Reducing error and improving efficiency during vascular interventional radiology: implementation of a preprocedural...

Area of Science:

• Medical Imaging
• Interventional Radiology
• Patient Safety

Background:

• Vascular interventional radiology (VIR) procedures are complex and prone to errors.
• Identifying and categorizing errors is crucial for improving patient outcomes and procedural efficiency.

Purpose of the Study:

• To identify the types and frequency of errors in VIR procedures.
• To design and implement an intervention to reduce errors and enhance efficiency.

Main Methods:

• 55 VIR procedures were observed, and failures were categorized using a 22-part classification system.
• A preprocedural team rehearsal (PPTR) was developed to address frequent, preventable failures.
• 33 procedures were observed post-intervention to assess PPTR efficacy using nonparametric statistical analysis.

Main Results:

• Before intervention, 1197 potential failures occurred, with 54.6% being preventable. Common errors included planning, staff absence, and equipment unavailability.
• After PPTR implementation, potential failures decreased to 352, with preventable failures dropping to 27.3% (P < .001).
• Potential failure rates per hour significantly reduced from 18.8 to 9.2 (P < .001) without increasing harm or workflow disruption.

Conclusions:

• VIR procedural failures often stem from non-technical issues like planning and communication, which are largely preventable.
• A preprocedural team rehearsal (PPTR) effectively targets and reduces frequent, preventable errors in VIR.
• Implementing PPTR improves efficiency by reducing procedural delays and enhances overall patient safety.