Aims Concise, comprehensive and contemporaneous documentation is the gold-standard in modern medicine. It is mandated by the General Medical Council¹ due to its importance for patient safety and maintaining high quality care.

A review of documentation of invasive pleural procedures at our Trust suggested non-compliance with the gold standard British Thoracic Society (BTS) guidance,² raising patient safety concerns. We led a quality improvement project aimed to quantify the problem, address non-compliance by introducing a checklist and review to assess its effectiveness.

Method Patient notes were reviewed and data collected on written evidence of compliance with important BTS mandated parameters for 4 weeks. A checklist standardising documentation was introduced, followed by a second round of data collection.

Results There was a significant increase in documentation between PDSA cycles of pre-procedure INR (61% increase, p=0.002), chest radiograph (73% p=0.0003), local anaesthetic (54%, p=0.006), sutures (58%, p=0.044) and drain type (83%, p=0.003) after introducing the checklist. Documentation of all other parameters increased (nearing significance) or remained static at 100%.

Conclusion Poor documentation may reflect inadequate safety checks and incorrect procedural technique. Our quality improvement project demonstrates that a simple intervention of introduction of a checklist measurable improved documented compliance with key BTS mandated parameters. This intervention improves patient safety.

After review by key emergency medicine, acute medicine and respiratory stakeholders, the checklist has been incorporated into the Trust pleural procedures protocol. This protocol will be rolled out trust-wide across three sites.

References

1. GMC, 2013. Good Medical Practice.

2. BTS Pleural Disease Guideline Group, 2010. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline2010.