ARRS 2022 Abstracts

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E1476. Standardization of the Pre-Procedural Timeout in Interventional Radiology as a Means of Reducing Medical Errors
Authors
  1. Steven Meng; University of Rochester Medical Center
  2. Devang Butani; University of Rochester Medical Center
  3. Andrew Cantos; University of Rochester Medical Center
Objective:
The purpose of this study is to standardize the pre-procedural timeout process and ultimately patient safety in the interventional suite. Timeouts are important in preventing medical error in surgical or procedural fields and have been the standard of practice since the establishment of the Universal Protocol in 2003. In interventional radiology, despite efforts to increase adherence to pre-procedural timeouts, there still exists medical error attributed to inadequate timeout process. In this single center study, we assess key components of the timeout before and after several interventions, including standardization of the process and reeducation.

Materials and Methods:
On April 2019, policies were updated at our institution to standardize the timeout process. New changes included daily audits from staff, discussions of audited data in monthly meetings, and feedback for individual improvement. The audit included six key components: attending initiation of timeout; patient, procedure, and lab value verification; site verification; active participation of group; attending solicitation of group agreement; and attending solicitation for opportunity to speak up. In addition, a required 15-minute online training program was created in July 2019 to further improve knowledge about the timeout process. Percent inclusion of each component of the audit was recorded on a monthly basis from April 2019–July 2020. Number of near misses and adverse events were also recorded and compared across each month to assess for improvement.

Results:
June 2019 represented the lowest percentage of timeouts including all key components at 94%, which also coincided with one of two adverse events requiring an RCA during the study period, prompting further training through the online education program. The monthly number of near misses decreased from three to less than one following the online training program in July 2019. All components of the timeout reached 100% for the first time in September 2019, 5 months after initiation of new policies and audits. All audited components achieved 100% for 5 consecutive months from Feb 2020–July 2020. Over the entire study period, active participation was the least included component of the timeout process at 97.6%.

Conclusion:
Pre-procedural timeouts are critical to prevent medical errors. In our study, we demonstrate that the timeout process improved through policy changes targeting standardization through frequent audits, data analysis with monthly feedback, and reeducation. Active participation represented the lowest percentage component of timeouts, highlighting a potential area to target for further improvement.