Abstract
The purpose of this action research study was to solve clinical risks in patient care by professional
health care teams. Researchers and participants were heath personnel in Sung Noen Community Hospi-tal, including the hospital director, physicians, pharmacists, registered nurses, laboratory technicians, radio-
logy technicians, physical therapists, psychologists and ayurvedic doctors. The study was divided
into three steps: (1) situation analysis: by analyzing clinical risk incident reports and former preventive
measures, (2) implementation: by setting up integrated case conferences, i.e. integrated patient care by
professional health care teams, with physicians serving as leaders (the physicians set up case conferences
once a month), (3) monitoring and evaluation: by participating in conference meetings, using questionnaires
created by a quality development center, evaluating new preventive measures and clinical practice
guidelines (CPG) released and enabled to practice. The study was conducted from October 2007 to December
2008, a total of 18 months. It was found that the clinical risk incident report in 2007 was higher in
coverage, especially patient care topics, but repeated incidents were still periodically reported; also there
was a lack of root cause analysis (RCA) of clinical risk in time and discontinuity of preventive measure
practices. An integrated case conference on high-level clinical risk topics, with physicians as leaders, was
set up to analyze the root cause analysis (RCA) of the patient care process. The results were new preventive
measures and new clinical practice guidelines that were more practical for promoting quality in patient
care teams. This study showed that integrated case conferences could be effectively conducted in
community hospitals
