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Enhancing Endoscopy Safety: Checklist Implementation Success Story

This patient story details the implementation of an endoscopy checklist to prevent misidentifications, errors, and improve patient safety. The methodology includes root cause analysis, process observation, and developing standard procedures. Results include no misidentifications in 3 years, preventing harm, ongoing support for staff, and education initiatives.

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Enhancing Endoscopy Safety: Checklist Implementation Success Story

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  1. An Endoscopy Checklist: Patient story, implementation of tool, and measuring successJacky WatkinsRN PG. Dip, MN, Erehi Tua RN, Linda Jackson CNM

  2. Contents • Background • Methodology • Process observation • Identification process • Time out • Checklist • Implementation • Results

  3. 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

  4. 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

  5. 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

  6. 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

  7. Script

  8. WHO Checklist

  9. Gastro Checklist

  10. 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

  11. Results • No misidentification 3 years • Incorrect patient highlighted – harm prevented • Ongoing support to maintain standards • Education for new staff • Updates for existing staff

  12. Thank you Any questions?

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