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Implementing the Clinical Occurrence Reporting and Learning System: A Double-Loop Learning Incident Reporting System
Hongli Sam Goh1, Vivian Tan, Jessy Chang
1Kwong Wai Shiu Hospital, Singapore (Dr Goh and Mss Tan and Chang); Singapore General Hospital, Singapore (Ms Lee); and Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (Dr Zhang).
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.
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