检查表
文档
患者安全
医学
审计
图表
医疗急救
病历
护理部
外科
心理学
医疗保健
计算机科学
经济
程序设计语言
管理
认知心理学
统计
经济增长
数学
作者
Verónica Kelly,K. Michelle Baar-Daley
出处
期刊:Gastroenterology Nursing
[Ovid Technologies (Wolters Kluwer)]
日期:2022-08-24
卷期号:45 (5): 328-334
被引量:1
标识
DOI:10.1097/sga.0000000000000656
摘要
Production pressure in endoscopy units, to avoid procedural delays, can lead to documentation gaps that pose a patient safety risk. Fast-paced, high-volume endoscopy units within a 673-bed academic medical center, incomplete and illegible documentation were identified during a 2018 Joint Commission survey. Pre-procedure safety checklists help ensure accurate clinical handovers. Checklists promote team communication that includes the patient to have complete and relevant information to perform a safe procedure and speak up to identify discrepancies. An endoscopy-specific safety checklist was used by the procedural team immediately pre-procedure. This quality improvement project used Plan Do Study Act cycles to incorporate changes suggested by users. Chart audits were conducted pre- and post-pilot. The results showed significant improvements in physician documentation completeness and legibility, suggesting the checklist prompted clarification of documentation and communication between the nurse and the physician. Nursing assessment saw a 27.1% improvement, suggesting clarification of clinical handover between the admitting and procedural nurses. Improved communication was perceived by staff. This project showed how a standardized tool to promote team communication and clarification of discrepancies pre-procedure can contribute to prevention of errors.
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