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  1. Goh, Hongli Sam DNurs, DBA, MN, BSN, RN
  2. Tan, Vivian MHSM, BSN, RN
  3. Chang, Jessy BSN, RN
  4. Lee, Chen Na MN, APN, RN
  5. Zhang, Hui PhD, MSN, BN, RN


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.