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
