Abdominal Imaging and Endoscopy

Biography

Biography: Stephen Wright

Abstract

Statement of the Problem: In 2009, the National Patient Safety Agency (NPSA) introduced the term “Never Events” into National Health Service practice (Moppett and Moppett, 2016). Never events are defined as a significant, fundamentally preventable patient safety incidents that could have been avoided if the healthcare provider had implemented suitable preventative measures (NPSA, 2009). Within the authors clinical area a never event occurred, following the insertion of the incorrect biliary stent.

This never event led to an evaluation of the existing nursing endoscopy documentation, which was noted to be unsatisfactory.

Methodology & Theoretical Orientation: Current literature regarding the incorporation of patient safety into endoscopy documentation was evaluated. Stakeholders with an interest in developing a new nursing care plan were approached and a new document was developed and completed within ten weeks. This new care plan contains Local Safety Standards for Invasive Procedures (LocSSIP’s) (NHS England, 2015; Tingle, 2016). An important element of the LocSSIP’s are the individual safety pauses which occur pre-procedure, during the procedure if any variances occur and finally, post-procedure, these replaced the currently used WHO checklist.  Prior to implementation of the nursing care plan into clinical practice the document underwent several PDSA cycles whilst being trialed by a group of endoscopy nurses caring for a small cohort of patients. Further training has been provided on the LocSSIP component of the document to enhance staffs understanding of this important patient safety improvement.

Conclusion & Significance: By implementing the new endoscopy nursing care plan with integrated LocSSIP and safety pauses an improvement in patient safety has been observed. Endoscopy staff have embraced the new documentation and no further never events have occurred since this document has been introduced.