Implementing the Clinical Occurrence Reporting and Learning System: A Double-Loop Learning Incident Reporting System in Long-term Care.

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Date: Oct. 2021
From: Journal of Nursing Care Quality(Vol. 36, Issue 4)
Publisher: Lippincott Williams & Wilkins, WK Health
Document Type: Brief article
Length: 199 words

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Abstract :

Byline: Hongli Sam Goh, Kwong 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).; Vivian Tan; Jessy Chang; Chen Na Lee; Hui Zhang 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.

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Gale Document Number: GALE|A673145647