A Patient Safety Programme in reducing the Number of Models of Oxygen Regulators and Enhancing Staff Competency on their Use

Transcription

1 A Patient Safety Programme in reducing the Number of Models of Oxygen Regulators and Enhancing Staff Competency on their Use Andy KWOK Manager (Quality & Safety) Quality & Safety Division New Territories West Cluster Hospital Authority, Hong Kong HA Convention May

2 Photo : An In-situ Simulation Drill in Tuen Mun Hospital, Hong Kong Patient transfer in hospital is very common 2

3 Ward A&E A Ward B A&E 3 3

4 Source: Administrative Services Division, Tuen Mun Hospital, Hong Kong No. of Patient Transfer in Tuen Mun Hospital, Hong Kong Average = 22,600 transfers/month Transfer Team: Doctor Nurse Portering Staff 4

5 Source: HA Taskforce on Patients Requiring Oxygen on Transfer (Nov 2013) Incidents related to oxygen therapy during patient transfer What happened inside: 1. Main switch of oxygen cylinder not turned on 2. Cylinder was empty 5

6 Non-compliance in checking before transfer Root Causes Identified Unfamiliar with the use of oxygen regulator Knowledge gap in monitoring of flowmeter Organizational Human Equipment Incidents related to oxygen therapy in patient transfer Training not structured Too many models being used 6

7 Formed a Workgroup in 2014 NTWC Workgroup on Standardisation of Oxygen Regulators Nursing Services Division Quality and Safety Division Procurement Materials and Management Unit 7

8 Actions Implemented 1 Situation study (Stocktaking exercise) NTWC Workgroup on Standardisation of Oxygen Regulators 8

9 Source: Nursing Services Division & Quality and Safety Division, New Territories West Cluster, Hong Kong Conducted a Stock Taking Exercise in Feb models of oxygen regulators!! 9

10 Actions Implemented 1 Situation study (Stocktaking exercise) NTWC Workgroup on Standardisation of Oxygen Regulators 2 Standardization of no. of models of oxygen regulators 10

11 Standardised No. of Models of Oxygen Regulators 44 2 standardised models in NTWC For nasal cannula & facial mask For nasal cannula, facial mask & ventilator 11

12 Photo : Ward Manager Meeting, New Territories West Cluster, Hong Kong Conducted a 1-for-1 Replacement Exercise (Apr Jul 2015) >600 oxygen regulators were replaced 12

13 Actions Implemented 1 Situation study (Stocktaking exercise) NTWC Workgroup on Standardisation of Oxygen Regulators 2 Standardization of no. of models of oxygen regulators 3 Staff training 13

14 Source: Quality and Safety Division, New Territories West Cluster, Hong Kong Enhanced Staff Training & Ensured Competency 14

15 Source: Nursing Services Division & Quality and Safety Division, New Territories West Cluster, Hong Kong Enhanced Staff Training & Ensured Competency 15

16 Source: Information Technology Department, New Territories West Cluster, Hong Kong Enhanced Staff Training & Ensured Competency Up till 31 March 2017, more than 4,200 staff had completed and passed the quiz 16

17 Source: Advance Incidents Reporting System, New Territories West Cluster, Hong Kong incident related to misuse of oxygen regulators in patient transfer in NTWC 17

18 Team Members Ms Queenie LEUNG, NTWC CGM(N) / TMH GM(N) Dr. K S TANG Dr, NTWC SD(Q&S) / NTWC Hon CON(A&IC) Mr. C M MAK, TMH Deputy GM(N) / TMH/POH DOM(ICU) / TMH DOM(NEURO) Mr. M S LAM, TMH SNO(NSD) Mr. C Y WONG, POH SNO(NSD) Ms K W WU, CPH NO(PSY) NSD Ms Apple CHENG, TMH EOI(NSD) Mr. Alvin NG, TSWH EOII(NSD) Ms Flora TSANG, NTWC HM(P)1 Mr. William CHAN, TMH ASO(S) Mr. Andy KWOK, NTWC M(Q&S) 18

19 Thank You! 19