1. Patient Safety in Interventional Radiology Big subject Current issue in NHS BSIR materials The System trailer Concentrate on 2 issues – Checklist – Time management

2. The System The System is a series produced by TVC in collaboration with BSIR and supported by The Healthcare Foundation. These support materials focus on Interventional Radiology issues. 2

4. Changing “The System” 4 Patient safety is paramount focus for the NHS and many other professional bodies worldwide. Despite previous efforts there is much room for improvement. Many of the issues in a large structure such as the NHS are cultural and institutional. Staff feel disempowered and unable to change or influence “The System”. We encourage you to use this film with its linked support material to make positive changes to patient safety.

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6. BSIR Biliary drainage Audit 2009 UK in hospital mortality for percutaneous biliary drainage – 1% – 5% – 7% – 10% – 20%

7. BSIR Biliary drainage Audit 2009 UK in hospital mortality for percutaneous biliary drainage – 1% – 5% – 7% – 10% – 20%

8. Scottish Audit of Surgical Mortality 2008-9 46 reported deaths post IR procedures 10 were biliary drainages in surgical patients 6 had factors related to their procedure that were suboptimal on peer review 3 of these contributed to or caused death

9. Scottish Audit of Surgical Mortality Patient Vignette from Report 2009 An elderly patient underwent percutaneous external biliary drainage for biliary obstruction due to pancreatic carcinoma. Overnight, he became unwell with hypotension and tachycardia. However, no specific action was taken until he collapsed the following morning. CT showed a large perihepatic haematoma and he subsequently underwent emergency embolisation to block a bleeding hepatic artery branch, but died a short while afterwards.. ERCP was not considered No record of any clotting study No procedural document or instructions to ward No arrangement to access IR services either on site or elsewhere.

10. Scottish Hospital August 2012 A young female patient underwent percutaneous external biliary drainage for biliary obstruction. Overnight, she became unwell with hypotension and tachycardia. However, no specific action was taken for several hours. It took a further 6 hours to locate an interventional radiologist, but the patient was moribund on arrival in the department.

11. Themes Consent Pre-procedure checklist Sedation protocols Staff conflict Handover arrangements Team meetings Morbidity and Mortality Meetings Post-operative care Out of hours arrangements Culture “just an x-ray” Small incisions belie major procedures

12. Pre-procedural checklist Everyone thinks that someone has checked something but no-one has Everyone aware of correct procedure and side and issues for particular patient Flattens hierarchy More professional and team atmosphere Exactly what is on it can be determined locally

13. 2007 80’s, IVC filter retrieval as OP Pre-arranged by colleague in discussion with clinician Attended with wife to take him home after 2h Post-op THR revision Radiology nurse queried necessity for procedure given patient age Distraction (too much on list / sorting absences / clinical discussions / sort via office/ phone calls) Registrar put patient on table and procedure started There was no pause (didn’t start until 2008) Complication -> pericardial tamponade -> death Widow went home by herself

14. 2007 80’s, IVC filter retrieval as OP Pre-arranged by colleague in discussion with clinician Attended with wife to take him home after 2h Post-op THR revision Radiology nurse queried necessity for procedure given patient age Distraction (too much on list / sorting absences / clinical discussions / sort via office/ phone calls) Registrar put patient on table and procedure started There was no pause (didn’t start until 2008) Complication -> pericardial tamponade -> death Widow went home by herself “does anyone have any concerns”

17. Pre-procedural checklist Takes 1 minute Do not hurry If you are too busy to do this, you are too busy to do the procedure

18. Team Meetings Issues, changes, agree protocols, audit, registries Morbidity and Mortality Carve out time assertively If you are too busy to do this, you are too busy to do the procedures

19. The System Full copies of this film are available to BSIR members via: office@bsir.orgoffice@bsir.org Copies for other organisations may be obtained from The Health Foundation: info@health.org.ukinfo@health.org.uk 19