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

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

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

Verification Process - Cont.

Correct Patient (Identification) Cont.

Inpatients

1. Ask patient to state Full Name/ DOB/ Procedure

2. 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).

Verification Process - Cont.

Outpatients

1.Ask patient to state Full Name/ DOB/ Procedure

2.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.

Reinforcing the Message

Displayed at all imaging consoles 

 

Have you checked the Patient ID ?- Prior to the Procedure -

Are you sure !

Asked patient their:

• Name

• DOB

• (Procedure)

Checked response & MRN against ID Band & Request Form

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).

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 to procedure 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)

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.

Time Out Verification sticker Scope: All radiology procedures

General vs. Interventional use

TIME OUT VERIFICATION Patient Identification VerifiedProcedure & Consent Verified Correct Site & Side VerifiedImaging Data Confirmed (priors)Implant/Equipment Confirmed RADIOLOGY St George Hospital

Yes N/A

Procedure : ……………………………Date: …………….Team member :………………………………………………Team member:………………………………………………Team Leader name:………………………………………..Team Leader signature:…………………………………..

SUMMARY

Getting in Right in Radiology

SUMMARY

Getting in Right in Radiology

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)”

Patient Transfers Cont.

The following questions should then be asked:

1. What is the patient MRN?

2. Is the patient ready for their procedure?

3. Do they travel in a bed or wheelchair?

4. Do they require a Nurse Escort?

5. What bed number are they?

6. Do they have electrical equipment on the bed e.g..IMED?

7. Do they need oxygen?

8. Does the Orderly need Personal Protective Equipment?

Patient Transfers Cont.

For all procedures, especially CT & Angiography

1. Has the patient consented or are they able to consent?

2. When was the last time the patient had something to eat?

3. Does the patient have a cannula?

4. Is the patient on anticoagulation therapy?

When all necessary information has been established, complete front side of Radiology Patient Transfer Slip.

Radiology Patient Transfer Slip

Front Side

Ward and Bed No. Destination General CT

Family name Screening Angio

Given name Ultrasound MRI

MRN Region

Nurse escort? Yes No Travel Chair Bed

Protective equipment? Yes No Checked by (signature)

Radiology Patient Transfer Slip

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:

• Identify themselves 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?

Radiology Patient Transfer Slip Cont.

Locate patient as directed by Ward Nurse

Radiology Orderly MUST:

• 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

Radiology Patient Transfer Slip

Rear Side

Radiology Ph 33565Emergency Ph 666Orderly has confirmed all the following:

All information is recorded on the slip?

Yes The patient is ready for transport Yes No

The patient’s ID indicates the correct patient?

Yes Does the patient need oxygen or electrical equipment?

Yes No

Radiology nursing staff have been informed of the patient’s imminent arrival?

Yes Does the patient need a Nurse Escort? Yes No

All patient notes are with the patient? Yes No

Orderly checklist