Where Angels Fear to Tread: A Checklist to Detect and Prevent Critical Errors

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The old adage small children, small problems, big children, big problems comes to mind when considering the tremendous challenge facing Max Grady, director of inpatient operations, Florida Hospital, who oversees clinical operations at seven hospitals, five hospital-based outpatient imaging centers, four freestanding outpatient imaging centers, and three PET centers performing nearly a million exams per year, with all modality managers reporting into him. Hats off to Grady, who designed and implemented a safety checklist that technologists are required to complete for each examination, designed to eliminate or hold techs accountable for critical errors.

Grady prefaced his description of the steps technologists are required to perform with this statement: “This is a journey for us it’s not a destination, and we are not quite there yet.”
Like airline pilots, technologists are required to complete the following ABC checklist and hit a stamp mark in the RIS when they have completed it:

A. Acknowledge that the patient is the person you think he/she is by confirming the full name and DOB (by speech and on armband), and that the procedure matches requisition and/or online worklist.
B. Become familiar with patient story in RIS. By reading a patient history, a technologist can avert preventable errors by stopping a patient with a pacemaker from going through with an MRI.
C. Confirm the correct procedure and protocol by verifying the RIS worklist requisition with the chart and modality worklist. This is to be sure we are doing what the physician orders, and if, for some reason, the physician has ordered a wrong site image, that the order is corrected so that it is not perpetuated throughout the system.
D. Determine laterality by asking patient location of injury and checking against order/requisition.
E. Evaluate exam in PACS immediately after being sent by verifying correct name and DOB; verifying correct exam description; verifying correct market annotation; verifying correct images/documents; and verifying correct anatomy/region of interest.

Once a quarter we do a review where a manager has to observe and validate that each of 600 technologists in the system is performing the checklist.

“That’s how much importance we put on this process,” Grady says.