Patient Safety in Interventional Radiology

• Big subject• Current issue in NHS• BSIR materials• The System trailer• Concentrate on 2 issues– Checklist– Time management

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.

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Changing “The System”

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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.

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BSIR Biliary drainage Audit 2009

• UK in hospital mortality for percutaneous biliary drainage– 1%– 5%– 7%– 10%– 20%

BSIR Biliary drainage Audit 2009

• UK in hospital mortality for percutaneous biliary drainage– 1%– 5%– 7%– 10%– 20%

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

Scottish Audit of Surgical MortalityPatient 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 consideredNo record of any clotting studyNo procedural document or instructions to wardNo arrangement to access IR services either on site or elsewhere.

Scottish HospitalAugust 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.

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

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

2007 • 80’s, 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 (didn’t start until 2008)• Complication -> pericardial tamponade -> death• Widow went home by herself

2007 • 80’s, 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 (didn’t start until 2008)• Complication -> pericardial tamponade -> death• Widow went home by herself

• “does anyone have any concerns”

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

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

The System

Full copies of this film are available to BSIR members via: office@bsir.orgCopies for other organisations may be obtained from The Health Foundation: info@health.org.uk

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