Formal and clearly documented safety checks and briefings are mandatory and essential if you want to reduce predictable and preventable errors during procedures. It has been clearly demonstrated that safety checks performed immediately before and after every surgical operation reduce patient morbidity regardless of the environment. The surgical safety checklist has been adopted worldwide and similar checks should be used in interventional radiology.
This chapter builds on the ethos of the surgical safety check and suggests reviewing complex elective cases in advance of the day of the procedure in addition to further formal reviews at the start and end of every day.
Advance planning
There are two separate aspects to advance planning: administrative and personal preparation.
Administrative preparation
This is usually the role of the radiographic or nursing staff. There should be a screening process aimed at identifying risk factors such as anticoagulation in advance of the procedure. The aim of this process is to avoid surprises on the day and thus prevent delays or cancellation. Screening is often carried out through a telephone checklist review with the patient or with their source ward. Once risk factors are identified, appropriate planning and mitigation should take place, e.g. converting a patient on warfarin to heparin or scheduling diabetic patients first on the list.
Personal preparation
It is always worth reviewing the imaging and mentally rehearsing the procedure. This is particularly true of more complex interventions and is mandatory for cases that require equipment which is not routinely stocked. This one habit prevents a lot of delay and disappointment and pre-rehearsal generates the opportunity to discuss cases where there is any uncertainty regarding the choice of treatment, how best to perform it and to consider potential problems and endpoints.
Advance review checklist
Always decide what you are aiming to achieve. Ask yourself the following questions, the answers will be useful when consenting the patient and carrying out the pre-procedure team briefing:
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Is this the correct procedure for this patient at this time? If there is any doubt, it is time to verify the clinical situation with the referring team; if there is still uncertainty, then discuss the case with your boss.
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What are the key steps and sequences in the procedure? Make sure you have a clear plan and know how to use the necessary equipment.
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What is the likelihood of the procedure having the desired technical and clinical outcome? Make sure that the patient and the referring team understand the limitations of the procedure, especially in cases where the clinical benefit is uncertain.
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What are the possible treatment strategies and which is most likely to succeed and least likely to cause harm?
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Does the case require specific equipment? If so, is it in stock or does it need to be ordered?
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What problems are likely to be encountered? Think about what you will do if there is a problem or you are not successful. You should always have a ‘Plan B’ and, if necessary, little plans C, D and E.
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Might you stop before your objective is reached? It is often better to ‘live to fight another day’ rather than ploughing on in a spiral of failure, especially if this might have an adverse clinical outcome for the patient – you did remember to warn them about this and document the discussion in the patient record didn’t you?
Finally, ask yourself the ME question: would I be happy to have someone with my skill and experience undertake this procedure on me? If the answer is yes, then go ahead but if the answer is no, then either reschedule the patient on a more appropriate list or make sure that you have appropriate assistance from a colleague.
On the day: staff, equipment and room preparation
It is essential to review how the list will run and requirements for individual cases. There is no hard and fast way to do this as long as all of the key aspects are covered.
Daily safety check
Before the list begins
Representatives from each of the teams who will be involved (radiologist, nursing, radiography, anaesthesia, surgery, etc.) should review all of the planned cases as a group. Some centres will choose to include a review of individual case management at this time.
It is the responsibility of these staff to disseminate important information to other members of their teams. The meeting should not take place in the absence of essential staff. One individual is responsible for recording the attendance and discussion and ensuring that the daily safety check is recorded in the radiology information system.
The purpose of this check is to:
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Review and agree the order of cases
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Consider complex or high-risk patients – this will include a review of your advance planning
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Consider risks to staff and other patients, such as infection control issues
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Verify that all required equipment is available.
The meeting should not take more than a few minutes assuming everyone has prepared.
Individual patient safety checks
The elements of the safety check are included in Table 2.1 and your institution will have its own version. What follows is intended to explain the ethos that lies behind the checks. If you understand this, you will be able to lead the team effectively through the process.
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