Image Consent Forms by kbi18197


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									Ensuring Patient Safety
     In Radiology

               June 2007 John Thomas
      Verification Process - STEP 1
Radiology ‘Request/Consent Form’
 Clear & legible
 Provision of mandatory information
    Patient Details(preferably Addressograph label)
        Full Name/ DOB/ MRN
    Ward & Date Written
    Procedure Requested (including side)
    Relevant Clinical History
    Referring Doctor Contact Details
        Printed Name/ Signature/ Page No.
 Incomplete/Incorrect Request Form – Immediately notify
Referrer or Ward Nurse
     Verification Process – STEP 2
Correct Patient (Identification)
Scope: All radiology procedures
 Ask the patient
  “What is your FULL NAME?”
  “What is your Date of Birth?”
  “What is the name of the PROCEDURE you are
     having today?”. Also ask SITE/SIDE if required
    Never state patient’s Name/ DOB/ Site & Side
     “Do not tell the patient… the patient tells you”
   E.g. Call “Mr. Brown”, then ask the above questions
   including additional questions related to clinical history
   as outlined on Request Form
        Verification Process - Cont.
Correct Patient (Identification) Cont.
 Inpatients
1. Ask patient to state Full Name/ DOB/ Procedure
2. Check responses against Referral Form & Patient ID Band
   (wrist/ankle) including MRN– MANDATORY
Do Not Proceed if :
   Patient ID Band is absent. Call Ward Nurse to personally ID
    patient and complete Time Out Verification sticker (all
    personnel sign). Complete online IIMS form & document
    into Escort Issues book
   Patient can not verbalise identity. Nurse Escort must verify
    patient identity. Complete Time Out Verification sticker (all
    personnel sign).
       Verification Process - Cont.
 Outpatients
1.Ask patient to state Full Name/ DOB/ Procedure
2.Check responses against Referral Form
Do Not Proceed if :
 Patient can not verbalise identity.
Proceed only after :
 Identity is verified by accompanying relative, family
member, friend or healthcare interpreter.
  Reinforcing the Message
Displayed at all imaging consoles

Have you checked the Patient ID ?
       - Prior to the Procedure -
                               Asked patient their:
                               • Name
                               • DOB
                               • (Procedure)
                               Checked response & MRN
                               against ID Band & Request

         Are you sure !
      Team Time Out – STEP 3
General X-ray
(General, Mobiles, Emergency - Resus, Mammography,
Confirm before procedure
 Correct patient is present (Full Name/DOB/MRN/ID Band)
 Clinical history corresponds with Requested exam
 Correct site & side is being examined
 Correct right & left markers are being used
Perform diagnostic examination (provided no discrepancies exist).
       Team Time Out – STEP 3 Cont.
Interventional (invasive) Radiology
(All invasive procedures covering CT / Ultrasound / Angiography /
Mammography and selective Screening procedures)
In procedure room, with patient present.
Confirm patient ID, request/consent forms, image data all correct.
Site marked by interventional doctor.
Team Leader (usually Nursing staff) calls Time Out immediately
prior to procedure commencement (patient draped) to confirm:
 Verification of patient identity (Full Name/DOB/MRN/ID Band)
 Agreement on the intended procedure
 Verification of correct position i.e level & side
 Verification of the visible marked site
 Availability of correct implants/equipment/medication
TTO discrepancies – DO NOT proceed until resolved (document)
Team Time Out – STEP 4
Post Procedure (all Radiology procedures)
Ensure that:
 Correct details are attached to the image/s
 Patient details & side marker/annotations on post-
processed image/s are correct
 Certified Time Out Verification sticker
     Radiographer/s to complete checklist,
    procedure, date, print name & sign
     scanned to PACS, then
     placed in patient medical notes.
 Time Out Verification sticker
     Scope: All radiology procedures

Patient Identification Verified        
Procedure & Consent Verified           
Correct Site & Side Verified           
Imaging Data Confirmed (priors)        
Implant/Equipment Confirmed            
   RADIOLOGY St George Hospital
Procedure : ……………………………Date: …………….
Team member :………………………………………………
Team member:………………………………………………
Team Leader name:………………………………………..
Team Leader signature:…………………………………..

        General vs. Interventional use
Getting in Right in Radiology
Getting in Right in Radiology
        Staff Related Responsibilities
Patient Transfers
Radiology staff (Front Desk) are required to complete ALL the
front section of the Radiology Patient Transfer Slip:
• Check adequacy of Request Form (completion of mandatory
information fields). Follow Request Form Completion Policy.
• To transcribe procedure & patient details from Request Form to
Patient Transfer Slip.
• Phone Ward Nurse responsible for patient to arrange transfer
    • Your name and department (Radiology)
    • “I have a Request Form for (Patient Name) to have an
    (Radiology procedure)”
Patient Transfers Cont.
The following questions should then be asked:
1. What is the patient MRN?
2. Is the patient ready for their procedure?
3. Do they travel in a bed or wheelchair?
4. Do they require a Nurse Escort?
5. What bed number are they?
6. Do they have electrical equipment on the bed e.g..IMED?
7. Do they need oxygen?
8. Does the Orderly need Personal Protective Equipment?
Patient Transfers Cont.
For all procedures, especially CT & Angiography
1. Has the patient consented or are they able to consent?
2. When was the last time the patient had something to eat?
3.   Does the patient have a cannula?
4.   Is the patient on anticoagulation therapy?

When all necessary information has been established,
  complete front side of Radiology Patient Transfer Slip.
          Radiology Patient Transfer Slip
                              Front Side

Radiology Patient Transfer Slip
 Ward and Bed No.                          Destination  General  CT

      Family name                                        Screening  Angio

       Given name                                        Ultrasound  MRI

              MRN                              Region
      Nurse escort?  Yes  No                 Travel  Chair  Bed
Protective equipment?  Yes  No           Checked by (signature)
Radiology Patient Transfer Slip
When all information fields are completed, patient transfer can
proceed. Radiology Orderly is given slip.
Upon arrival on Ward, the Radiology Orderly must:
• Identify themselves to Ward staff and Department (Radiology)
• State name of patient to be transferred & procedure (as outlined
on accompanying Transfer Slip).
• Consult Ward Nurse (or NUM) responsible for patient and verify
    • patient is ready for transfer?
    • needs a Nurse Escort?
    • requires oxygen &/or electrical equipment?
    • you need to wear PPE?
Radiology Patient Transfer Slip Cont.
Locate patient as directed by Ward Nurse
Radiology Orderly MUST:
• Verify Patient Identification
    • Radiology Orderly to ask patient to state Full Name & Date
    of Birth as outlined on Patient Transfer Slip. Check
    • Check response against ID Band (wrist/ankle). This is
    mandatory. Check MRN against ID Band (Patient is not to be
    transferred without ID Band or correct identification)
• Ensure all Patient Notes & X-rays accompany patient to
Radiology Orderly then completes checklist on rear side of slip
                  Radiology Patient Transfer Slip
                                           Rear Side

Radiology Ph 33565
Emergency Ph 666                      Orderly checklist
Orderly has confirmed all the following:
  All information is recorded  Yes                The patient is ready for transport     Yes    No
                  on the slip?
   The patient’s ID indicates  Yes        Does the patient need oxygen or electrical     Yes    No
          the correct patient?                                          equipment?
      Radiology nursing staff  Yes          Does the patient need a Nurse Escort?        Yes    No
  have been informed of the
  patient’s imminent arrival?
                                               All patient notes are with the patient?    Yes    No

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