Download safe site recommendations for interventional radiology

Safe Site Recommendations for Interventional Radiology
Why Safe Site in Interventional Radiology?
In the most recent Minnesota Adverse Healthcare Event Report, 20% of reported wrong site
events and 30% of reported wrong procedure events occurred during interventional radiology
procedures (Figure 1 and 2).
Figure 1: Location of Wrong Body Part Events (2008-2009)
Figure 2: Location of Wrong Procedure Events (2008-2009)
The Society of Interventional Radiology1 and the American College of Radiology2
recommendations align with the Minnesota Safe Site recommendations for site marking in
interventional radiology procedures when the procedure site is predetermined and in the
conducting of a “time-out” regardless of whether or not the procedure site is predetermined.
Site Marking Recommendations: (See full recommendations)
19. Site marking for procedures done under
radiologic image-guidance – procedure site
not predetermined
Person performing the procedure should
lead verbal confirmation of final site
selection with team/patient. Documentation
following the procedure should reflect the
use of imaging to determine site.
20. Site marking for procedures done under
radiologic image-guidance – procedure site
is predetermined
 Site marking should occur to include
procedure destination site.
 If site mark cannot be visualized during
the time-out, an alternative method of
indicating the procedure must be used.
 A time-out prior to procedure start
should be conducted.
 A second pause for internal laterality
does not need to be conducted.
1Society

of Interventional Radiology:
“For interventional radiology, the side or individual structure may be known, in which
case it should be marked on the skin. Alternatively, the lesion may be identified during
intra-procedural imaging, in which case it cannot be marked on the skin. This situation
would normally be exempted based on the continuous presence exemption.
College of Radiology – Practice Guideline for the performance of image-guided
percutaneous needle biopsy in adults:
 “Adherence to the Joint Commission’s Universal Protocol for Preventing Wrong Site,
Wrong Procedure, Wrong Person Surgery is required for procedures in non-operating
room settings including bedside procedures.
 “Site marking is not required for interventional procedures when the site of entry is not
predetermined and imaging guidance is used to identify the lesion. The remainder of the
universal protocol must still be followed.”
2American
Time-Out Recommendations
Who will participate in the time-out? All principals involved in the procedure should attend.
 Person performing the procedure and a second healthcare provider, at minimum, will be
involved in the verification steps of the time-out.
When and where
will you hold the time-out? This time-out should be held in the
procedure room prior to procedure start after patient is prepped and draped.
What is the visual reminder to perform the time-out? A time-out sign or similar
reminder should be in place in the instrument pack or in another location that provides a visual
reminder to staff to conduct the time-out.
What are the roles of the team members?
 Person performing the procedure: Initiates the time-out
 2nd Healthcare provider:
 Reads aloud the patient’s name, procedure and procedure site from the informed
consent that has been previously verified*.
 Visualizes the site mark, if applicable, verbally indicated that he/she sees the mark
and where it is located (refer to your hospital policy for site marking exclusions).
 Person performing the procedure:
 States the full procedure.
 If applicable, verifies that he/she see his/her mark prior to beginning the procedure.
What is the plan if there is a discrepancy?
The procedure does not proceed until
discrepancies are resolved. If the discrepancy cannot be resolved, the case may need to be
delayed or rescheduled.
What is the process if there are multiple procedures performed?
The time-out is performed prior to each procedure to verify procedure and site.