Interventional Radiology: A Case Study

Allison, I agree that improving communication in health care will improve patient outcomes. I work in a busy interventional radiology (IR) suite where we perform many procedures every day. Interventional Radiology is normally vigilant regarding patient safety and preventing wrong site errors. When patients arrive in our department we identify the patient, and begin a time out form, the time out form is a written safety check list meant to prevent errors. A patient came to our department for a G-J tube exchange, the patient had an existing G tube that needed exchanged to a G-J tube because he was aspirating with the G tube. The patient’s order was hand written and difficult to read, the patient was nonverbal and could not communicate during the time out process.
The pre-procedure nurse initiated the time out form and documented the procedure to be done was a G-J tube exchange on the time out form. The procedure nurse assumed responsibility of the patient, the nurses discussed the patient’s allergies, consents, the patient’s medication record, when they discussed the patient’s procedure, the pre-procedure nurse indicated the patient was having a “feeding tube exchange”. The pre-procedure nurse failed to communicate the exact order for the procedure and she did not indicate how difficult the order was to read. The pre-procedure nurse did not discuss the difficult order with the team and the remainder of the team did completely read the order and did see the order was for a G-J tube exchange, not a G-tube exchange. The team took short cuts during the time out, and allowed a wrong site patient error, which is a sentinel event. During the Root Cause Analysis, it was determined contributing factors to the sentinel event were lack of communication and short cuts taken during the time