Authors (including presenting author) :
(1) Cheung SM, Kwan MY, Mak KM, Lee MF, Tam CL, Ruth Lau KY, Tong KL, Fong YL, Chow HC, Grace Chan YS, Kong YY, Chu YM, Mak YW Candic Tang MK (Team supervisor)
Affiliation :
(1) Department of Medicine and Geriatrics, Princess Margaret Hospital
Introduction :
Data from Japan Council for Quality Health Care database, 702 near miss cases related to mechanical ventilation between 2010 and 2017; among all, 19% caused disability or death. Literature reviews that inappropriate setting changes, failure to set appropriate alarms, changing setting without appropriate prescriptions, communication breakdown among healthcare team were underreported. Locally, in Hospital Authority, two near miss cases had been reported in 2008 and 2015. Frontline staff switched a ventilator to standby mode during procedures which demands brief disconnection of the patient from the ventilator, at the end of the process, it was then noticed that the ventilator was still on the standby mode, and was corrected immediately.
Pointing and Calling (P&C) originated in Japan in early 1900s and had proven effective in reducing occupational incidents. The application of P&C approach had been first started in a hospital in Hospital Authority since 2015. Looking at the object (eyes), pointing (fingers), hearing (ears), and speaking out (mouth), which strengthens the effect of an action.
Objectives :
1. To raise nurses’ awareness on importance of safe checking in both Invasive Mechanical ventilation (IMV) and Non-Invasive Mechanical Ventilation (NIV).
2. To understand the approach of Pointing and Calling and its applicability in ventilator checking.
3. To understand 3 Rights (Right Assembling, Right Setting, Right Alarm set up); Start Ventilator; 3 Checks (Check Patient; Check Ventilator; Check Observations).
Methodology :
A workgroup had been formulated in Respiratory team since 2017, video design and production was completed in Jan 2018. Pilot practices with reviews and modifying ventilator cue cards had been carried out in 2 Respiratory wards. Video was promulgated to nurses in Department of M&G in meetings and web. In 3Q2019, countercheck and sign by two nurses on start and restart ventilator after standby mode to enhance mutual confirmation. One-day department workshop with total 6 identical sessions had been held on 17 Sep 2019, including pre and post knowledge assessment, video demonstration, lecture and skills compliance introduction.
Result & Outcome :
Total 114 nurses as ward Train-The-Trainer attended (27% of department nurses). In Pre knowledge assessment, score ranging from 0.26 to 0.43, mean score 0.39. Results of Post knowledge assessment significantly improved from 0.39 to 0.91 (conducted right after the workshop). Some successful factors had been identified in survey from ward nurses. During P&C process, since it raised attention and concentration level with mutual confirmation, human errors could be minimized, including lack of knowledge or experience with a particular process, misinterpretation or misuse of relevant data, omitted tasks, etc. The essence of P&C start cultivating in the department. It was a good start to develop a culture to empower nurse safety checking in clinical practices. The way forward for P&C method might be applied to other critical nursing procedures, such as Haemodialysis, ECMO etc.; moreover, the checking system in some crucial, expensive medical equipment and instruments. The applicability of P&C to different areas in health care setting would be further studied.
