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Enhanced staff communication and reduced near-miss errors with a neurointerventional procedural checklist
  1. Kyle M Fargen1,
  2. Gregory J Velat1,
  3. Matthew F Lawson2,
  4. Christopher S Firment3,
  5. J Mocco4,
  6. Brian L Hoh1
  1. 1Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
  2. 2Department of Neurosurgery, Tallahassee Neurological Clinic, Tallahassee, Florida, USA
  3. 3Department of Radiology, University of Florida, Gainesville, Florida, USA
  4. 4Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA
  1. Correspondence to Dr Kyle Michael Fargen, Department of Neurosurgery, University of Florida, Box 100265, Gainesville, FL 32610, USA; Kyle.fargen{at}neurosurgery.ufl.edu

Abstract

Introduction Over the past several decades, checklists have emerged in a variety of different patient care settings to help reduce medical errors and ensure patient safety. To date, there have been no published accounts demonstrating the effectiveness of checklists designed specifically for the unique demands of neurointerventional procedures.

Methods A three-part, 20-item checklist was developed specific to neurointerventional procedures using the WHO surgical checklist as a template. Staff members (nurses, radiation technologists and physicians) were surveyed regarding near-miss adverse events and the quality of communication immediately following each neurointerventional procedure for 4 weeks prior to implementation of the checklist and again for 4 weeks after using the checklist. Staff members were asked to complete final surveys at the end of the study period.

Results 71 procedures were performed during the 4 weeks prior to checklist implementation and 60 procedures were performed during the 4 weeks after institution of the checklist. Post-checklist surveys indicated significantly improved communication compared with pre-checklist surveys (χ2 29.4, p<0.001). The number of adverse events was lower after checklist implementation for eight of the nine adverse event types (not individually significant), but the total number of adverse events was significantly lower after checklist implementation (χ2 11.4, p=0.001). Final staff surveys were uniformly positive with 95% of individuals indicating that the checklist should be continued in the department.

Conclusions Use of a neurointerventional procedural checklist resulted in statistically significant improvements in team communication and a significant reduction in total adverse events, with uniformly positive staff feedback.

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Footnotes

  • Provenance and peer review Not commissioned; externally peer reviewed.

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