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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Adverse events in surgery account for between one-half and two-thirds of all medical errors in hospitals,1–4 and it is estimated that around half of these events are preventable.1 ,4–6 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. Most notably, as part of the ‘Safe Surgery Saves Lives’ project, the WHO developed a perioperative surgical checklist designed to minimize the risk of adverse events during non-cardiac surgery. After a thorough development process, the Safe Surgery Saves Lives Study Group generated a 19-item checklist that addressed surgical issues orally at three time points: ‘sign-in’, ‘time-out’ and ‘sign out’. Studies using this checklist have shown a significant decrease in surgery-related complications and in-hospital deaths.7 ,8 Other medical and procedural checklists have similarly improved morbidity, mortality and other patient quality metrics.9–15
To date there have been no published reports demonstrating effectiveness of endovascular checklists in the medical literature. Similar to the operating theater, complications associated with neuroendovascular procedures are common (up to 5% for diagnostic procedures and even higher for interventions) and are best avoided through sound practices with meticulous attention to detail.16 These procedures are often performed on critically ill patients, involve numerous devices of different specifications and require the coordinated effort of multiple healthcare workers including proceduralists, anesthesiologists, nurses, radiation technologists and others. The purpose of this study is to improve communication and reduce adverse events during neurointerventional procedures by implementation of a procedural checklist developed from concepts derived from the WHO surgical checklist, specific for the unique demands of the neurointerventional suite.
This project was initiated as an institutional quality improvement project. A three-part, 20-item checklist was developed specific to neurointerventional procedures using the WHO surgical checklist as a foundation (figure 1). The checklist was designed to standardize pre- and peri-procedural protocols for tasks relevant within the neurointerventional department at our institution.
A post-procedural survey instrument was developed and all procedural staff were asked to complete a survey form at the end of all neurointerventional procedures over a 4-week period (February–March 2012) prior to checklist implementation. The surveys were completed for all procedures including diagnostic or treatment procedures during the study period. Staff members were not informed of the reason for the surveys, other than that they were for quality improvement purposes. Survey forms asked for the date, case number and staff member title (radiation technologist, nurse, neurointerventional physician). Furthermore, staff were asked to rate the communication among the healthcare team during the procedure as excellent, good, average, poor or very poor and were then asked if any of nine adverse events (near-misses) occurred during the preceding procedure (see table 1 for list of events). These nine events were chosen by the authors as they represent either procedure-specific universal problems (such as excessive contrast administration or irradiation of women of child-bearing age without addressing pregnancy status) or institution-specific recurring problems (such as having the incorrect patient name in the computer during procedural time-out) that can detrimentally affect patient outcomes or care and can usually be avoided through enhanced team communication. After 4 weeks of survey collection without use of the checklist to determine baseline communication and adverse event rates, the checklist was implemented and surveys were continued for an additional 4 weeks (March–April 2012). In almost all cases the neurointerventional fellow was responsible for leading the team through the checklist and ensuring it had been completed in its entirety. At the conclusion of the 8 week study period, all participating non-physician healthcare staff were provided with a final survey form addressing their opinions regarding the checklist (see table 3 for questions). This survey was not completed by the investigating physicians as their answers were likely to be biased.
An adverse event (near-miss) was counted if any staff member identified one of the nine events occurring peri-procedurally, even if other staff members did not identify this event on the survey. Data were compiled and analyzed using SPSS statistical software.
Seventy-one neurointerventional procedures were performed during the 4 weeks prior to implementation of the checklist and 60 procedures were performed during the 4 weeks after institution of the checklist. One hundred and twenty-one post-procedural surveys were performed for the first 71 cases (average 1.7 surveys per case, range 1–4) and 132 were performed for the last 60 cases (average 2.2 per case, range 1–4). Of the 253 total surveys, 36.8% were completed by radiation technologists, 33.2% by nurses and 30.0% by physicians.
When analyzed individually, post-checklist surveys indicated significantly improved communication compared with pre-checklist surveys (table 2; figure 2). This effect remained significant when survey scores were averaged for each case and analyzed as continuous data by t test (p<0.001).
Table 2 lists the number of cases with adverse events before and after implementation of the checklist. The number of adverse events was lower after checklist implementation for eight of the nine event types, although none of these individual analyses were statistically significant. However, when the total number of adverse events among all nine types was compared between groups, events were significantly lower after checklist implementation (p=0.001).
