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Universal Radiology Time Out
The Problem
To address persistent errors in procedures outside
of the OR, the Interventional Procedures Committee
(IPC) mandated a standardized Time Out process be
implemented in all procedural areas.
Root cause analysis of procedure cases resulting
in complications from errors found that if a more
robust time out had taken place the error could
have been avoided.
Each area within the IPC was tasked to draft a
scripted Time Out that contained the 7 elements
recommended by TJC (The Joint Commission).
We had to develop one script that would cover a
range of different procedures across our entire
department.
Aim/Goal
Develop a standardized Time Out script for all procedure
personnel regardless of procedure or modality. Procedures
are performed by rotating staff and at various locations,
such that having a universal script became essential for
personnel to have the same expectations and the same
tools. A universal Time Out would promote consistency and
compliance, preventing errors and increasing patient safety.
The Team
Radiology: Misti Mullins, RN; Bridget O’Bryan-Alberts RN BSN;
Jonathan Kruskal MD PhD; Donna Wolfe, Michael Larson,
Section Chiefs, Managers, and Staff.
Interventions
Met with radiology section chiefs to draft one script to fit all procedures, e.g., liver biopsy, dialysis catheters,
therapeutic injections, vertebroplasties, etc. across all modalities, i.e., interventional, musculoskeletal,
abdominal, CT, ultrasound, fluoroscopy etc.
Invited feedback from radiology managers on roles in the Time Out process, best way to educate staff and
implement new script.
Educated staff on new script at section staff meetings, laminated scripts and produced video demonstrating
Time Outs across the department.
Progress to Date
Since implementation of a universal Time Out script
in interventional radiology procedures, compliance
rates have been consistently high and we have not
experienced any procedure errors.
Lessons Learned
When we developed the time out script we looked to
the Radiology Technologists to be the leader for our
script because they are the common denominator
in all interventional procedures. During piloting of
the script, several technologists voiced concerns
about leading the time out due to clinical elements
not within their scope of care, e.g., they felt that
leading the time out made them responsible for
knowing acceptable lab values and medications. To
address this, we discussed their role issues during
staff meetings and clarified that leading the Time
Out ensured that the procedure team covered each
of the Time Out elements but did not make them
responsible for elements not within their scope of
care.
This project brought to light another discovery we
made during the implementation of our script, that
leading the Time Out empowered technologists
to feel comfortable calling out any issues they
encounter.
Next Steps
Continue audits and analyses
Develop and implement a post procedure
“closeout” process to cover the 5 D’s:
Disposal of sharps
Disposition of the specimen
Documentation
Discharge of the patient, & any remaining
Details
On-going monthly audits to measure compliance with script use. Any problems or issues are examined using
root cause analysis.
For More Information Contact:
Misti Mullins RN (mmullin2@bidmc.harvard.edu)
Bridget O’Bryan Alberts, RN (bobryan@bidmc.harvard.edu)
Jonathan Kruskal, MD PhD (jkruskal@bidmc.harvard.edu)
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Misti Mullins (<a href="mailto:mmullin2@bidmc.harvard.edu">mmullin2@bidmc.harvard.edu</a>)<br />Bridget O’Bryan Alberts (<a href="mailto:bobryan@bidmc.harvard.edu">bobryan@bidmc.harvard.edu</a>) <br />Jonathan Kruskal (<a href="mailto:jkruskal@bidmc.harvard.edu">jkruskal@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Radiology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Misti Mullins
Bridget O’Bryan-Alberts
Jonathan Kruskal
Donna Wolfe
Michael Larson
Section Chiefs, Managers, and Staff
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Universal Radiology Time Out
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Safety