Authors (including presenting author) :
Chu LY (1), Dr. Cheng LF (2), Ho TY(1), Dr. Leung YW (1)
Affiliation :
(1) Quality and Safety Department, Princess Margaret Hospital & Kowloon West Cluster
(2) Department of Radiology, Princess Margaret Hospital
Introduction :
• There were incidents related to wrong drain removal by interns or wrong drain shifting by nurses occasionally in KWC.
• the drain labeling was noted to be non-standardized with illegible handwriting. Thus, incidents may prone to happen.
• There’s an urge to have some system changes instead of solely reinforcing colleagues for stringent checking prior to drain related procedures.
Objectives :
• System change in standardizing drain identification with clear illustration in terms of wordings and pictures.
Methodology :
• Stakeholders of various departments are included in meetings to discuss on their current methods of drain labeling for gap analysis.
• Commercially printed drain labels with Chinese and English wordings with pictorgrams are designed for users’ feedback and hands-on trial.
• Pilot implementation in operation theatre and interventional suites was commenced in PMH in April, while this was rolled out in May in CMC.
• Evaluation was conducted after half year roll-out in Oct 2024.
Result & Outcome :
• All procedures involving in operation theatre and interventional suites including radiology were involved in the pilot.
• Colleagues gradually found this useful and thus this was further implemented in bedside procedures, for instance, during chest drain insertion.
• Online survey was conducted in Oct 2024, with a total of 120 respondents from 12 specialties. 3 Doctors and 7 nurses were recruited from each specialty.
• Around 70% colleagues agreed that the colour-coding drain labels was clear and easy to understand. It helps them to promptly identify the drain type, improved communication and handover during patient care activities. It also reduced the risk of drain misidentification. It also facilitated identification of drains during ward rounds.
• Around 68% colleagues also thought that the overall quality & durability of the outsourced colour-coded labels are satisfactory.
• Challenges identified might be privacy issues if the labels were not removed upon discharge, but this issue was addressed by HAHO LSD.
• After implementation of this improvement measures, no incident related to wrong drain removal or shifting was yielded.
• In view of the promising results, we tend to roll this out to other hospitals in KWC and all hospitals are guaranteed for further rollout.
