Implementation of a Standardized Pre-procedure Handoff Bundle

Abstract

Problem & Purpose: Within the Interventional Radiology (IR) department at a large, academic medical center, instances of patient harm and sentinel events have occurred due to improper patient, procedure, or site verification. Literature review reveals the use of a pre-procedure safety checklist may contribute to the prevention of wrong-patient, wrong-procedure, or wrong-site events, and supports the use of the Situation, Background, Assessment, Recommendation (SBAR) model for pre-procedure handoff to improve communication among staff. The aim of this quality improvement (QI) initiative was to implement a pre-procedure handoff bundle to prevent wrong-patient, wrong-procedure, or wrong-site events. Methods: The pre-procedure handoff bundle, including completion of the Procedure Pass checklist and the performance of bedside handoff using SBAR, was implemented over 15 weeks within the IR department. All inpatients and outpatients undergoing vascular or neurovascular intervention who were prepped for a procedure within the prep and recovery area were included for intervention. Weekly chart audits and review of morbidity and mortality reports were performed using the electronic health record to determine whether project outcomes were met. Results: 100% of eligible patients (952/952) were included in data collection, with no occurrences of wrong-patient, wrongprocedure, or wrong-site events. Average Procedure Pass compliance was 31% (295/952), while average pre-procedure handoff compliance was 20% (190/952). Conclusions: Findings suggest that the implementation of a pre-procedure handoff bundle within the IR department was successful at preventing wrong-patient, wrong-procedure, or wrong-site events. The inclusion of a pre-procedure handoff bundle was both feasible and necessary to improve patient safety and staff communication within the IR department. Keywords: handoff, communication, wrongprocedure, wrong-patient, wrong-site events.