Ensuring Patient Safety

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Ensuring Patient Safety In Radiology
June 2007 John Thomas
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• NSW Patient Safety Clinical Quality Program
• NSW 2004
• Managing incident information
• IIMS (Incident Information Management System)
• Purpose
• Improve quality safety of patients by
  minimising the risk of system error

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• Overarching 3C Principle
• Healthcare professionals are responsible for
  eliminating risk to patient safety by ensuring
• Correct Patient
• Correct Procedure
• Correct Site
• NSW HEALTH Policy Directive
• All healthcare staff
• Understanding Compliance
• All medical imaging examinations

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• Serious Policy Breaches
• Causes of Adverse Events
• Staff miscommunication, negligence or
  misinterpretation
• Unavailable or incorrect data (prior images)
• Lack of standardised checking processes (Patient
  ID / Team Time Out)
• Lack of patient involvement (referral form
  clinical information correlation, ask the
  questions!)
• All incidents are preventable

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• Impact of an Adverse Event
• (wrong patient / wrong procedure / wrong site)
• Death , serious harm and/or distress
• Patient, family and health professional
• Unnecessary diagnostic (invasive) procedure
• Unnecessary radiation exposure
• Unwarranted costs to organisation govt.
• Wasted time resources reporting,
  investigating fixing problem/s

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IIMS Severity Assessment Code (SAC) Chart
- Radiology incidents are all SAC 1 events -
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Incident Reporting Pathway Action
Process Incident IIMS
Report (SAC 1) Patient
disclosure Radiation Incident form Hospital
CPIU Dr. Smart RCA RIB Full
investigation by CPIU Cause Individuals
interviewed Dose Report Policy process
review Action Plan Action Plan (address
system deficiencies) Report to
EPA Report to SESIH DOH
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3C Breaches at STG Radiology
Critical Message Correct Patient, Procedure, Site
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• Verification Process - STEP 1
• Radiology Request/Consent Form
• Clear legible
• Provision of mandatory information
• Patient Details(preferably Addressograph label)
• Full Name/ DOB/ MRN
• Ward Date Written
• Procedure Requested (including side)
• Relevant Clinical History
• Referring Doctor Contact Details
• Printed Name/ Signature/ Page No.
• Incomplete/Incorrect Request Form Immediately
  notify Referrer or Ward Nurse

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• Verification Process STEP 2
• Correct Patient (Identification)
• Scope All radiology procedures
• Ask the patient
• What is your FULL NAME?
• What is your Date of Birth?
• What is the name of the PROCEDURE you are
  having today?. Also ask SITE/SIDE if required
• Never state patients Name/ DOB/ Site Side
• Do not tell the patient the patient tells
  you
• E.g. Call Mr. Brown, then ask the above
  questions including additional questions related
  to clinical history as outlined on Request Form

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• Verification Process - Cont.
• Correct Patient (Identification) Cont.
• Inpatients
• Ask patient to state Full Name/ DOB/ Procedure
• Check responses against Referral Form Patient
  ID Band (wrist/ankle) including MRN MANDATORY
• Do Not Proceed if
• Patient ID Band is absent. Call Ward Nurse to
  personally ID patient and complete Time Out
  Verification sticker (all personnel sign).
  Complete online IIMS form document into Escort
  Issues book
• Patient can not verbalise identity. Nurse Escort
  must verify patient identity. Complete Time Out
  Verification sticker (all personnel sign).

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• Verification Process - Cont.
• Outpatients
• Ask patient to state Full Name/ DOB/ Procedure
• Check responses against Referral Form
• Do Not Proceed if
• Patient can not verbalise identity.
• Proceed only after
• Identity is verified by accompanying relative,
  family member, friend or healthcare interpreter.

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Reinforcing the Message Displayed
at all imaging consoles
 
Have you checked the Patient ID ? - Prior to the
Procedure -

• Asked patient their
• Name
• DOB
• (Procedure)
• Checked response MRN against ID Band Request
  Form

Are you sure !
 
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• Team Time Out STEP 3
• General X-ray
• (General, Mobiles, Emergency - Resus,
  Mammography, Screening)
• Confirm before procedure
• Correct patient is present (Full Name/DOB/MRN/ID
  Band)
• Clinical history corresponds with Requested exam
• Correct site side is being examined
• Correct right left markers are being used
• Perform diagnostic examination (provided no
  discrepancies exist).

