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Ensuring Patient Safety In Radiology June 2007 John Thomas Verification Process - STEP 1 Radiology ‘Request/Consent Form’ Clear & legible Provision of mandatory information Patient Details(preferably Addressograph label) Full Name/ DOB/ MRN Ward & Date Written

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slide1

Ensuring Patient Safety

In Radiology

June 2007 John Thomas

slide2

Verification Process - STEP 1

  • Radiology ‘Request/Consent Form’
  • Clear & legible
  • Provision of mandatory information
    • Patient Details(preferably Addressograph label)
      • Full Name/ DOB/ MRN
    • Ward & Date Written
    • Procedure Requested (including side)
    • Relevant Clinical History
    • Referring Doctor Contact Details
      • Printed Name/ Signature/ Page No.
  • Incomplete/Incorrect Request Form – Immediately notify Referrer or Ward Nurse
slide3

Verification Process – STEP 2

  • Correct Patient (Identification)
  • Scope: All radiology procedures
  • Ask the patient

“What is your FULL NAME?”

“What is your Date of Birth?”

“What is the name of the PROCEDURE you are having today?”. Also ask SITE/SIDE if required

    • Never state patient’s Name/ DOB/ Site & Side

“Do not tell the patient… the patient tells you”

E.g. Call “Mr. Brown”, then ask the above questions including additional questions related to clinical history as outlined on Request Form

slide4

Verification Process - Cont.

  • Correct Patient (Identification) Cont.
  • Inpatients
  • Ask patient to state Full Name/ DOB/ Procedure
  • Check responses against Referral Form & Patient ID Band (wrist/ankle) including MRN– MANDATORY

Do Not Proceed if :

  • Patient ID Band is absent. Call Ward Nurse to personally ID patient and complete Time Out Verification sticker (all personnel sign). Complete online IIMS form & document into Escort Issues book
  • Patient can not verbalise identity. Nurse Escort must verify patient identity. Complete Time Out Verification sticker (all personnel sign).
slide5

Verification Process - Cont.

  • Outpatients
  • Ask patient to state Full Name/ DOB/ Procedure
  • Check responses against Referral Form

Do Not Proceed if :

  • Patient can not verbalise identity.

Proceed only after :

  • Identity is verified by accompanying relative, family member, friend or healthcare interpreter.
slide6

Reinforcing the Message

Displayed at all imaging consoles

Have you checked the Patient ID ?

- Prior to the Procedure -

  • Asked patient their:
  • Name
  • DOB
  • (Procedure)
  • Checked response & MRN against ID Band & Request Form

Are you sure !

slide7

Team Time Out – STEP 3

  • General X-ray
  • (General, Mobiles, Emergency - Resus, Mammography, Screening)
  • Confirm before procedure
  • Correct patient is present (Full Name/DOB/MRN/ID Band)
  • Clinical history corresponds with Requested exam
  • Correct site & side is being examined
  • Correct right & left markers are being used

Perform diagnostic examination (provided no discrepancies exist).

slide8

Team Time Out – STEP 3 Cont.

  • Interventional (invasive) Radiology
  • (All invasive procedures covering CT / Ultrasound / Angiography / Mammography and selective Screening procedures)
  • In procedure room, with patient present.
  • Confirm patient ID, request/consent forms, image data all correct.
  • Site marked by interventional doctor.
  • Team Leader (usually Nursing staff) calls Time Out immediately prior toprocedure commencement (patient draped) to confirm:
  • Verification of patient identity (Full Name/DOB/MRN/ID Band)
  • Agreement on the intended procedure
  • Verification of correct position i.e level & side
  • Verification of the visible marked site
  • Availability of correct implants/equipment/medication

TTO discrepancies – DO NOT proceed until resolved (document)

slide9

Team Time Out – STEP 4

  • Post Procedure (all Radiology procedures)
  • Ensure that:
  • Correct details are attached to the image/s
  • Patient details & side marker/annotations on post-processed image/s are correct
  • Certified Time Out Verification sticker
    • Radiographer/s to complete checklist, procedure, date, print name & sign
    • scanned to PACS, then
    • placed in patient medical notes.
slide10

TIME OUT VERIFICATION

Patient Identification Verified

Procedure & Consent Verified

Correct Site & Side Verified

Imaging Data Confirmed (priors)

Implant/Equipment Confirmed

RADIOLOGY St George Hospital

YesN/A

 

 

 

 

 

Procedure : ……………………………Date: …………….

Team member :………………………………………………

Team member:………………………………………………

Team Leader name:………………………………………..

Team Leader signature:…………………………………..

Time Out Verification sticker

Scope: All radiology procedures

General vs. Interventional use

slide11

SUMMARY

Getting in Right in Radiology

slide12

SUMMARY

Getting in Right in Radiology

slide13

Staff Related Responsibilities

  • Patient Transfers
  • Radiology staff (Front Desk) are required to complete ALL the front section of the Radiology Patient Transfer Slip:
  • Check adequacy of Request Form (completion of mandatory information fields). Follow Request Form Completion Policy.
  • To transcribe procedure & patient details from Request Form to Patient Transfer Slip.
  • Phone Ward Nurse responsible for patient to arrange transfer stating:
    • Your name and department (Radiology)
    • “I have a Request Form for (Patient Name) to have an (Radiology procedure)”
slide14

Patient TransfersCont.

  • The following questions should then be asked:
  • What is the patient MRN?
  • Is the patient ready for their procedure?
  • Do they travel in a bed or wheelchair?
  • Do they require a Nurse Escort?
  • What bed number are they?
  • Do they have electrical equipment on the bed e.g..IMED?
  • Do they need oxygen?
  • Does the Orderly need Personal Protective Equipment?
slide15

Patient TransfersCont.

  • For all procedures, especially CT & Angiography
  • Has the patient consented or are they able to consent?
  • When was the last time the patient had something to eat?
  • Does the patient have a cannula?
  • Is the patient on anticoagulation therapy?
  • When all necessary information has been established, complete front side of Radiology Patient Transfer Slip.
slide17

Radiology Patient Transfer Slip

  • When all information fields are completed, patient transfer can proceed. Radiology Orderly is given slip.
  • Upon arrival on Ward, the Radiology Orderly must:
  • Identifythemselves to Ward staff and Department (Radiology)
  • State name of patient to be transferred & procedure (as outlined on accompanying Transfer Slip).
  • Consult Ward Nurse (or NUM) responsible for patient and verify whether:
    • patient is ready for transfer?
    • needs a Nurse Escort?
    • requires oxygen &/or electrical equipment?
    • you need to wear PPE?
slide18

Radiology Patient Transfer Slip Cont.

  • Locate patient as directed by Ward Nurse
  • Radiology OrderlyMUST:
  • Verify Patient Identification
    • Radiology Orderly to ask patient to state Full Name & Date of Birth as outlined on Patient Transfer Slip. Check
    • Check response against ID Band (wrist/ankle). This is mandatory. Check MRN against ID Band (Patient is not to be transferred without ID Band or correct identification)
  • Ensure all Patient Notes & X-rays accompany patient to Radiology
  • Radiology Orderly then completes checklist on rear side of slip