1. The System
The System is a series produced by TVC in collaboration with BSIR and supported by The Healthcare Foundation. These support materials focus on Interventional Radiology issues.

2. Changing “The System”
Patient safety is paramount focus for the NHS and many other professional bodies worldwide. Despite previous efforts there is much room for improvement.
Many of the issues in a large structure such as the NHS are cultural and institutional. Staff feel disempowered and unable to change or influence “The System”.
We encourage you to use this film with its linked support material to make positive changes to patient safety.

3. Guidance for Learning outcomes
The following slides are an aid to discussion for your team. They aim to show the main areas of learning identified in the film but are not an exhaustive list.
Take time to consider the points raised
Note potential areas of action
Take the three most important areas and decide how you will progress.
Book the follow up meeting for the actions – now- and review progress

4. Strategy to generate discussion
Tackle each theme in turn
Identify key issues for each theme
Ask what “local issues” you have or share
Answer any direct questions we have asked
Discuss ways forward to address each issue

5. Action Watch the film now – it lasts 15 minutes
Jot down a list of themes you think it raises
Restart the PowerPoint to discuss the themes

6. Themes identified in the film
People: consent, staff conflict
Procedure: sedation and analgesia
Equipment: biliary stent unavailable
Process: Handover and post-operative care, 24/ 7 services
Environment: 24/7 services
Underlying systemic issues
You may have identified others ….

7. Patient consent The film shows an episode of consent
How was consent established and think how it could be improved?
The following specific questions may be useful

8. Patient consent- discussion
Are patients seen at an IR outpatient clinic ?
Are elective patients consented in the department- why?
Do all patients receive patient information leaflets?
Have you audited this process?
Consent
How can we ensure this is done by the operator or staff familiar with the procedure

9. Patient consent – Best practice
Primary operator consents is the default
Any consent delegation clearly defined
Elective cases consented at clinic
Audit of consenting practice
Regular staff education re consenting process
Understanding of incapacity consent
Understanding of research consent

10. Sedation The patient received sedation during the procedure.
As a group discuss how sedation was undertaken in the film and how it could be improved
The following discussion points may be helpful

11. Sedation-discussion points
Poor communication
Anxious patient
Patient thought they were getting a GA
Sedation protocol
consultant over-ruling nurse
over sedation and reversal
Conflict within the team
Had a GA been considered

12. Sedation- Best practice
Better communication reduces patient anxiety
Agreed pain protocol with anaesthetic input
Strategy for managing breakthrough pain
Regular audit of protocol effectiveness
GA lists for identified procedures
biliary drainage, TIPS, vertebroplasty, AVM`s

13. Staff conflict Staff conflict is demonstrated during the procedure
As a group reflect on why this happened and how this can be prevented
The following discussion points maybe useful

14. Staff conflict- discussion points
How can a team brief help understand the relative roles of team members?
Departmental protocols can help reduce conflict- how do we make sure all parties know the current protocols?
Inevitably protocols cannot be followed for every case. Can we agree beforehand as a team the process for moving from the protocol?

15. Staff conflict- Best practice
Self respect and respect for others
Culture of openness
Team meetings
Immediate de-brief after case
Understanding of grievance procedures
aim to avoid this by the above measures

16. Benefits of a Team conference
Education
Encourages discussion within the MDT to address issues in a non clinical environment
Helps to abolish the “Blame Culture”
Raises awareness of wider aspects of patient safety
Raises the question “Could we do better?”

17. Pre-operative checklist
What are the issues in the film ?
Discuss as a team how the pre-operative checklist is used in your department.
The following discussion points may be useful

18. Pre-operative checklist- discussion points
Issues
No radiology checklist or brief done !
Coagulation status
wrong patient, same name
Stock control
only one stent
Ultrasound machine not available
borrowed by Obstetrics

19. Pre- op checklist- Best practice
Checklist/brief/pause for each case
Audit practice of this
Stock control management
responsibility and process clear
barcode system – Tesco, Asda etc
Emergency equipment bag “to go “
e.g. PPH off main site

20. Post-operative care
The film demonstrates a number of possible issues with post-operative care ?
Discuss as a group how your team provides post- operative care. What issues does the film raise?
The following discussion points may be useful

21. Post-operative care
How are aftercare instructions delivered to the ward?
Are written instructions given for each case?
Are thresholds for intervention identified- eg if BP<100 then seek medical advice
Are the common complications of the procedure known to the ward?
How might improvements be made in aftercare instructions for your patient groups?

22. Post- Operative Care- Best practice
Written instructions in the case notes
Pre-printed version for common procedures
Is patient going back to most appropriate ward
Explicit instructions needed
e.g. can care of the elderly ward manage the groin
Are ward team aware of clinical situation
Has possibility of HDU / ITU been considered

23. 24/7 services
The film shows difficulty in contacting an Interventional Radiologist out of hours
Consider how out of hours provision is provided in your unit
The following specific questions may be useful

24. 24/7 services- discussion
Does your unit provide robust 24/7 IR services?
Is there any variation in services OOH?
Do you have suitable nurse and radiographer cover?
If you can’t provide some elements of OOH cover do you have arrangements with a neighbouring centre?

25. 24/7 services - Best practice
24/7 cover for all acute sites
Interventional radiologist (s),Nurse (s), Radiographer
Ensure staffing levels (safety) maintained at night
If not possible make arrangements for network cover from adjacent centre(s)
Has possibility of HDU / ITU been considered

26. Morbidity and Mortality Meetings
Although not a theme of the film we hope you agree cases such as this should be discussed at a regular “M & M “ meeting.

27. M&M Meetings- Discussion
Does your unit hold regular M&M meetings?
Are all staff groups invited and do they attend?
How do you record results from the meeting?
Are the results and actions of the meeting reviewed?

28. Morbidity and Mortality Meetings
Suggested minimum standards
Regular meeting schedule
Record of attendance
Structured format
Structured record and actions: consider using the methods in the references
Regular 6-12 month review of previous meetings

29. Resources
The following resource list may be useful. We have provided current copies of the documents in a separate folder on this CD when possible. Documents are regularly updated and users are asked to check on line for latest versions.

30. Resources Health Foundation Human Factors and systems
Royal College of Radiologists
Standards for 24 hour Interventional radiology provision. Update 2014
Standards for patient consent particular to radiology, Second edition. Update 2015
NPSA checklist guidance RCR 2009 (2012 and under review)

31. Resources Royal College of Radiologists (Cont)
NPSA RCR checklist RCR 2010 Update 2013
RCR vascular standards 2011 Update 2014
Department of Health/ Nat Imaging Board
Interventional Radiology: Improving Quality and Outcomes for patients 2009
Interventional Radiology: Guidance for Service Delivery 2010

32. Resources NHS Improvement
Towards Best Practice In Interventional Radiology 2012
Morbidity and Mortality

33. The System
Full copies of this film are available to BSIR members via: Copies for other organisations may be obtained from The Health Foundation: