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Patient Safety in Interventional Radiology

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Patient Safety in Interventional Radiology Big subject Current issue in NHS BSIR materials The System trailer Concentrate on 2 issues Checklist Time management – PowerPoint PPT presentation

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Title: Patient Safety in Interventional Radiology


1
Patient Safety in Interventional Radiology
  • Big subject
  • Current issue in NHS
  • BSIR materials
  • The System trailer
  • Concentrate on 2 issues
  • Checklist
  • Time management

2
The System
  • The System is a series produced by TVC in
    collaboration with BSIR and supported by The
    Healthcare Foundation.
  • These support materials focus on Interventional
    Radiology issues.

3
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4
Changing The System
Patient safety is paramount focus for the NHS and
many other professional bodies worldwide. Despite
previous efforts there is much room for
improvement. Many of the issues in a large
structure such as the NHS are cultural and
institutional. Staff feel disempowered and unable
to change or influence The System. We
encourage you to use this film with its linked
support material to make positive changes to
patient safety.
5
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6
BSIR Biliary drainage Audit 2009
  • UK in hospital mortality for percutaneous biliary
    drainage
  • 1
  • 5
  • 7
  • 10
  • 20

7
BSIR Biliary drainage Audit 2009
  • UK in hospital mortality for percutaneous biliary
    drainage
  • 1
  • 5
  • 7
  • 10
  • 20

8
Scottish Audit of Surgical Mortality 2008-9
  • 46 reported deaths post IR procedures
  • 10 were biliary drainages in surgical patients
  • 6 had factors related to their procedure that
    were suboptimal on peer review
  • 3 of these contributed to or caused death

9
Scottish Audit of Surgical Mortality Patient
Vignette from Report 2009
An elderly patient underwent percutaneous
external biliary drainage for biliary obstruction
due to pancreatic carcinoma.  Overnight, he
became unwell with hypotension and tachycardia.
However, no specific action was taken until he
collapsed the following morning.  CT showed a
large perihepatic haematoma and he subsequently
underwent emergency embolisation to block a
bleeding hepatic artery branch, but died a short
while afterwards.. ERCP was not considered No
record of any clotting study No procedural
document or instructions to ward No arrangement
to access IR services either on site or
elsewhere.
10
Scottish Hospital August 2012
A young female patient underwent percutaneous
external biliary drainage for biliary
obstruction. Overnight, she became unwell with
hypotension and tachycardia. However, no specific
action was taken for several hours. It took a
further 6 hours to locate an interventional
radiologist, but the patient was moribund on
arrival in the department.
11
Themes
  • Consent
  • Pre-procedure checklist
  • Sedation protocols
  • Staff conflict
  • Handover arrangements
  • Team meetings
  • Morbidity and Mortality Meetings
  • Post-operative care
  • Out of hours arrangements
  • Culture just an x-ray
  • Small incisions belie major procedures

12
Pre-procedural checklist
  • Everyone thinks that someone has checked
    something but no-one has
  • Everyone aware of correct procedure and side and
    issues for particular patient
  • Flattens hierarchy
  • More professional and team atmosphere
  • Exactly what is on it can be determined locally

13
2007
  • 80s, IVC filter retrieval as OP
  • Pre-arranged by colleague in discussion with
    clinician
  • Attended with wife to take him home after 2h
  • Post-op THR revision
  • Radiology nurse queried necessity for procedure
    given patient age
  • Distraction (too much on list / sorting absences
    / clinical discussions / sort via office/ phone
    calls)
  • Registrar put patient on table and procedure
    started
  • There was no pause (didnt start until 2008)
  • Complication -gt pericardial tamponade -gt death
  • Widow went home by herself

14
2007
  • 80s, IVC filter retrieval as OP
  • Pre-arranged by colleague in discussion with
    clinician
  • Attended with wife to take him home after 2h
  • Post-op THR revision
  • Radiology nurse queried necessity for procedure
    given patient age
  • Distraction (too much on list / sorting absences
    / clinical discussions / sort via office/ phone
    calls)
  • Registrar put patient on table and procedure
    started
  • There was no pause (didnt start until 2008)
  • Complication -gt pericardial tamponade -gt death
  • Widow went home by herself
  • does anyone have any concerns

15
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16
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17
Pre-procedural checklist
  • Takes 1 minute
  • Do not hurry
  • If you are too busy to do this, you are too busy
    to do the procedure

18
Team Meetings
  • Issues, changes, agree protocols, audit,
    registries
  • Morbidity and Mortality
  • Carve out time assertively
  • If you are too busy to do this, you are too busy
    to do the procedures

19
The System
  • Full copies of this film are available to BSIR
    members via office_at_bsir.org
  • Copies for other organisations may be obtained
    from The Health Foundation info_at_health.org.uk
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