469 - Reducing risk of harm- a quality improvement in theatre listing

A Dahill K Maxwell T Sato E Woolley
Presented by: Anna Dahill
Glan Clwyd Hospital

Introduction Theatres are a complex healthcare setting with a potential for risk of errors and harm to patients. A significant number of errors in the OMFS theatre lists was noted which were deemed a potential factor contributing to the increased risk of wrong side operating and inefficient use of theatre time. It was clear that an improvement in the accuracy of the information in theatre lists was needed. The aim of the quality improvement project was to audit the error rate and ascertain the nature of the errors to inform and enable an improvement initiative to improve safety and efficiency in theatre. Methods Retrospective data was collected from electronic records for Maxillofacial Day Case Lists for September-November 2018. An alteration from the procedure listed to that recorded in the operation notes was noted. The patients file was looked at to find the reason for the error. This was re-audited in June-July 2019. Results The initial audit showed that 15 of 145 cases were incorrectly listed in September-November 2018, giving an error rate of 10%. The most common cause of error was found to be unclear booking forms. After feedback from the Maxillofacial team booking forms were altered to make them clearer, and both secretaries and clinical staff were educated on the best way to complete/understand them. A re-audit target was set of an error rate of less than 5% by August 2019. From June to July 2019 there were 56 cases and 3 errors, giving an error rate of 5%. Conclusion There has been a reduction in the theatre list errors to 5%. Going forward, forms to complete in theatre after an error is noted would help unpick the cause. Education on the correct way to fill in and read booking forms should be continued. A reaudit is suggested with a target to reduce the error rate further. This audit quality improvement project shows the importance of a multidisciplinary approach to patient care and taking an active role in quality improvement of the healthcare.
Consent Statement: There are no details on individual patients reported within the abstract.

Poster