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Post on 06-Jan-2016
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An Endoscopy Checklist: Patient story, implementation of tool, and
measuring success Jacky Watkins RN PG. Dip, MN, Erehi Tua RN,
Linda Jackson CNM
Contents Background Methodology
• Process observation• Identification process• Time out• Checklist• Implementation
Results
Two patients with similar Names• Patient A for gastroscopy, Patient B for
bronchoscopy• Dr called for A, B responded, consented and had a
gastroscopy. Bronchoscopy was rescheduled Elderly, confused patient for inpatient
gastroscopy• Follow up post bleeding gastric ulcer• NJ tube was removed (standard practice)• Wrong sticker on referral form• Perforation during procedure to replace NJ tube
Background
Methodology Root Cause Analysis Observational study
• Review sticky label process • Review identification process• Theatre time out development• Develop standard operation procedures/ Role
descriptions• Review consenting process
Identify Actions Plan do check act interventions
Observation The different areas of patient travel were
analyzed which identified four processes, namely:• The reception admission Process.• The clinical admission Process.• The procedure Process.• The recovery Process.
This analysis helped us to develop a Near Miss Template that captured data
Identification process Current practice – close ended questions
• Before procedure room Change to open ended question
• At each stage Script used to embed change in practice.
• Entire team
Script
PATIENT LABEL
TIME OUT BEFORE ANY PROCEDURE/SEDATION CHECKLIST
(FORM TO BE COMPLETED BY THE HEAD OF PATIENT NURSE PLEASE)
Question Write the actual response that the patient gives
What is your full name?
What is your date of birth?
What is your understanding about what we are going to do today?
If the Patient does not understand OR is unsure STOP
Have you signed the consent form for what you are having today?
Do you have any allergies?
WHO Checklist
Gastro Checklist
AFFIX PATIENTS ID LABEL PROCEDURE SAFETY CHECKLIST – Generic V. 3
CHECK IN (On arrival /hand over to the department)
TIME OUT (prior to procedure beginning)
CHECK OUT (Prior to patient leaving the room/dept.)
Nurse confirms with Patient Endoscopist confirms Nurse confirms
What is your full name Identity Procedure performed
________________________________ Indication Specimen correctly labelled/presented
What is your date of birth ______________________________________
Procedure & Reason for procedure Key concerns for hand over e.g. sedation
What are we doing today? _______________________________________
Consent Obtained and Signed Follow-up instructions recorded e.g. drugs
Allergies Critical events recorded
Staff Check Discuss
Have you signed consent for this procedure?
Anticipated or potential adverse events
Do you have any allergies? Speciality specific requirements
Set up – equipment medications required available
Antibiotics
Monitoring in place (pulse-oximeter, BP cuff)
IV fluids
CHECK IN signature: _____________________ TIME OUT signature: _____________________ CHECK OUT signature: _____________________
PDCA Combined team meeting to establish purpose Trialed 1 list, 1 endoscopist, nursing team Altered until consensus reached Rolled one consultant at a time Support for all staff in use of form Commitment from Heads of Department
Results No misidentification 3 years Incorrect patient highlighted – harm
prevented Ongoing support to maintain standards
• Education for new staff• Updates for existing staff
Thank you
Any questions?
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