Authors (including presenting author) :
HAU LM (1), KWOK YT (1), LEUNG PMQ (2), LI MN (2), SHING LY (1), WONG PMB (1)
Affiliation :
(1) Quality & Safety Division, NTWC
(2) Nursing Services Division, NTWC
Introduction :
A review of past incidents along with references from other hospitals and international standards indicated that non-standardised clinical and operational practices could be key risk factors for clinical incidents. Moreover, existing policies and guidelines often lack detailed operational descriptions, leading to challenges in local implementation and inconsistencies across clinical units. On the other hand, international references state that standardisation of practices is a strong intervention at the organisation level to prevent incidents. Therefore, the New Territories West Cluster (NTWC) identified numerous practices which could be standardised and published in a Handbook to facilitate implementation and ensure sustainability in the cluster.
Objectives :
To develop a set of standardised patient safety practices in in-patient wards of the three acute hospitals in NTWC to minimize variations across clinical units, thereby enhancing compliance with the requirements set forth by Hospital Authority and NTWC policies and guidelines and minimizing the risk of clinical incidents.
Methodology :
In August 2024, all patient safety practices were reviewed by Quality and Safety Division based on previous publications, recommendations from past incidents and good practices identified from Patient Safety Walk Rounds. The practices were discussed with Nursing Services Division and clinical department to confirm the practices which should be standardised in the cluster. The practices were subsequently discussed in relevant risk-related committees. Comments from department and ward representatives were sought.
Result & Outcome :
13 patient safety topics covering 80 standardised patient safety practices, including patient identification, medication safety, fall prevention, and patient transfers, etc were identified. All standardised practices were summarized into a Handbook on Standardised Patient Safety Practices and the Handbook was endorsed by Cluster Management Committee in November 2024. In each topic of the Handbook, relevant policies and guidelines, operational descriptions of each practice, essential contact points and reference materials were delineated. The Handbook was disseminated to all in-patient wards of acute hospitals and the standardised practices took effect on 1 January 2025. To ensure the standardised practices are fully implemented, self compliance check was conducted by the respective ward manager. The compliance would also be checked by senior executives in the weekly Patient Safety Walk Rounds. In the future, standardised practices of other clinical settings, e.g. out-patient clinics, would be developed.
