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Whats 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 WHOs
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
Dont 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 Vanderbilts
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 PICCs 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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