ABSTRACT
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.