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• Team Time Out STEP 3 Cont.
• Interventional (invasive) Radiology
• (All invasive procedures covering CT / Ultrasound
  / Angiography / Mammography and selective
  Screening procedures)
• In procedure room, with patient present.
• Confirm patient ID, request/consent forms, image
  data all correct.
• Site marked ( ) by interventional doctor.
• Team Leader (usually Nursing staff) calls Time
  Out immediately prior to procedure commencement
  (patient draped) to confirm
• Verification of patient identity (Full
  Name/DOB/MRN/ID Band)
• Agreement on the intended procedure
• Verification of correct position i.e level
  side
• Verification of the visible marked site
• Availability of correct implants/equipment/medica
  tion
• TTO discrepancies DO NOT proceed until resolved
  (document)

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• Team Time Out STEP 4
• Post Procedure (all Radiology procedures)
• Ensure that
• Correct details are attached to the image/s
• Patient details side marker/annotations on
  post-processed image/s are correct
• Certified Time Out Verification sticker
• Radiographer/s to complete checklist, procedure,
  date, print name sign
• scanned to PACS, then
• placed in patient medical notes.

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Time Out Verification sticker Scope All
radiology procedures
General vs. Interventional use
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SUMMARY Getting in Right in Radiology
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SUMMARY Getting in Right in Radiology
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• Staff Related Responsibilities
• Patient Transfers
• Radiology staff (Front Desk) are required to
  complete ALL the front section of the Radiology
  Patient Transfer Slip
• Check adequacy of Request Form (completion of
  mandatory information fields). Follow Request
  Form Completion Policy.
• To transcribe procedure patient details from
  Request Form to Patient Transfer Slip.
• Phone Ward Nurse responsible for patient to
  arrange transfer stating
• Your name and department (Radiology)
• I have a Request Form for (Patient Name) to
  have an (Radiology procedure)

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• Patient Transfers Cont.
• The following questions should then be asked
• What is the patient MRN?
• Is the patient ready for their procedure?
• Do they travel in a bed or wheelchair?
• Do they require a Nurse Escort?
• What bed number are they?
• Do they have electrical equipment on the bed
  e.g..IMED?
• Do they need oxygen?
• Does the Orderly need Personal Protective
  Equipment?

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• Patient Transfers Cont.
• For all procedures, especially CT Angiography
• Has the patient consented or are they able to
  consent?
• When was the last time the patient had something
  to eat?
• Does the patient have a cannula?
• Is the patient on anticoagulation therapy?
• When all necessary information has been
  established, complete front side of Radiology
  Patient Transfer Slip.

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Radiology Patient Transfer Slip Front Side
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• Radiology Patient Transfer Slip
• When all information fields are completed,
  patient transfer can proceed. Radiology Orderly
  is given slip.
• Upon arrival on Ward, the Radiology Orderly must
• Identify themselves to Ward staff and
  Department (Radiology)
• State name of patient to be transferred
  procedure (as outlined on accompanying Transfer
  Slip).
• Consult Ward Nurse (or NUM) responsible for
  patient and verify whether
• patient is ready for transfer?
• needs a Nurse Escort?
• requires oxygen /or electrical equipment?
• you need to wear PPE?

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• Radiology Patient Transfer Slip Cont.
• Locate patient as directed by Ward Nurse
• Radiology Orderly MUST
• Verify Patient Identification
• Radiology Orderly to ask patient to state Full
  Name Date of Birth as outlined on Patient
  Transfer Slip. Check
• Check response against ID Band (wrist/ankle).
  This is mandatory. Check MRN against ID Band
  (Patient is not to be transferred without ID Band
  or correct identification)
• Ensure all Patient Notes X-rays accompany
  patient to Radiology
• Radiology Orderly then completes checklist on
  rear side of slip

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Radiology Patient Transfer Slip Rear Side
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• Interdepartmental Patient Transfers
• Two new SESIH forms
• Aim Improve level of patient safety care by
  ensuring clinical status (management) of patient
  is maintained
• Completed by Ward Nurse responsible for patient
• Patient Transfer Summary (awaiting release)
• all procedures NOT requiring Consent
• majority of X-ray Ultrasound procedures
• used in absence of Nurse Escort
• Procedure Checklist
• procedures requiring Consent only
• all interventional Radiology procedures

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• Where To From Here
• Communication
• 3C - Agenda Item for all Committee Meetings
• Education
• Presentation sessions - mandatory annual
  attendance
• Induction/Orientation Program inclusion
• 3C materials General X-Ray Interventional
  posters/ Time Out Verification Stickers/ Patient
  Transfer Slips/ mandatory Referral Form
  information / Why do we keep asking you who you
  are? posters
• Regular audits 3C Policy / Time Out
  Verification Stickers / Patient Transfer Slips /
  Referral Forms
• Compliance with DOH Policies
• Abolition of 3C errors
• Thank you / Questions