Authors (including presenting author) :
Yeung TY(1), Kwok FL(1), Lam PH(1), Lai ML(1), Chiu CWH(1), Leung WK(1), H EMT(1), Leung MKW(1), Hui E(1)(2)
Affiliation :
(1) Department of Family Medicine, NTEC (2) Department of Medicine & Geriatrics of Shatin Hospital, NTEC
Introduction :
Correct identification (CID) is one of the top three clinical risk registries in Family Medicine, New Territories East Cluster (FM, NTEC). Patient misidentification may lead to medical error, medication error, and wrong clinical intervention (e.g. X-rays, referral, specimen’s collection), etc. From 2016 to 2018, there were total 19 misidentification incidents reported to Advance Incident Reporting System (AIRS) due to improper checking process. To assess front-line staff's compliance on patient identification, the Continuous Quality Improvement (CQI) program was initiated by FM, NTEC Quality and Safety (Q&S) workgroup in August 2018.
Objectives :
1. To enhance staff's awareness on the proper CID checking steps. 2. To monitor staff's general practices of CID in daily routines. 3. To decrease the CID incidents rate.
Methodology :
1. Conducted root cause analysis of CID incidents by Q&S workgroup to identify existing mal-practices in GOPCs. 2. Established "3 Steps Approach" strategy guiding staff to comply with CID in daily routines. 3. Produced a video to demonstrate the proper CID checking process by applying "3 Steps Approach". 4. Developed a tailor-made observation form to facilitate onsite "CID Surprise Check Exercise". 5. All items in “3 Steps Approach” were mandatory procedures and staff should comply 100% in the exercise. 6. The exercise was conducted among 9 clinics in NTEC FM in January 2019.
Result & Outcome :
1. A total of 300 (97.1 %) staff working in the department had participated in the CID Surprise Check Exercise which included 81 doctors, 100 nurses, 62 PCAs, and 57 clerical staff. 2. The overall compliance rate was 96.7%, and only 10 items were failed in "Step 3" (1 in consultation, 7 in Shroff registration, and 2 in vital sign records). 3. Further improvement activities were carried out according to the results of the exercise. 4. The CID video was uploaded to iFM@NTEC for staff training. 5. The CID incident rate dropped significantly in 2019-2020 after the implementation of "CID Surprise Check Exercise". Conclusions: 1. The tailor-made observation form was tested as a useful tool to monitor staff’s compliance of CID. 2. CID Surprise Check Exercises could be conducted periodically in the department by using the newly developed observation form.
