Kumaravel Kanagavelu Aravind Sunderavel, Josan Ashweta, Khan Rimsha, Alhammo Israa, Barati Elham, Sharma Vikram
Gastroenterology and Hepatology, Barts Health NHS Trust, London, GBR.
Cureus. 2024 Nov 29;16(11):e74796. doi: 10.7759/cureus.74796. eCollection 2024 Nov.
Inconsistent documentation of large-volume paracentesis (LVP) procedures in a tertiary hospital presents risks to patient safety and procedural quality. This study aimed to improve the completeness and accuracy of LVP documentation through the implementation of a structured checklist, developed in alignment with the British Society of Gastroenterology (BSG) Safety Toolkit. The intervention was conducted over three Plan-Do-Study-Act (PDSA) cycles and involved multidisciplinary collaboration, the integration of Local Safety Standards for Invasive Procedures (LocSSIPs) into the Clinical Record System (CRS), and targeted training for staff. Sample sizes across the cycles were 35, 34, and 35 participants, respectively. Significant improvements were achieved in key documentation metrics, encompassing pre-procedure, post-procedure by doctors, and post-procedure by nurses. The results demonstrate the efficacy of structured interventions in standardising procedural documentation, improving compliance, and enhancing patient safety within clinical practice.
在一家三级医院中，大量腹腔穿刺术（LVP）程序的记录不一致，给患者安全和程序质量带来风险。本研究旨在通过实施一份结构化检查表来提高LVP记录的完整性和准确性，该检查表是根据英国胃肠病学会（BSG）安全工具包制定的。干预措施在三个计划-实施-研究-改进（PDSA）循环中进行，涉及多学科协作、将侵入性操作的本地安全标准（LocSSIPs）整合到临床记录系统（CRS）以及对工作人员进行针对性培训。各循环的样本量分别为35名、34名和35名参与者。在关键记录指标方面取得了显著改善，包括术前、医生术后和护士术后的记录。结果表明，结构化干预措施在规范程序记录、提高依从性以及增强临床实践中的患者安全方面具有有效性。
