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A patient safety checklist for the cardiac catheterisation laboratory
  1. T J Cahill1,
  2. S C Clarke2,
  3. I A Simpson3,
  4. R H Stables4
  1. 1Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
  2. 2Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
  3. 3Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  4. 4Institute of Cardiovascular Medicine and Science, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
  1. Correspondence to Dr Thomas J Cahill, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK; thomas.cahill{at}

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The avoidable risk of patient harm from a complication in the cardiac catheterisation laboratory (cath lab) remains too high. The causes are often multifactorial, reflecting the complex interaction between operator, patient, team and procedure. Adverse events are typically preceded by missed opportunities for recognition and prevention by members of the team. Safety in the airline industry has been revolutionised by understanding the importance of human factors, encompassing team leadership, structured communication and resource management. Addressing the role of human factors in the cath lab has the potential to improve safety and clinical outcomes.

Adverse events affect approximately 10% of acute inpatients.1 Repeated analyses indicate that errors are rarely a failure of technical ability, but occur due to breakdown of teamwork and communication. In the surgical operating theatre, there is a relationship between the frequency of communication errors and the incidence of adverse events.2 Safety checklists and team briefing are proven interventions to support communication in safety-critical situations.

Safety checklists: from aviation to healthcare

The safety checklist was developed after the Boeing Model 299 crashed on its maiden test flight in 1935, due to a simple pilot error. It acts as a safeguard against lapses in concentration, a reminder to actively review safety-critical steps. The first systematic study of a healthcare checklist was performed in 2004: implementation of a care bundle which included a checklist dramatically reduced the rate of central line infection in the intensive care unit.3

WHO's Surgical Safety Checklist (SSC) was a landmark checklist in medicine.4 Introduction of the checklist was associated with a reduction in surgical complications and mortality.5 The UK National Patient Safety Agency mandated use of the SSC for patients undergoing a surgical procedure from 2009 onwards, and a number of specialties such as interventional radiology have since produced adapted versions.

The reason for the efficacy …

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  • Contributors RHS suggested the concept of a checklist for interventional cardiology. TJC and RHS designed the checklist and conducted the pilot evaluations. TJC wrote the original draft of the manuscript, which was revised by SCC, IAS and RHS.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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