Patient Safety

PV QA 3 - Poster Viewing Q&A 3

TU_28_3089 - Observation Audits of Treatment Safety Checklist Timeouts are Necessary to Improve and Maintain Safe Delivery of Radiation

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Observation Audits of Treatment Safety Checklist Timeouts are Necessary to Improve and Maintain Safe Delivery of Radiation
T. Palmison1, T. Meier1, S. T. Chao2, P. Barrett3, and A. Hill4; 1Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 2Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, 3Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, 4Cleveland Clinic Radiation Oncology Taussig Cancer Institute, Cleveland, OH

Purpose/Objective(s): Safety Checklist timeouts confirming correct patient, site, devices and setup tools are critical for safe delivery of radiation. This academic center is investigating if the implementation of observation audits influence the quality and documentation compliance of safety checklists and will promote a more comprehensive and sustainable timeout.

Materials/Methods: Outcomes from quality meetings focused on incident reduction through new comprehensive timeouts. A treatment room timeout and console timeout are completed prior to beam on. Unannounced audits of timeouts began in October 2017 as a metric for a quality team board. 12 observational audits are performed monthly using a standard checklist to assess the quality of timeouts being performed and include table position, patient marks, positioning devices, therapist engagement, documentation and an infection control audit for hand hygiene. Completed checklists are reviewed to dive deeper into problem areas contributing to lack of quality timeouts. Evaluations and adjustments to the auditing form coincide with a change in therapist behavior and have become a benchmark to maintain the safety of patients, quality of treatments and risk reduction. The safety checklist process is repeated and required for every case, is impactful and is becoming a consistent, sustainable practice. A Safety Checklist Timeout report is run to confirm documentation compliance verifying a timeout was performed.

Results: Results show areas of noncompliance. After 4 months of observations, audits demonstrate complete and quality timeouts are not consistently occurring. Areas of noncompliance include failure to affirm setup instructions, not obtaining patient’s first and last name, no verification of correct site and side, no confirmation of table vertical position, no active engagement in the timeout process and improper hand hygiene. The quality of timeouts has increased as a consequence of auditing. It is believed quality will continue to rise to 100% compliance.
Oct 2017 Nov Dec Jan 2018
Compliance % 54 100 86 100
Observing neglected areas allows for adjustments to be made to the audit form and behavior modification specific to the areas of need. This allows coaching on a standard for increased quality and safety. Results indicate a positive trend towards reduced risk and improved quality. Updated data will be available October 2018 as a result of ongoing audits.

Conclusion: Safety checklist timeouts may be the single most important step in the process towards safe treatment delivery. Auditing the quality of timeouts by observation identifies those areas of opportunity for increased quality of care. The goal is safe delivery of radiation and consistent, sustained documentation compliance behavior.

Author Disclosure: T. Palmison: None. T. Meier: None. S.T. Chao: Honoraria; Varian Medical Systems, Zeiss, Abbvie. Consultant; Abbvie. P. Barrett: None. A. Hill: None.

Send Email for Timothy Meier


Assets

TU_28_3089 - Observation Audits of Treatment Safety Checklist Timeouts are Necessary to Improve and Maintain Safe Delivery of Radiation



Attendees who have favorited this

Please enter your access key

The asset you are trying to access is locked. Please enter your access key to unlock.

Send Email for Observation Audits of Treatment Safety Checklist Timeouts are Necessary to Improve and Maintain Safe Delivery of Radiation