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The implementation of a comprehensive endoscopy checklist significantly improved patient safety by preventing misidentification incidents. This study focuses on two patients with similar names undergoing different procedures—Patient A for gastroscopy and Patient B for bronchoscopy. Through a root cause analysis and observational study, we streamlined processes and introduced a Near Miss Template. Key interventions included revising the identification process, utilizing an open-ended questioning script, and adopting the WHO Checklist. The results showed zero misidentifications over three years, highlighting the success of our changes.
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An Endoscopy Checklist: Patient story, implementation of tool, and measuring successJacky WatkinsRN PG. Dip, MN, Erehi Tua RN, Linda Jackson CNM
Contents • Background • Methodology • Process observation • Identification process • Time out • Checklist • Implementation • Results
Background • 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
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
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?
