Authors (including presenting author) :
Ho KKB(1), Lam LM(1), Wong WK(1)
Affiliation :
Department of Orthopaedics & Traumatology, Tseung Kwan O Hospital
Introduction :
One of the most challenging patient safety issues is to prevent wrong patient, wrong procedure, wrong site, which are all classified as sentinel events. Surgical checklist and user guide was implemented to ensure the highest standards for patient safety in the operating room. However, invasive bedside procedures pose the same threat occurring outside the operating room. A systematic guide and monitoring is absent and the risk is underestimated. Therefore, it is important to have the corrected mindset when performing bedside procedure. This project is an opportunity to improve bedside procedure safety, reinforce current safety practices and prevent errors by implementing environmental & safety inspection check and enhancing communication among colleagues.
Objectives :
(1) To ensure patient quality and safety for those who underwent invasive procedures at bedside; (2) to identify a potential error before it results in harm to patient; and (3) to enhance staff’s compliance in performing safety checks, collaboration and communication
Methodology :
The project is system approach. A team to improve the safety of patients who undergo invasive procedures at bedside was established in 2019. The main contribution is to develop a new working plan and revise the invasive bedside procedures safety policy, implement an environmental and safety inspection based on Fishbone Diagram Analysis for invasive bedside procedure risk control management. For sustainability, environmental and safety inspection is performed regularly to look for potential error. Moreover, a survey is made and seek comments from staff to investigate their interests and confidence level on invasive surgical procedures to review their competence. Various strategies and Continuous Quality Improvement (CQI) projects was implemented to revise current practice and ensure our standard to prevent errors including: (1) Cue cards and QR codes are designed for preparing medical invasive bedside procedures to familiarize the related procedures; (2) Patient’s vital signs are ensured to be monitored during invasive bedside procedures; (3) Cue cards and educations sessions are designed to enhance nurse knowledge and confidence on managing tourniquet and diathermy.
Result & Outcome :
A surgical safety team was established and environmental & safety inspection is developed to maintain the sustainability of the project. Potential error was identified and intervention was performed. Various CQI was implemented. All interventions improve staff’s confidence and compliance while handling invasive bedside procedures significantly.
