Abigail Morbi, Presenter: Nothing to Disclose

PURPOSE Adverse events occur in approximately 10% of hospitalised patients and approximately half of these are judged to be preventable. Patient safety has therefore, quite rightly, been identified as a priority in all aspects of healthcare, to reduce harm to patients. Many of these events occur during patient intervention. Within surgical procedures, many factors over and above technical skill and patient-related factors have been identified as the root cause of error. Vascular surgery poses many unique safety risks with higher reported rates of adverse events than non-vascular procedures. Validated safety guidelines and checklists are crucial in reducing errors. The WHO checklist has been developed for surgical procedures, with global studies showing a reduction in adverse events. As yet, a pre-operative checklist, specific to radiology has not been developed. There is a need to determine whether a similar intervention is needed, specifically for vascular interventional radiological procedures, to improve safety, reduce delays and improve efficiency. Our aim was to study vascular interventional radiological procedures, to determine the type and frequency of failures, to identify which are preventable and to direct intervention to target these failures and improve patient safety as a whole. This is the first comprehensive study on safety and efficiency in vascular interventional radiology, as limited data has been published in the current literature. METHODS A direct observational study was undertaken, where field notes were recorded during endovascular procedures in the angiography suite, over a 5-week period. Two blinded assessors examined whether these events should be classified as failures. A 22-part classification system was used to categorise failures. The preventability of each failure was also assessed. RESULTS 61 vascular cases (89hrs operating time) were observed, of which 55 cases were purely interventional (63hrs, 42min) and 6 were combined cases with the vascular surgery team. 1197 failures were recorded during the 55 interventional-only cases, 612 (51.13%) of which were judged to be preventable. A classification system was used, to classify each failure into 1 of 22 failure-types. Each failure could be classified into more than 1 failure-type, resulting in 2040 failures after further analysis. Communication (11.23%), staff absence (16.18%), largely accounted for by staff dealing with equipment unavailability during the procedure, planning failure (19.71%), equipment unavailability (12.21%) and safety consciousness (6.08%) were the 5 most frequent failure types, accounting for a total of 65.39% of all failures. There was a positive correlation between the number of failures and the length of the procedure (Spearman’s rank correlation coefficient rho=0.80). CONCLUSION Preliminary data shows planning and absence to be the most frequent failures during procedures in the angiography suite, followed by equipment unavailability. However, when equipment-related failures are grouped together, this becomes the second most frequent category. The high frequency of absence is largely accounted for by equipment unavailability, with staff having to leave the angiography suite to locate equipment. Equipment unavailability in turn, may be primarily related to poor pre-procedure planning. These failures are preventable and it is likely that improved pre-procedure planning would enhance teamwork, communication and equipment availability, thus reducing absence and procedural delays. Further analysis of results will show whether the number of failures is related to procedure complexity, the stage of the procedure and the number of staff present. Our research group is currently in the process of designing and implementing a pre-procedure rehearsal, to target preventable failures in the angiography suite, to demonstrate whether or not this is an effective means of reducing delays and improving safety and efficiency. Many complex cases are unpredictable and therefore, not all failures can be corrected by pre-procedure planning, as a change in plan may result in a change in equipment requirements. However, we would expect that many of the 51.13% of failures deemed to be preventable, could be avoided.

Morbi, A, Safety and Efficiency during Vascular Interventional Radiologic Procedures:.  Radiological Society of North America 2010 Scientific Assembly and Annual Meeting, November 28 - December 3, 2010 ,Chicago IL. http://archive.rsna.org/2010/9020339.html