1. An Endoscopy Checklist: Patient story, implementation of tool, and measuring success Jacky Watkins RN PG. Dip, MN, Erehi Tua RN, Linda Jackson CNM

2. Contents  Background  Methodology Process observation Identification process Time out Checklist Implementation  Results

3.  Two patients with similar Names Patient A for gastroscopy, Patient B for bronchoscopy Dr called for A, B responded, consented and had a gastroscopy. Bronchoscopy was rescheduled  Elderly, confused patient for inpatient gastroscopy Follow up post bleeding gastric ulcer NJ tube was removed (standard practice) Wrong sticker on referral form Perforation during procedure to replace NJ tube Background

5. Methodology  Root Cause Analysis  Observational study Review sticky label process Review identification process Theatre time out development Develop standard operation procedures/ Role descriptions Review consenting process  Identify Actions  Plan do check act interventions

6. Observation  The different areas of patient travel were analyzed which identified four processes, namely: The reception admission Process. The clinical admission Process. The procedure Process. The recovery Process.  This analysis helped us to develop a Near Miss Template that captured data

8. Identification process  Current practice – close ended questions Before procedure room  Change to open ended question At each stage  Script used to embed change in practice. Entire team

9. Script

10. WHO Checklist

11. Gastro Checklist

12. PDCA  Combined team meeting to establish purpose  Trialed 1 list, 1 endoscopist, nursing team  Altered until consensus reached  Rolled one consultant at a time  Support for all staff in use of form  Commitment from Heads of Department

13. Results  No misidentification 3 years  Incorrect patient highlighted – harm prevented  Ongoing support to maintain standards Education for new staff Updates for existing staff

14. Thank you Any questions?