Assessing and Improving the Documentation of Large-Volume Paracentesis Procedures in a Tertiary Hospital: A Quality Improvement Project

Inconsistent documentation of large-volume paracentesis (LVP) procedures in a tertiary hospital presents risks to patient safety and procedural quality. This study aimed to improve the completeness and accuracy of LVP documentation through the implementation of a structured checklist, developed in alignment with the British Society of Gastroenterology (BSG) Safety Toolkit. The intervention was conducted over three Plan-Do-Study-Act (PDSA) cycles and involved multidisciplinary collaboration, the integration of Local Safety Standards for Invasive Procedures (LocSSIPs) into the Clinical Record System (CRS), and targeted training for staff. Sample sizes across the cycles were 35, 34, and 35 participants, respectively. Significant improvements were achieved in key documentation metrics, encompassing pre-procedure, post-procedure by doctors, and post-procedure by nurses. The results demonstrate the efficacy of structured interventions in standardising procedural documentation, improving compliance, and enhancing patient safety within clinical practice.