A new study finds that the use of a checklist as part of concluding imaging-guided procedures can greatly limit the number of adverse events and decrease the need for repeat procedures. In research published in the Journal of Vascular and Interventional Radiology, study authors set out to assess whether adherence to a post-procedure closeout (PPC) checklist would decrease adverse events during imaging-guided procedures (2022; https://doi.org/10.1016/j.jvir.2022.06.023).
The team, which included researchers from Beth Israel Deaconess Medical Center, sought to improve patient outcomes from interventional radiology procedures, adopting a post-procedure closeout checklist for image-guided procedures.
"Over several years, our peer learning program detected a trend of somewhat isolated serious adverse events that were occurring following the critical stage of a procedure, something that the vast majority of systems would not detect," noted Jonathan Kruskal, MD, Chair of the Department of Radiology and Radiologist-in-Chief at Beth Israel Deaconess Medical Center, and one of the study's authors.
Events related to follow-up and discharge standardization, deployment of hardware, managing samples, medication recommencement, and catheter management, for example, are "isolated events with very low frequency that, in and of themselves, wouldn't lead to much change, yet when viewed from the perspective of all occurring following a procedure, made a lot of sense," he explained. "Based on this, we developed a simple checklist that was used during a mandatory hard stop at the end of a procedure, just like the pre-procedure pause."
The checklist that Kruskal and colleagues developed was implemented on Nov. 1, 2016, across all procedural service lines-vascular and cross-sectional interventional radiology, musculoskeletal, breast imaging, and neuroradiology.
The team then compared the annual number of serious reportable adverse events related to image-guided procedures performed in radiology before the adoption of the checklist (2015-2016) and after it was put in place (2017-2021). The rate of adverse events was normalized to the procedure volume in the corresponding time periods. The number of patients requiring repeat procedures was recorded, and severity of impact was classified according to the SIR Adverse Event Classification System.
Overall, 77 safety reports were identified in image-guided procedures over the study period. Forty-three cases were not related to the PPC, leaving 34 cases for analysis.
The researchers found the addition of the checklist yielded a 42 percent reduction in the number of adverse events, in addition to decreasing the need for repeat exams by 80 percent. The authors also saw a drop in the severity of adverse events that did occur.
The investigators also noted that procedural incidents still occurred after the introduction of the checklist, pointing out that a post-procedure checklist was not performed in 30 percent of incidents, but that the use of a checklist would have prevented errors. According to the authors, 70 percent of incidents involved new error types that the current checklist would not have prevented, including specimen and order mismatch when multiple specimens were obtained, incomplete order forms, and incorrect patient labels on order forms.
The items on the researchers' checklist were developed based on a detailed analysis of 18 years of accumulated quality improvement data, Kruskal noted. Use of the checklist has reduced not only the need to repeat studies, he added, but a variety of other factors that add value, such as stakeholder experience, improved quality of care, cost savings, and staff satisfaction by standardizing many aspects of procedures, such as discharge times and follow-up and catheter management.
Using this type of post-procedure closeout checklist "has resulted in many quality improvements in our center and is being used by other clinical care teams to improve safety as well," said Kruskal. "Depending on local culture and the nature and complexity of procedures being performed, we strongly advocate for teams to consider using post-procedure closeouts and consider such a checklist as a useful item to help high-performing teams to provide top-level care."
Checklists have also been used successfully in other "high-reliability" industries such as the airline industry, added Bettina Siewert, MD, Associate Professor of Radiology at Beth Israel Deaconess Medical Center, and a co-author of the study. Utilizing a checklist "focuses the attention of staff to aspects of processes that may otherwise be overlooked," she noted, citing biopsies as an example.
"Biopsies are usually ordered to exclude a malignancy," she explained. "In rare cases, there may also be a concern for an infection which requires an additional biopsy. The checklist specifically asks about these scenarios and additional samples can be obtained if needed. Errors can thus be prevented and repeat biopsies are unnecessary."
Ultimately, Siewert noted she would like to see checklists considered "in all areas in which systemic errors occur. This does not only apply to image-guided procedures, but [applies to] diagnostic imaging and treatments, as well as communication between providers."
Mark McGraw is a contributing writer.