Make a Change in 8 Steps – Ensuring Correct Patient Identification (CPI)

in Accident and Emergency Department of Pok Oi Hospital

Presentation No. is F2.7. HA Convention 2017 Prepared by Correct Patient Identification Subcommittee of AED POH

Background

• One of the identified risks in Accident and Emergency Department (AED) of Pok Oi Hospital (POH) is Patient Misidentification.

• In ward settings, 2D barcode wristband enhanced the correct patient identification (CPI).

• It is believed that the introduction of 2D barcode wristband to AED patients can help to ensure the CPI, especially in specimen collection and blood transfusion.

Background

Proposal: Apply 2D barcode wristband to all patients

during nursing triage in AED POH

Background

• In 2016, average daily attendance : 332

• Applying 2D barcode wristband to all AED patients during nursing triage => WORKLOAD!

• Manpower in triage counter : 1 nurse + 1 supporting staff ± 1 nursing officer => SHORTAGE!

Why do we need to change?

Why do we need to change?

• Patient misidentification is one of the identified clinical risks in POH AED risk registry.

POH AED Risk Registry

Rank 2015/16 2016/17

1 Medication Patient misidentification

2 Patient misidentification Patient missing

3 Medical Information security & privacy

Patient observation

4 Infection control Medication

5 Workplace violence Fall

Why do we need to change ?

Patient misidentification incidents reported (2015 – 2017)

0

1

2

3

4

5

6

7

8

2015 2016 2017

Transfer wrong patient towardWrong particular on drugsheetWrong particular onreferralWrong particular on GCRSlabel

Near Miss CPI incidents reported (2015 – 2017)

0

1

2

3

4

5

6

7

8

2015 2016 2017

Mismatch AE records

Wrong particular on AErecordUse wrong particular toprescribe treatmentWrong particular on drugsheetWrong particular onreferral/SL cert.Wrong particular on GCRSlabel

How to make the change success (Kotter‘s 8 Step Model)

• Step 1: Create Urgency • Step 2: Form a Powerful Coalition • Step 3: Create a Vision for Change • Step 4: Communicate the Vision • Step 5: Remove Obstacles • Step 6: Create Short-Term Wins • Step 7: Build on the Change • Step 8: Anchor the Changes in Corporate Culture

How to Create Urgency

• Constructive reviews • Build up consensus • Seize the right moment • Seek support

Program Time Line Jan

2015 Feb

2015 Mar 2015

Apr 2015

Jul – Dec 2015

Jan-May 2016

Jun 2016

Sep-Nov 2016

Dec 2016

Feb 2017

Site visit to AED PWH and AED NDH

Start procurement process to install hardware

Staff training

Trial run for 1 week

Enhance Staff training Develop in-house training Kit http://ntwccorpis01/poh/aed/Education Materials/Others/Correct Patient Identification.pptx

Kick off

1st Audit Touch base with IT to

explore the feasibility in technology

Touch base with Q&S and get the supplier contact to further explore the feasibility in technology

Touch base with HAHO Q&S

Brief in DMC

Form taskforce group to plan for the application

Seek approval in DMC

Submit 16/17 Annual Plan

How to Form a Powerful Coalition

• Recruit change leaders • Build Team

NTWC Q&S

NTWC NSD

NTWC AED

POH Admin

COC AED NTWC

Q&S HAHO

POH IT

Nurses Doctors

POHAED

Supporting staff (PCA)

Supporting staff

(OPA)

Department Management

Committee

Clerical staff

How to Create a Vision for Change

• Engaging staff • Effective & Regular staff communication

How to Communicate the Vision

• Sharing of the vision in every possible occasions • Report other’s success.

How to Remove Obstacles

• Two major obstacles are identified: – Perception of increased workload. – Fear of patient misidentification in applying 2D barcode

wristband

• Share others’ success – arrange site visit to AED PWH and NDH.

• Adequate Training • Pilot run

How to Create Short-Term Wins • Report results

– Bi-monthly regular meetings with different staff groups

– Quarterly incident report – Half-yearly audit

• Reward staff – Staff Development Record (SDR) – Encourage and support staff to share project

report and achievement in conference.

How to Build on the Change

• Set goals • Look for improvements • Recruit new change agents and leaders for the

change coalition.

How to Anchor the Changes in Corporate Culture

• Report progress • Share successful stories • Training for new joins • Inject new blood into the coalition team.

Our WINS

• 2D barcode wristband for all AED patients was introduced in POH since 16th Dec 2016

• Staff awareness of CPI improved • High compliance rate was noted in the audit performed in

Feb 2017 • No incident or near miss incident related to specimen

collection and blood transfusion in AED POH afterwards

Why do we need to change?

Acknowledgment

• AED of PWH & NDH • Q&S division of HAHO & NTWC • NSD & HIRO of NTWC • All the people who support & help

THANK YOU