

Community Nursing Service, United Christian Hospital, Kowloon East Cluster, Hong Kong

Introduction :

From 8/2017 to 7/2018, Community Nurse Service department, Kowloon East Cluster was reported 10 clinical incidents regarding nursing procedure, which included near miss incidents. The result showed human errors should be avoidable to minimize negative impact on patient and management. In fact, Pointing and Calling has proven to be an effective method to implement to increase staff awareness in nursing checking procedures in order to enhance patient safety. Thus, this method was selected which emphasizes on using the standard steps of finger pointing, vision, hearing and speaking to enhance the cognitive process, and to increase the attention.

Objectives :

Reducing clinical incident on nursing procedures and medication administration through implementing the Pointing and Calling method

Methodology :

Working group was formulated to analyze and identify high risk practice for improvement in the period of 8/2017-7/2018. The working group studied the feasibility of Pointing and Calling method when applying it on checking procedure and the implementation plan started in 8/2018. In addition, the analysis found out the frequent errors on medication administration and checking the date of stitches removal. Firstly, the slogan constitutes 「手指點；眼看清；口講耳聽；來確認」which helps to recognize and recall the importance of concentration while carrying out checking procedure. A video was produced to demonstrate the correct application on frequent errors. Besides, poster was designed to promote and increase the awareness of change in checking procedures. Moreover, training sessions were conducted to all staff. It should be used in their daily practice and the staff was encouraged to apply it on checking step when providing nursing procedure. Finally, Nurses in-charge will arrange joint home visits with staff to ensure the correct application and compliance of the method. On the other hand, numbers of clinical incidents including near miss will be collected from 8/2018-7/2019, compared with the same period in 2017/18.

Result & Outcome :

100% nurses were trained and there is 100% compliance rate of applying the method. Zero clinical incident was reported up to 31/1/2019 after implementation. We have zero tolerance in clinical incident. In the project, working group delivered the importance of patient safety -- concentration on the work; implementation of different strategies for promotion and encouraging compliance are also needed. The positive results showed that patient safety concept was enhanced and the habit of using Pointing and Calling was achieved.