2021_Book_TextbookOfPatientSafetyAndClin

228
cation rates there substantially no data about
other quality measures. For example, we know
that the most common AE of thoracentesis is
pneumothorax occurring in up to 39% of
patients [63] (10–50% of them requiring tube
thoracostomy), but we know very few about
success rate, adequacy of the diagnostic specimens
obtained, wait time, accuracy and completeness
of clinical documentation, and patient
satisfaction of thoracentesis and other procedures
performed bedside on IM inpatients. On
such premises, at General Hospital of Toronto
an audit on procedural quality of interventional
procedures was conducted in General Internal
Medicine [64].
Over a 2-week period, 19 procedures (4 thoracenteses,
6 paracenteses, 8 lumbar punctures,
and 1 arthrocentesis) were attempted, of which
14 at the bedside and 5 by interventional radiology.
Only 7 (50%) of the bedside procedures
were successful. The most common reason for
failure was inability to aspirate fluid. Less than
25% of bedside procedures were done on ultrasound
guidance. The majority were carried out
by students and residents, but only 7 (50%) were
documented as supervised. None of the operators
used procedural timeouts or checklists. Over
50% of the bedside procedures were performed
on evenings or weekends with less success (44%
vs 60%), suggesting that procedures should be
done during the daytime, when there is more
availability of support and supervision. The
quality of documentation was also suboptimal.
Less than 50% of the procedures documented
that the specific risks of the procedure were
explained to the patient, how much local anesthetic
was used, or what was the side (i.e., left or
right). Communication with general practitioner
was poor as well: only 66% of the discharge
summaries included the date of the procedure
and only 75% the results of the procedure [64].
Another study on lumbar puncture investigating
for headache on an acute medical admission unit
reported that documentation of position and
cerebrospinal fluid (CSF) opening pressure was
poor (42% and 32%, respectively) even if essential,
and only 32% had paired serum glucose
measured [65].
Procedure-related errors are due to procedural
and system factors [66], such as lack of clinician
comfort with performing the procedure, inadequate
supplies, insufficient time, or patient factors
such as body habitus or characteristics of the
fluid collection such as loculation. Once more,
there is good evidence that clinicians are performing
fewer bedside procedures and are less
confident in their bedside procedural skills [67,
68]. So, interventions able to improve safety turn
out to be: ultrasound guidance, use of a procedurespecific
checklist, patient identification policy
and pre-procedural briefing about patient characteristics
and risk factors, routine review of
physician- specific procedural outcomes, periodic
evaluation of operators’ competences, training
through simulation, supervision until competence
is consistently demonstrated and creation
of dedicated teams [69–71], periodic assessment
of procedural quality including informed consent
obtained, waiting time, use of procedural timeout
and sonography if needed, number of attempts,
success and complication rate, diagnostic sampling
quality, completeness of diagnostic tests,
avoidance of waste, documentation completeness,
legibility (for handwritten notes) and accuracy,
wrong side errors, need for repeat procedure
and patient satisfaction [64].
17.2.5 Communication Errors
M. L. Regina et al.
Inter-professional communication in IM wards is
complex, owing to the variety of patients’ population
with changing clinical conditions and constant
turnover, and multiple providers’ alternation
[72]. A lot of information is exchanged every day
among care providers in IM, through face-to-face
(ward rounds, handover, briefing), synchronous
(telephone or page), or asynchronous ways (clinical
chart, text messages, emails, written handoff).
Anyway, there are only few empirical studies that
explore inter-professional communication in IM
[73], even if effective inter-professional communication
in such information-intensive environment
is critical to achieve a safe and timely care.
The most common communication strategies
in IM include: handover, ward rounds, clinical