1. Students' Reflection on Current Practice
to Avoid Tubing Misconnection: A Simple Solution,
A Difficult Compliance, A Training Opportunity
AlRasheedi S [1]
, Borahmah A [1]
, Al-Braheem A [1]
, Elamir H [3]
, Jacob S [1]
, Bouhaimed M [1,2]
[1] Department of Community Medicine and Behavioural Sciences, Kuwait University Faculty of Medicine.
[2] Department of Surgery, Kuwait University Faculty of Medicine.
[3] Department of Quality and Accreditation, Mubarak Al-Kabeer Hospital, MOH
Case Summary:Background:
Learning consists of cognitive, emotional and social dimensions. In medical education, the cognitive dimension is usually measured through
assessments of performance (Fig 1), while the social and emotional dimensions are more challenging to capture. One of the objectives of the
course on “Patient Safety: Better Knowledge for Safer Care” is to support emotional reflection in the learning process to enable a critical
assessment of both self as a professional –in our case a future doctor- and as an agent of change. The Kolb’s cycle (Fig 2) begins with
a concrete experience or task, reflecting on the experience and then applying the learning to new situations. In this case report, we present
the task of carrying out a patient safety hospital round as an object of reflection to explore adherence to the “Avoiding Catheter and Tubing
Misconnections” protocol which is one of the World Health Organization (WHO) “Nine Patient Safety Solutions” adopted by the Ministry of
Health in Kuwait.
Harming patients can take place at different levels within health care like lack of funding, system level (structure or process), or at the point
of interaction between patients and practitioners. When asked to reflect about their experience, it was evident that the students in this
elective course successfully developed a new realisation of the role of human factors in errors and the concept of system failure suggesting
that training for patient safety should start early during medical education.
Conclusion:
We would like to acknowledge the assistance provided by Quality Nurses of Mubarak Al-Kabeer Hospital:
Abeer G. Dossokey, Amal T. Mohamed, Asila A. Alrasheedi, Lea Martinez & Rinto Francis.
Acknowledgement:
Contacts:
The students completed a hospital round of 19 wards and inspected 175 opportunities in tubing of 152 patients who had different
catheters and tubes for the following criteria:
Nursing Notes
Labelling of Proximal
and Distal ends
Full 53.1%
Partial 8.6%
Not 38.3%
Full 55.4%
Partial 1.7%
Not 42.9%
Rooting Tubes and
Catheters in correct
directions
Yes 99.4%
No 0.6%
Name or Number and
Date of insertion
Yes 85.1%
No 14.9%
Documentation of
Tubes and Catheter
in nursing notes at
the start of the shift
Concrete
Experience
(Feeling)
Fig 2: Kolb’s Learning Cycle
Abstract
Conceptualisation
(Thinking)
Adapted by Ivan Mactaggart from Mcleod,2010
“Learning is the process whereby knowledge is created
through the transformation of experience”
(David A Kolb, 1984)
http://www.simplypsychology.org/learning-kolb.html
#sthash.DOwEfaZC.q20UZ5MW.dpbs
Reflective
Observation
(Watching)
Active
Experimentation
(Doing)
Remembering
Understanding
Applying
Analyzing
Evaluating
Creating
1. Bloom, Benjamin (ed.). Taxonomy of Education al Objectives. Handbook I: Cognitive Domain. David McKay Company, Inc. New York: 1956.
http://pcs2ndgrade.pbworks.com/w/page/46897760/Revised%20Bloom's%20Taxonomy
Fig 1: Bloom’s Taxonomy (Revised)
Can the student distinguish
between different parts?
Appraise, compare, contrast, criticize,
differentiate, discriminate, distinguish,
examine, experiment, question, test
Define, duplicate, list, memorize,
recall, repeat, state
Can the student recall or
remember the information?
Can the student explain ideas or
concepts?
Can the student use information
in a new way?
Classify, describe, discuss, explain,
identify, locate, recognize, report,
select, translate, paraphrase
Choose, demonstrate, dramatize,
employ, illustrate, interpret, operate,
schedule, sketch, solve, use, write
Can the student justify a stand
or decision?
Appraise, argue, defend, select,
support, value, evaluate
Can the student create a new
product or point of view?
