How can hospitalists be frontline defenders of procedural patient safety?
What should hospitalists ask themselves before performing any procedure safely?
What are additional considerations for training and supervising trainees? What is the role of simulation?
What is state of the art in procedural competence assessment?
How can hospitalists have an impact on an institutional policy and practice in procedures?
Though traditionally considered a nontechnical role, hospitalists are increasingly performing procedures. In small hospitals without extensive specialty resources, hospitalists are often firstline operators of procedures. Continuing medical education courses on common procedures are being geared toward hospitalists. Procedure services staffed by hospitalists are emerging around the country, leading some hospitalists to call themselves proceduralists. In light of the fact that technical errors are a common cause of inpatient morbidity and mortality, hospitalists are well positioned to improve patient safety.
Before performing any procedure, a hospitalist must ask him- or herself the following questions to reduce potential procedural errors (Table 113-1).
Table 113-1 Preparation |Favorite Table|Download (.pdf)
Table 113-1 Preparation
Is the procedure indicated?
Have I considered any possible contraindications for the procedure?
Have I mentally rehearsed the steps of the procedure?
Have I obtained consent from the patient or the appropriate designee?
Are the coagulation parameters within acceptable limits (as deemed by clinical policies and/or according to the literature)?
Are any imaging studies necessary to confirm the anatomy or the location of the fluid?
Have I performed a preprocedural time-out?
What is the level of contact precautions required for this procedure?
Have I familiarized myself with the kit?
Will I need extra antiseptic?
Will I need extra lidocaine?
Will I need extra collection tubes?
Is a bedside ultrasound available?
Who is available to help in case I need additional materials? How will I contact them?
Have I set up the room in a way that will allow me to access my materials safely?
Have I identified the locations of the sharps container and the trash can?
What will I do with my pager and/or cell phone?
Who is available for backup if I do not succeed?
Which other consultation services can I contact if the procedure cannot be done at the bedside?
Immediate complications—what can I anticipate and how long should I monitor for them?
Delayed complications—what potential problems exist and how will I monitor for them?
Considerations for using interventional radiology even before attempting at the bedside include: distorted anatomy due to prior surgeries (eg, posterior spinal fusion for lumbar punctures), small fluid volumes, previous failed attempts, and a narrow window for tolerating complications (eg, central lines in patients on positive-pressure ventilation).
For the hospitalist working in a teaching hospital, there are additional considerations when supervising an individual trainee performing a procedure. He or she should perform a needs assessment ...