National Survey: Use of Safety Checklist

1. National Survey: Use of Safety Checklist Dr R Uberoi

2. WHO Radiology Checklist • One can see obvious parallels for interventional radiology but is there really a role for this in diagnostic procedures? • It is clear that significant errors, despite current safeguards • Occur in all aspects of radiology and those being reported nationally comprise only a tip of the iceberg. • Any procedure that requires needle insertion into a patient has the potential for catastrophic consequences. • No doctor wants to inadvertently harm patients but errors will occur in every department and often for the daftest reasons.

3. WHO Radiology Checklist • March 2009 the RCR published its guidelines for radiologists in implementing the NPSA Safe Surgery requirement • Began work on modifying the list in August 2009: • Working group • R Uberoi • T Nicholson • Anna Belli • Joan Russell.

4. WHO Radiology Checklist • Draught Sept 2009 • Pilot Oct-Dec 2009 at 9 sites in the UK • Consultation with radiologists, radiographers and nurses who took part in the pilot, further modifications made to make it even simpler, quicker and appropriate for the wide variety of procedures performed • Finalize Launch in Feb 2010

6. WHO Radiology Checklist • The NPSA has clearly identified that the checklist should apply to all patients undergoing procedures under general or local anaesthesia • The checklist is a ‘pause’ - to reflect before embarking on any procedure which requires the insertion of a needle into a patient for the purpose of biopsy or intervention

7. WHO Radiology Checklist • The checklist is not intended to replace current good practice or protocols -but is an additional safeguard • Implementation best undertaken on a small scale, by enthusiastic staff to adopt it, with ongoing local adaptation, testing and reviewing improvements • Systematically extending to other areas. • Aim of adopting it throughout the department for all appropriate procedures.

8. There remains the potential to modify these locally to adapt to local needs and protocols but the basic checklist questions should not be altered. An enlarged version of the form can be put onto the wall in all procedural rooms. This can be read out by any member of staff before each case Documented in the notes and/or on PACS/CRIS WHO Radiology Checklist

9. WHO Radiology Checklist • We have a duty of care to our patients and ‘do no harm’. • The modified WHO checklist is an extremely simple tool in helping us deliver this aim. • So let’s use it!

10. Next steps • Audit practice in the UK • Standards for the NPSA and RCR Safety Checklist for Radiological Interventions. • Authors: R Uberoi and N Cozens • Develop an Audit Template

11. WHO Radiology Checklist • ‘One avoidably dead patient in a whole working lifetime . That’s all it takes to ruin an otherwise glittering career. • A deep breath, a one minute chat to the team. • A reappraisal of what you are doing, how and why. • Staff who are empowered, know their role and are part of the team. That’s all it takes to avoid the major complication, the one death.’ • T Nicholson Dean RCR

12. WHO Radiology Checklist • 1. http://www.who.int/patientsafety/safesurgery/knowledge_base/faq.pdf • 2. Haynes AB, Weiser TG, Berry WR et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM 2009; 360: 491-499 • 3. Guidelines for radiologists in implementing the NPSA Safe Surgery requirement. The Royal college of Radiologists March 2009. • 4. http://www.nrls.npsa.nhs.uk/resources/?entryid45=73612 • 5: www.who.int/patientsafety/en • 6. http://www.who.int/patientsafety/safesurgery/checklist_adaptation.pdf • 7. ttp://www.who.int/patientsafety/safesurgery/testing/participate/starter_kit-sssl.pdf