Authors (including presenting author) :
Ho M, Lee CM, Fung LY, Tsang KB, Tse YK, Wong YK, Lee J
Affiliation :
Department of Paediatrics and Adolescent Medicine, QMH
Introduction :
In Paediatric and Neonatal Intensive Care Unit (PNICU), patients required to monitor blood gas / metabolite frequently. In our hospital, we are using one Blood Gas / Metabolite Analyzer (i-STAT) to perform the test. Nurses were trained and assessed their competencies before using this analyzer. A standard step is to use Hospital Number (HN) as patients' identity by scanning patients' 2D barcode bracelets. However, five incidents related to wrong patient's identity were happened from January to October 2019. In view of this, a team was formed in November 2019 to investigate the root cause and provided measures to prevent further incidents related to this procedure.
Objectives :
▪ To detect any malpractice in scanning patient's identity.
▪ To provide measures to avoid malpractice in order to prevent further incidents.
Methodology :
By reviewing the five incidents happened from January to October 2019, we found out that wrong patient's gum label or mother's gum label of newborn were used in scanning HN number, instead of using patients' 2D barcode bracelets.
A survey was done both by asking and observing nurses' practices and found out that most nurses would scan patient's identity from patient's gum labels.
Three measures were introduced to reinforce nurses to perform the standard practice using 2D barcode bracelet for scanning the HN number of the patient.
1) An imitated 2D barcode bracelet was attached on the i-STAT machine to remind nurses to scan HN number from patients' 2D barcode bracelets.
2) Cross out the barcodes on the patients' gum labels by case nurses to prevent wrong scanning.
3) A signage or reminder was attached on every patients' gum labels folders to remind nurses not to scan HN number on patients' gum labels.
From December 2019 to January 2020, our team members held talks to reinforce the standard practice of scanning and to introduce the three preventive measures to nursing staff in the ward.
From February to September 2020, audit on procedure of performing i-STAT and spot check on the compliance of the three measures were carried out.
Result & Outcome :
Total 116 nursing staff had completed and passed the audit on performing i-STAT procedure. Spot checks on the compliance of the three preventive measures from February to September 2020 resulted in 100% compliance.
To evaluate the program, a second audit to check nurses' compliance on the three preventive measures was carried out from December 1-31, 2020 resulted in 99.5% compliance. There is no Incident on performing i-STAT occurred since December 2019.
