An Endoscopy Checklist: Patient story, implementation of tool, and

measuring success Jacky Watkins RN PG. Dip, MN, Erehi Tua RN,

Linda Jackson CNM

Contents Background Methodology

• Process observation• Identification process• Time out• Checklist• Implementation

Results

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

Background

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

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

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

Script

PATIENT LABEL

TIME OUT BEFORE ANY PROCEDURE/SEDATION CHECKLIST

(FORM TO BE COMPLETED BY THE HEAD OF PATIENT NURSE PLEASE)

Question Write the actual response that the patient gives

What is your full name?

What is your date of birth?

What is your understanding about what we are going to do today?

If the Patient does not understand OR is unsure STOP

Have you signed the consent form for what you are having today?

Do you have any allergies?

WHO Checklist

Gastro Checklist

AFFIX PATIENTS ID LABEL PROCEDURE SAFETY CHECKLIST – Generic V. 3

CHECK IN (On arrival /hand over to the department)

TIME OUT (prior to procedure beginning)

CHECK OUT (Prior to patient leaving the room/dept.)

Nurse confirms with Patient Endoscopist confirms Nurse confirms

What is your full name Identity Procedure performed

________________________________ Indication Specimen correctly labelled/presented

What is your date of birth ______________________________________

Procedure & Reason for procedure Key concerns for hand over e.g. sedation

What are we doing today? _______________________________________

Consent Obtained and Signed Follow-up instructions recorded e.g. drugs

Allergies Critical events recorded

Staff Check Discuss

Have you signed consent for this procedure?

Anticipated or potential adverse events

Do you have any allergies? Speciality specific requirements

Set up – equipment medications required available

Antibiotics

Monitoring in place (pulse-oximeter, BP cuff)

IV fluids

CHECK IN signature: _____________________ TIME OUT signature: _____________________ CHECK OUT signature: _____________________

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

Results No misidentification 3 years Incorrect patient highlighted – harm

prevented Ongoing support to maintain standards

• Education for new staff• Updates for existing staff

Thank you

Any questions?