Table 3 lists the results of the final survey of staff members regarding their opinions on checklist effectiveness. Twenty-one individuals were surveyed, including 14 (66.7%) radiation technologists and 7 (33.3%) nurses. The results were uniformly positive across all six survey questions, with 95% of individuals indicating that the checklist should be continued in the department.
After implementation of the checklist, staff-reported communication improved significantly and staff-reported adverse events or near-misses were lower. Furthermore, staff members indicated that the checklist was useful in preventing adverse events, enhanced communication and made procedures safer for patients. While some adverse events and cases with poor communication continued to occur even after checklist implementation, their numbers were reduced, indicating that the checklist was an effective instrument in improving, but not eradicating, the quality metrics that we originally intended to address.
Dysfunctional communication, particularly during medical procedures, has been shown to have a negative effect on patient care quality, morbidity and mortality.17 ,18 Checklists may facilitate ‘informational’ utility, defined as those actions that may impact a team members’ specific awareness by the passage of new information and the correction of erroneous information, as well as ‘functional’ utility, or interactions prompted by the checklist that led to a procedural change or decision.19 ,20 Functional utility includes identifying and anticipating potential problems, perhaps the single most integral role of the checklist in improving patient safety. In a field observation of these concepts, the implementation of a preoperative checklist significantly reduced miscommunication events and led to a 64% reduction in miscommunications that caused at least one detectable consequence.19 Furthermore, checklists may enhance teamwork and cooperation by eroding the typical hierarchy of the operating room that emphasizes individualism and autonomy, which can be counterproductive for team efficiency.20 ,21 However, because checklist completion requires input from many different individuals among the healthcare team, the operation's progress becomes democratized among the team, flattening the traditional hierarchy. In fact, the positive effects of checklists on team mentality have been consistently reported in other settings19 ,22–24 and were present based upon survey data from our study.
There are no published reports documenting the effectiveness of endovascular checklists in the medical literature. These procedures are often performed on critically ill patients, require intense focus from the proceduralist, involve numerous devices of different specifications and require the coordinated effort of multiple healthcare workers including proceduralists, anesthesiologists, nurses, radiation technologists and others. In addition, a successful procedure entails completing a number of essential tasks not ordinarily performed in other surgical procedures—such as the timely administration of intravenous heparin, arteriotomy closure and confirmation of distal pulses, and monitoring contrast load and radiation exposure. A checklist designed to encompass the unique peri-procedural patient characteristics, medications, devices and communication necessary during neurointerventional procedures may therefore be of significant benefit to the neurointerventional community. Our checklist is presented here to serve as evidence of utility in our chosen field as well as to provide a template for other institutions interested in enhancing patient care and communication in their neurointerventional suite through the use of a procedural checklist.
There are significant limitations to this study. Although the majority of non-physician staff were not informed about the intervention and methods of the study, there is significant bias that is introduced secondary to both a Hawthorne effect25 and from participant measurement bias. Secondly, only 4 weeks of pre- and post-checklist monitoring was used amounting to 131 total cases, and survey completion was on a voluntary basis. Survey completion was more frequent after checklist implementation than before implementation (average 2.2 per case vs 1.7 per case), which may further bias the results. In an attempt to control for the number of surveys per case, communication quality was averaged per case using a numerical scale and analyzed separately, revealing a persistent significant improvement in communication with the checklist. Furthermore, this checklist was developed as a quality improvement instrument at our institution and may not necessarily be generalizable to other centers. Most notably, the near-miss events chosen for our study were based on both procedural and institution-specific factors, and therefore some of these may not be relevant to other centers. Finally, there was no standardized means to ensure accurate reporting of adverse events on post-procedure surveys as reporting was based on the identification and reporting of such events by any staff members participating in the procedure.
A 20-item checklist was developed, specific to neurointerventional procedures, to enhance communication and reduce adverse events during procedures in the neurointerventional suite. Use of this checklist resulted in statistically significant improvements in team communication and a significant reduction in total adverse events.
We would like to acknowledge the nurses, radiation technologists and other interventional radiology staff for their support in this quality initiative.
Contributors All authors contributed to the work presented here through study design, patient care, manuscript composition and/or critical review.
Provenance and peer review Not commissioned; externally peer reviewed.
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