Implementing the Clinical Occurrence Reporting and Learning System: A Double-Loop Learning Incident Reporting System in Long-term Care. Issue 4 (October 2021)

• Record Type: Journal Article
• Authors: Goh, Hongli Sam; Tan, Vivian; Chang, Jessy; Lee, Chen Na; Zhang, Hui
• Is Part Of: Journal of nursing care quality. Volume 36:Issue 4(2021)
• Publication Date: 2021-10
• Subjects: adverse events -- clinical incident -- health care quality -- incident reporting -- long-term care -- nursing home; Nursing -- Standards -- Periodicals; Nursing audit -- Periodicals; Health facilities -- Safety measures -- Periodicals; Nurse administrators -- Periodicals; 610.73
• DOI: 10.1097/NCQ.0000000000000555
• Languages: English
• ISSNs: 1057-3631

Abstract

Abstract : Background: Most incident reporting systems have been questioned for their effectiveness in improving patient safety as they serve as an administrative reporting system. Local Problem: The long-term-care sector faced unique challenges, such an aging population and resource constraints, and its current incident reporting systems lack contextualization to address its needs. Methods: This quality improvement project was conducted at a 624-bed nursing home in Singapore from January to September 2019, using the Plan-Do-Study-Act methodology. Intervention: The existing incident reporting system (known as Clinical Occurrence Reporting and Learning System—CORALS) was redesigned to facilitate double-loop learning and workplace improvement initiatives. Results: The results demonstrated significant improvement in nurses' postintervention knowledge and confidence in handling future adverse events and greater staff awareness and information dissemination on patient safety issues. Conclusion: A double-looped system could improve nurses' patient safety awareness and their workplace practices, which would ultimately lead to better patient outcomes. Abstract : Supplemental Digital Content is Available in the Text.