Assemble, construct, create, design,
develop, formulate, write
For further information, please contact Dr. Manal Bouhaimed Email: manal_q8 @hsc.edu.kw - Tel (office): 24636532
![Students' Reflection on Current Practice
to Avoid Tubing Misconnection: A Simple Solution,
A Difficult Compliance, A Training Opportunity
AlRasheedi S [1]
, Borahmah A [1]
, Al-Braheem A [1]
, Elamir H [3]
, Jacob S [1]
, Bouhaimed M [1,2]
[1] Department of Community Medicine and Behavioural Sciences, Kuwait University Faculty of Medicine.
[2] Department of Surgery, Kuwait University Faculty of Medicine.
[3] Department of Quality and Accreditation, Mubarak Al-Kabeer Hospital, MOH
Case Summary:Background:
Learning consists of cognitive, emotional and social dimensions. In medical education, the cognitive dimension is usually measured through
assessments of performance (Fig 1), while the social and emotional dimensions are more challenging to capture. One of the objectives of the
course on “Patient Safety: Better Knowledge for Safer Care” is to support emotional reflection in the learning process to enable a critical
assessment of both self as a professional –in our case a future doctor- and as an agent of change. The Kolb’s cycle (Fig 2) begins with
a concrete experience or task, reflecting on the experience and then applying the learning to new situations. In this case report, we present
the task of carrying out a patient safety hospital round as an object of reflection to explore adherence to the “Avoiding Catheter and Tubing
Misconnections” protocol which is one of the World Health Organization (WHO) “Nine Patient Safety Solutions” adopted by the Ministry of
Health in Kuwait.
Harming patients can take place at different levels within health care like lack of funding, system level (structure or process), or at the point
of interaction between patients and practitioners. When asked to reflect about their experience, it was evident that the students in this
elective course successfully developed a new realisation of the role of human factors in errors and the concept of system failure suggesting
that training for patient safety should start early during medical education.
Conclusion:
We would like to acknowledge the assistance provided by Quality Nurses of Mubarak Al-Kabeer Hospital:
Abeer G. Dossokey, Amal T. Mohamed, Asila A. Alrasheedi, Lea Martinez & Rinto Francis.
Acknowledgement:
Contacts:
The students completed a hospital round of 19 wards and inspected 175 opportunities in tubing of 152 patients who had different
catheters and tubes for the following criteria:
Nursing Notes
Labelling of Proximal
and Distal ends
Full 53.1%
Partial 8.6%
Not 38.3%
Full 55.4%
Partial 1.7%
Not 42.9%
Rooting Tubes and
Catheters in correct
directions
Yes 99.4%
No 0.6%
Name or Number and
Date of insertion
Yes 85.1%
No 14.9%
Documentation of
Tubes and Catheter
in nursing notes at
the start of the shift
Concrete
Experience
(Feeling)
Fig 2: Kolb’s Learning Cycle
Abstract
Conceptualisation
(Thinking)
Adapted by Ivan Mactaggart from Mcleod,2010
“Learning is the process whereby knowledge is created
through the transformation of experience”
(David A Kolb, 1984)
http://www.simplypsychology.org/learning-kolb.html
#sthash.DOwEfaZC.q20UZ5MW.dpbs
Reflective
Observation
(Watching)
Active
Experimentation
(Doing)
Remembering
Understanding
Applying
Analyzing
Evaluating
Creating
1. Bloom, Benjamin (ed.). Taxonomy of Education al Objectives. Handbook I: Cognitive Domain. David McKay Company, Inc. New York: 1956.
http://pcs2ndgrade.pbworks.com/w/page/46897760/Revised%20Bloom's%20Taxonomy
Fig 1: Bloom’s Taxonomy (Revised)
Can the student distinguish
between different parts?
Appraise, compare, contrast, criticize,
differentiate, discriminate, distinguish,
examine, experiment, question, test
Define, duplicate, list, memorize,
recall, repeat, state
Can the student recall or
remember the information?
Can the student explain ideas or
concepts?
Can the student use information
in a new way?
Classify, describe, discuss, explain,
identify, locate, recognize, report,
select, translate, paraphrase
Choose, demonstrate, dramatize,
employ, illustrate, interpret, operate,
schedule, sketch, solve, use, write
Can the student justify a stand
or decision?
Appraise, argue, defend, select,
support, value, evaluate
Can the student create a new
product or point of view?
Assemble, construct, create, design,
develop, formulate, write
For further information, please contact Dr. Manal Bouhaimed Email: manal_q8 @hsc.edu.kw - Tel (office): 24636532](https://image.slidesharecdn.com/82c7e14c-002a-4ba3-9295-d8219191efd9-150603054353-lva1-app6891/85/HSC-poster4-1-320.jpg)
