A recent clinical investigation from The Netherlands, published in the journal Cardiovascular and Interventional Radiology (CVIR), has revealed that the use of a validated comprehensive patient safety checklist in interventional radiology in a tertiary referral centre led to a significant decrease in process deviations and procedure postponements.
The study investigators of the CVIR paper that was published in May, Inge C J Koetser et al, developed a specific Radiological Patient Safety System (RADPASS) checklist for interventional radiology and assessed its impact on healthcare processes of radiological interventions. CIRSE has also recently published a checklist for interventional radiology in CVIR, which was modified from the World Health Organization (WHO) surgical safety checklist.
Koetser et al wrote that interventional radiology is a fast-developing discipline with procedures and equipment getting more advanced and complicated by the day. “Increasingly invasive procedures are being performed in a wide variety of patients, many of whom have not been evaluated by the interventional radiologist before the intervention. The need for improvements in quality and patient safety is increasingly being recognised,” they wrote.
Koetser et al made the point that a great effect on mortality and complications in hospitals with a high standard of healthcare quality was seen after the implementation of the Surgical Patient Safety System (SURPASS) checklist that covers the entire surgical in-hospital pathway.
The investigators said that in interventional radiology, the use of checklists is gradually being introduced. “The RADPASS checklist covers all stages of the pathway for interventional radiology procedures (planning, preparation, and day-of-treatment and postprocedural care).
It is a generic checklist that can be used in all settings and includes three Joint Commission on Accreditation in Healthcare Organizations safety goals: improving the accuracy of patient identification, improving communication between caregivers, and eliminating wrong-site, wrong-patient, and wrong-procedure interventions. The use of this checklist led to a significant decrease in process deviations and procedure postponements,” they noted.
The results of their study showed that the use of the RADPASS checklist, a validated comprehensive patient safety checklist in interventional radiology, was associated with a decrease in process deviations per procedure from 24% before implementation to 5% after implementation. The proportion of postponed and cancelled procedures decreased from 10% to 0%. After a six-month period of use, 91% of users found the checklist user-friendly and all users believed that patient safety had increased by using RADPASS.
Interventional News asked Krijn P van Lienden, Department of Interventional Radiology, Academic Medical Center, The Netherlands, the lead author of the paper, some questions:
What is the importance of implementing the RADPASS checklist?
A recent systematic review has shown that nearly one out of every 10 patients admitted to a hospital will experience an adverse event. Almost half of in-hospital adverse events are related to invasive procedures such as surgical procedures, endoscopy or radiological interventions.
Interventional radiology is a fast-developing discipline with both the procedures and equipment getting more complicated by the day. Increasingly invasive procedures are being performed in a wide variety of patients, many of whom have not been evaluated by the interventional radiologist prior to the intervention. In interventional radiology, as in all medical disciplines, the need for improvements in quality and patient safety is increasingly being recognised. The importance of safety checks has long been recognised in other areas, such as aviation and high-risk industries. Recently, the WHO introduced a safety checklist in the operating room that reduces the rates of death and complications associated with surgery. An even greater effect on mortality and complications in hospitals with high standard of healthcare quality is seen after implementation of the Surgical Patient Safety System (SURPASS) checklist that covers the entire surgical in-hospital pathway.
When we, as interventional radiologists, want to take our work seriously, and want to reduce the number of adverse events and complications, it is unthinkable that we do not follow our surgical colleagues and start to use a safety checklist before any intervention. It forces you to check systematically the medical history and the current complaints of your patient, the safety matrices, the presence of the material needed for the intervention, and to estimate the risks of the procedure, so that precautions can be taken.
A better preparation of the procedure reduces the risk of getting in trouble during a procedure or starting a procedure without the appropriate materials available. For this reason the checklist is divided into three parts. The first part (planning and preparation) has to be checked the day before the intervention, the second part (procedure) contains the items checked directly before the intervention and finally the third part which contains items concerning the post-procedural care. It is a generic checklist that can be used in all settings and includes three “Joint Commission on Accreditation in Healthcare Organizations (JCAHO)” safety goals: improving the accuracy of patient identification, improving communication between caregivers, and eliminating wrong-site, wrong-patient and wrong-procedure procedures.
How easy was it to implement this checklist?
Before the implementation of the RADPASS checklist, no standardised system for the preparation of interventional radiology procedures was operative in our department.
Checking safety matrices (eg lab values, contrast allergies, medications) was left to the individual initiative of the ward doctor in in-hospital patients, the referring doctor in out-clinic patients or the radiologist, which resulted in interpersonal variations in the timing and method of checking safety items.
Implementing the checklist itself was not very difficult. Initially it was more difficult to keep the people involved motivated to continue the use of the checklist. There will always be some resistance of part of the team members, because the use of the checklist takes extra time and requires extra effort.
We started the implementation by organising a meeting in which all the advantages and disadvantages were explained to the different users. It is very important in a process like this, that everybody is convinced of the usefulness of the checklist.
Therefore the interventional radiologists, residents, fellows and technicians were instructed in the use of the list.
In our experience, it took at least six months before everyone systematically used the RADPASS list. During this period, the initiators constantly reminded the team members to use the list before every patient, which finally led to a culture change. At present time, it is routine procedure and no patient is treated without a completed RADPASS checklist.
In general, how did the relevant teams respond to the implementation of the checklist?
Using the checklist is an additional administrative activity, which costs extra time, at the expense of procedure time (not just filling out the form but also preserving the data and storing it digitally in the patient medical record). Therefore some team members had to be convinced of the advantage. The majority, however, responded enthusiastically, as patient safety is a very important issue in our department. After the implementation period of six months, it turned out that it saves time, as the number of process deviations were drastically reduced!
If the checklist is primarily completed by the resident or fellow, some of the items (the procedure itself, the indication and expected difficulties or possible complications) are discussed with one of the supervising staff members on the day before the procedure. This not only creates the opportunity to detect potential adverse events, but also creates extra teaching time. Six months after implementation at our department, almost all users considered the RADPASS checklist user-friendly, agreed that it improved safety awareness and patient safety, and agreed that the checklist improved efficiency. Nine out of 11 would rather work with than without the checklist.
What is your advice to interventional radiology teams all over the world regarding the use of checklists?
Patient safety in interventional radiology is a very important issue.
Recently, an interventional radiology checklist from the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), which was partially based on the WHO checklist, was published in CVIR. This checklist is available for everyone and should therefore be used.
The use of a checklist is easy. It takes some extra time but it creates a patient safety awareness, which is very important in avoiding adverse events and complications during the procedure.
There is also more that contributes to a more professional and “clinical’ way of working.
Informing patients and obtaining a registered informed consent is not just the responsibility of the referring clinician, but also of the interventional radiologist. Every interventional radiology department should have a complication registration and a regular complication discussion. If possible, patients should be seen on the ward by their own interventional radiologist after the intervention. This should be the clinician who discharges them after having ensured that no complications have occurred. All these things that are considered “normal” or “routine” for surgical specialists should become a daily routine for interventional radiologists as well. The implementation of the RADPASS checklist is an easy start towards a more standardised approach for interventional radiology.