Interventional Radiology

Safety Culture and Teamwork in Interventional Radiology

The practice of interventional radiology (IR) is distinct from that of diagnostic radiology (DR) in that IR is able to treat patients with a wide variety of vascular and nonvascular disorders. Inherent in these abilities is the responsibility to provide safe, evidence-based, and patient-centered care. One method of working toward this goal is creating a safety culture within the IR team. The safety culture requires a commitment at all levels of an organization, including hospital administration, physician leaders, physicians, managers, nursing, and technical staff. According to the American Board of Radiology, a safety culture encompasses these four features: (1) acknowledgement of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations, (2) a blame-free environment, (3) encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems, and (4) organizational commitment of resources to address safety concerns. There are several validated resources available that aim to measure the safety culture within an institution or team, such as the Agency for Healthcare Research and Quality Patient Safety Culture Surveys and the Safety Attitudes Questionnaire.

Even though an improved safety culture can enhance patient care and reduce medical errors, there is still considerable work to be done in achieving sustainable increases in safety culture and addressing heterogeneity in perceived safety culture among team members. One potential reason for this heterogeneity may be due to steep authority gradients , in which team members who view themselves as lower in the hierarchy are hesitant to raise patient safety concerns. Overcoming such obstacles necessitates a team-oriented approach in which the contributions of all team members are acknowledged and valued. Teamwork is a critical component during preprocedure preparation, procedure performance, and postprocedure care. Teamwork relies on open, respectful communication. This is particularly evident during the preprocedure checklist or time-out . The time-out immediately precedes the procedure and serves as the last defense against wrong site, wrong patient, and wrong procedure events. To eliminate these never events , the time-out and other communications need to extend beyond simply broadcasting information. Rather, effective communication is defined by its ability to eliminate uncertainty in the message’s recipients. All team members are encouraged to actively participate, raise concerns, and exchange information. When viewed from this perspective, communication depends on team members having shared mental models of not only the planned task but also its likely failure modes. High-performing teams will also share strategies for detecting and recovering from potential errors. As part of this preparation, the team anticipates communication errors and minimizes the impact of such errors through redundancy and closed feedback loops. For example, the use of multiple patient identifiers (name, date of birth, and/or medical record number) and reviewing the patient’s allergies illustrate how redundancy can reduce communication breakdowns. Reconciling the consent form with the referring physician’s order creates a feedback loop. Reviewing procedure-specific details such as plans for specimen handling, preprocedure antibiotics, and needs for special equipment and supplies serves to get the entire team on the same page.

A second barrier in achieving a safety culture is the tendency to blame individuals. In a culture of individual blame, excessive emphasis is placed upon the person who makes the error rather than focusing on the contributive systemic and environmental factors. This approach to patient safety often results in punitive or corrective actions toward the individual team member. Unfortunately, this has the untoward effect of making team members less likely to report mistakes and raise concerns. If errors are underreported, then the team misses an opportunity to address systemic patient safety issues, which increases the likelihood that the error will be repeated in the future. Therefore, when considering medical errors within a culture of safety, it becomes necessary to distinguish between active errors (mistakes that occur at the point of contact between a caregiver and patient, e.g., performing a percutaneous biopsy on the wrong kidney) and latent errors (systemic, design, or organizational failures that contribute to adverse events). However, it should be recognized that there are certain situations in which the specific actions of an individual team member need to be addressed. Therefore, the concept of a just culture has been introduced. A just culture does not punish team members when their actions are commensurate with their experience and training but does hold them accountable for negligent or reckless behavior. In a just culture, it is critical to distinguish human errors (also referred to as slips or mistakes) from at-risk behavior (e.g., not placing sharps within the appropriate container on the procedure table) from reckless behavior (e.g., proceeding with central line placement without performing the required time-out). In this model, any punitive measures to the individual would be based upon the type of behavior exhibited rather than the severity of the event or whether a patient was actually harmed by the incident.

Preprocedural Care

Many of the noninterpretive skills necessary for IR occur before the patient ever enters the procedure suite. It is crucial that the interventionalist approaches each case with a thorough patient assessment including an evaluation of the patient’s history, physical exam findings, imaging data, and review of pertinent laboratory values. The initial interaction between the IR service and the referring team should be viewed as a request for a consultation rather than an order for a procedure. As consultants, the IR team adds value to the patient’s care. Such an approach will maximize the opportunities for success while minimizing the possibility of errors. Moreover, it allows the interventionalist a chance to determine the appropriateness of the requested procedure. In some instances, it may be necessary to offer an alternative treatment from that which was originally requested. The following section discusses several subsequent aspects of preprocedural care including determining the appropriateness of the procedure, establishing realistic patient expectations, planning for pain control and sedation, managing coagulation status, and obtaining informed consent.