Throughout our health care system there’s evidence that the use of checklists can improve communication among care teams, streamline complex processes and prevent patient harm. The Surgical Safety Checklist is a well-known example that underscores the importance of a thoughtful and careful approach to design, implementation, evaluation and sustainment, all necessary to increase the likelihood of successful adoption.
For the past several months, a team from the St. Paul’s Hospital (SPH) CT Department has been closely monitoring their BCPSLS data to identify instances where patients requiring tests such as CT or x-ray have been scanned incorrectly. Missed or inadvertent scans can result in patient harm, such as treatment of the wrong body part, delayed or incorrect diagnoses, extra doses of contrast media or unnecessary exposure to radiation.
“Two patient safety events stood out to us as being particularly alarming, so we agreed as a team that changes had to be made before something serious happened,” says Eric Scholz, Acting Supervisor. “We talked about possible scenarios where things can go wrong and decided to implement a checklist because it seemed like the quickest and simplest approach to prevent errors in the future.”
Prior to going live, the team participated in a brainstorming exercise called TRIZ under the leadership of Sarah Carriere, Leader for Patient Safety at Providence Health Care. TRIZ is useful in health care settings to identify potential gaps in patient care and instances where mistakes can potentially be made. In this case, the exercise was for the team to ask the question, How can we make sure that the wrong patient gets the wrong scan every time? From there, they reviewed their BCPSLS data to see if any of those errors had been made in the past, which then prompted the question, How can we stop this from happening?
“We take patient safety very seriously here so we’ve actually been working on several initiatives over the past year – using PSLS as a baseline – but launching this checklist is something we’re quite proud of. The extra few minutes it takes to fill out the checklist is well worth the effort if patient harm can be prevented,” Eric says.
The checklist promotes the use of the patient requisition as the primary source of patient identifiers and clinical data, a step that could easily be missed during a busy day on the unit, and prompts staff to tick off important steps in the patient identification process.
The checklist has only been in use for a short time, but is already helping to foster collaboration with other areas of the hospital, resulting in more effective teamwork and improved patient flow.
“I’m so impressed by the Radiology team and I felt it was important to share their early success with the rest of the province. It’s been a team effort and their dedication to patient safety is evident every single day,” Sarah says.
The team will evaluate the checklist and we’ll catch up with Eric and Sarah in a few months to learn more.
Congratulations to the St. Paul’s Hospital CT team and thank you for sharing your story!
Sarah Carriere is Leader for Patient Safety at Providence Health Care. Her areas of focus include supporting leaders on the frontline and in management positions with their safety ideas, as well as providing education on patient safety principles and BCPSLS.
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