Minnesota Hospital Association



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)

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Figure 2: Location of Wrong Procedure Events (2008-2009)

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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 |Person performing the procedure should lead verbal confirmation |

|image-guidance – procedure site not predetermined |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 |Site marking should occur to include procedure destination site. |

|image-guidance – procedure site is predetermined | |

| |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.

2American 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.”

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.

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