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What’s New in the Patient Safety World

August 2022

Postprocedure Closeout Checklist Reduces Adverse Events

Most of the literature on checklists focuses on their use prior to surgery or other procedures. But how about using checklists after a procedure? A recent study (Siewert 2022) looked at the impact of a post-procedure “close-out” checklist during image-guided procedures. The authors found that the post-procedure close-out checklist improved patient outcomes by decreasing the number of adverse events that occur from inadequate safety processes at the conclusion of an image-guided procedure by 43%, the need for repeat procedures by 80%, and the severity of impact of an error.

Overall compliance with the postprocedure closeout checklist was in the high 90% range but compliance was lower in the group of patients with procedural errors reported (60%). In reviewing those incidents where the checklist was not used, the authors felt that most adverse events would have been prevented by use of the checklist.

Preventable errors were mostly related to obtaining and handling of specimens and retained foreign objects such as guidewires.

They did note some new error types after implementation of the checklist and plan to revise the checklist further. They anticipate that, with further modification of the checklist, 70% of incidents would have been preventable.

Some of our prior columns on checklists:

• June 5, 2007 “Patient Safety in Ambulatory Surgery”
• July 24, 2007 “Serious Incident Response Checklist”
• March 11, 2008 “Lessons from Ophthalmology”
• July 1, 2008 “WHO’s New Surgical Safety Checklist”
• September 23, 2008 “Checklists and Wrong Site Surgery”
• November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
• November 25, 2008 “Wrong-Site Neurosurgery”
• January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
• January 19, 2010 “Timeouts and Safe Surgery”
• June 2010 “WHO Checklist for Radiological Interventions”
• June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
• July 6, 2010 “Book Reviews: Pronovost and Gawande”
• September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
• November 30, 2010 “SURPASS: The Mother of All Checklists”
• December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
• February 2011 “SURPASS Checklist Reduces Malpractice Claims”
• March 2011 “Michigan ICU Collaborative Wins Big”
• June 6, 2011 “Timeouts Outside the OR”
• August 16, 2011 “Crisis Checklists for the OR”
• July 2012 “VA Checklist Reduces Suicide Risk”
• July 2012 “WHO Safe Childbirth Checklist”
• October 2012 “Another PCA Pump Safety Checklist”
• February 2013 “Checklists for Surgical Crises”
• April 2014 “Checklists Don’t Always Lead to Improvement”
• May 2015 “The Great Checklist Debate”
• August 25, 2015 “Checklist for Intrahospital Transport”
• September 1, 2015 “Smarter Checklists”
• September 15, 2015 “Another Possible Good Use of a Checklist”
• September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
• November 2016 “Oxygen Tank Monitoring”
• November 1, 2016 “CMS Emergency Preparedness Rule”
• January 10, 2017 “The 26-ml Applicator Strikes Again!”
• May 2017 “Another Success for the Safe Surgery Checklist”
• May 2, 2017 “Anatomy of a Wrong Procedure”
• June 2017 “Another Way to Verify Checklist Compliance”
• August 22, 2017 “OR to ICU Handoff Success”
• November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• December 19, 2018 “More on Overlapping Surgery”
• February 2018 “Oxygen Cylinders Back in the News”
• October 30, 2018 “Interhospital Transfers”
• November 20, 2018 “Checklist Implementation”

· May 2019 “WHO Surgical Safety Checklist Cut Mortality 37% in Scotland”

· July 16, 2019 “Avoiding PICC’s in CKD”

· June 2020 “Are Two Checklists Better Than One?”

· March 2021 “Medical Crisis Checklists in the ED”

· June 21, 2022 “Preventing Post-op Pneumonia”

References:

Siewert B, Brook OR, Swedeen S, et al. Impact of a post-procedure close-out checklist on the incidence of preventable adverse events during interventional radiology procedures: an initiative to improve outcomes. Journal of Vascular and Interventional Radiology 2022; Published July 04, 2022

https://www.jvir.org/article/S1051-0443(22)01052-1/pdf

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