Improving Patient Safety through Better Record-Keeping: A Quality Improvement Project to Standardize Large-Volume Paracentesis Documentation in the Medicine Unit of a Tertiary Care Hospital in Pakistan

Quality improvement project

Abstract

ABSTRACT

Background: Large-volume paracentesis (LVP) is a critical therapeutic procedure for patients with decompensated cirrhosis and tense ascites. While technically straightforward, safe outcomes depend not only on the operator’s skill but also on adherence to protocols and complete documentation of all procedural steps. International guidelines recommend recording indication, consent, aseptic precautions, ultrasound use, fluid volume drained, albumin administration, complications, and post-procedure monitoring. At Ayub Teaching Hospital, Abbottabad, an initial audit revealed highly inconsistent documentation practices, raising concerns for patient safety, medico-legal accountability, and quality monitoring.

Methods: A baseline retrospective review of 50 LVP records (June–July 2024) was conducted using a structured checklist based on AASLD/EASL standards. Documentation was frequently incomplete, with major omissions in consent, aseptic precautions, albumin replacement, and post-procedure monitoring. To address this, a structured proforma was developed through faculty and resident consensus, ensuring coverage of pre-, intra-, and post-procedure parameters. Implementation was carried out through iterative Plan–Do–Study–Act (PDSA) cycles with staff orientation and regular feedback. Post-intervention, 50 consecutive LVP procedures (August–September 2024) were re-audited, and compliance rates were compared using chi-square and paired t-tests.

Results: Baseline findings showed serious deficiencies: only 42% of cases documented informed consent, 38% recorded aseptic technique, 22% mentioned ultrasound use, 32% noted albumin replacement, and just 16% captured all essential details. After introducing the proforma, compliance improved markedly: consent documentation rose to 92% (+40%), aseptic technique to 88% (+42%), fluid volume recording to 96% (+36%), albumin replacement to 86% (+46%), and post-procedure monitoring to 84% (+40%). Operator identity and supervision were recorded in 96% and 72% of cases, respectively. Overall documentation compliance increased from 50.3% at baseline to 89.2% post-intervention (p < 0.001). The mean documentation score improved significantly from 3.88 ± 1.12 to 7.57 ± 0.86 (p < 0.001; Cohen’s d = 3.1, very large effect size). Importantly, no major complications were recorded post-intervention, compared with two minor events during baseline.

Conclusion: a standardized documentation proforma for LVP led to substantial improvements in record completeness, safety monitoring, and accountability in a busy tertiary care unit. This low-cost, easily implementable intervention not only aligned practice with international standards but also enhanced patient safety and medico-legal protection. The success of this QIP highlights the importance of structured documentation in resource-limited healthcare systems and offers a scalable model for other high-volume procedures.