Checklists for image-guided interventions: a systematic review

Abstract

Objectives:

Safety checklists have improved safety in patients undergoing surgery. Checklists have been designed specifically for use in image-guided interventions. This systematic review aimed to identify checklists designed for use in radiological interventions and to evaluate their efficacy for improving patient safety. Secondary aims were to evaluate attitudes toward checklists and barriers to their use.

Methods:

OVID, MEDLINE, CENTRAL and CINAHL were searched using terms for “interventional radiology” and “checklist”. Studies were included if they described pre-procedural checklist use in vascular/body interventional radiology (IR), paediatric IR or interventional neuro-radiology (INR). Data on checklist design, implementation and outcomes were extracted.

Results:

Sixteen studies were included. Most studies (n = 14, 87.5%) focused on body IR. Two studies (12.5%) measured perioperative outcome after checklist implementation, but both had important limitations. Checklist use varied between 54 and 100% and completion of items on the checklists varied between 28 and 100%. Several barriers to checklist use were identified, including a lack of leadership and education and cultural challenges unique to radiology.

Conclusions:

We found few reports of the use of checklists in image-guided interventions. Approaches to checklist implementation varied, and several barriers to their use were identified. Evaluation has been limited. There seems to be considerable potential to improve the effective use of checklists in radiological procedures.

Advances in knowledge:

There are few reports of the use of checklists in radiological interventions, those identified reported significant barriers to the effective use of checklists.

Introduction

Nearly one out of every ten patients admitted to an acute care hospital will experience an adverse event.¹ Between half and two-thirds of these adverse events are related to invasive procedures, such as surgery, endoscopy or image-guided interventions.² Data suggest that at least half of all adverse events are preventable.^2,3

Interventional radiology (IR), interventional neuro-radiology (INR) and paediatric IR are rapidly developing, invasive disciplines. Since IR gained subspecialty status in the UK in 2010, the number of IR procedures performed has increased by 50%.⁴ The incidence of complications in radiological interventions is typically lower than after surgery overall. However, complications still occur, and these may have a significant impact on patients’ recovery and quality of life.^5–8

Complications in surgery reflect the inherent risk of invasive procedures, the complexity of the interventions, the different natures of the specialties involved and the presence of multiple patient transfer moments.^9,10 In image-guided interventions, there are additional factors that may contribute to adverse events. These include the positioning of the patient relative to the imaging field and the use of intraprocedural imaging to determine the site of the procedure.¹¹ Image-guided interventions are becoming increasingly complex and procedures relying on new technology have a higher proportion of equipment-related errors.¹² Patients undergoing these interventions may have only been briefly evaluated by a radiologist prior to the procedure (or not at all). Patients are typically sent back to the ward post-procedure, where referring clinicians may not have an in-depth understanding of the procedure or potential late procedural complications.¹³

Safety checklists are well established in the aviation industry and other high-risk industries. In 2009, the World Health Organization introduced a safety checklist for surgery. Introduction of this checklist in eight centres around the world was associated with a substantial reduction in the rates of complications and mortality after surgery.¹⁴ The results of subsequent studies have been variable, but there is at least a strong consensus that this checklist, if introduced and used appropriately, does contribute to improving patient safety.^15–18 Several other checklists have been shown to reduce surgical complications and to improve team work and communication in the operating theatre.^19–21

A number of checklists have been adapted or developed for use during radiological interventions.^11,22 These are increasingly recognised by governing bodies such as the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR) as an important means for improving patient safety.^13,23 However, no systematic review has evaluated the experience with checklist use in image-guided interventions.

In the present study, we have undertaken a systematic review to summarise experience with checklists during radiological interventions. Primary aims were to understand checklist construction (selection of items and domains) and development, and to evaluate their efficacy for improving patient safety. Secondary aims were to evaluate attitudes toward checklists and barriers to their use.

Methods and materials

Data sources and search strategy

The study protocol is available on Open Science Forum (https://osf.io/2aqf8). OVID Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled trials were searched from database inception until April first 2020, using a combination of medical subject headings and key words related to checklists and IR. No restrictions were used. The full search string is provided in Supplementary Table 1.

We focussed on studies which examined the use of pre-procedural safety checklists for use in general (body or vascular) IR, paediatric IR and interventional neuro-radiology (INR). Studies were eligible for inclusion if they described any aspect of the development, validation or evaluation of a safety checklist, examined compliance with checklist use or assessed attitudes toward checklist use during radiological interventions. Studies were included regardless of study type, but conference abstracts were excluded.

Studies describing checklists used for cardiac catheterisation or central venous access were excluded, as these procedures are not typically performed by radiologists. Studies examining the use of safety checklists for managing complications arising during radiological procedures were also excluded.

Data extraction

The titles and abstracts of all identified papers were screened by two reviewers (HA, SM) using Endnote X9. If there was concern about an article’s eligibility, the full text was evaluated. All identified full texts were reviewed independently by two reviewers (HA, SM), and data extracted into an electronic spreadsheet using Microsoft Excel. Discrepancies were resolved by discussion between the two reviewers.

Data were collected in the following categories: study details, checklist components, checklist development, checklist validation, checklist compliance and attitudes toward checklists. Data were reported in accordance with the PRISMA guidelines.²⁴

Quality assessment and planned analysis

No formal quality assessment was performed, due to significant heterogeneity in the design of included studies and a paucity of eligible observational studies

Results

Search results

We identified 818 publications, which were narrowed to 16 studies after excluding duplicates and screening abstracts and full texts (Figure 1). A summary of all included studies is provided in Table 1.

Figure 1.

PRISMA diagram demonstrating study selection.²⁴

Table 1.

Summary of included studies

Author	Title:	Study design	Study aim	Checklist name(s):
Ariyanayagam et al25	UK national audit of safety checks for radiology interventions	Survey	To re-audit the use of safety checklists in radiology departments in NHS departments throughout the UK.	Modified WHO (74%) Local (22%) CIRSE (1%)
Athreya et al26	Patient safety in interventional radiological procedures: safety checklists and protocols	Discussion	To introduce our implementation of our own safety checklist in IR at our institution.	IRPaSS
Corso et al27	Use of “Time-Out” checklist in interventional radiology procedures as a tool to enhance patient safety	Retrospective cohort	To evaluate the feasibility and effectiveness of adopting a safety checklist in the angiography suite during IR procedures to enhance patient safety.	‘Time Out’
Dommaraju et al28	Impact of Pre-procedure Time-Out Checklist for Computed Tomography-Guided Procedures on Workflow and Patient Safety	Mixed methods (Observational, survey)	To assess the impact of pre-procedural time-out on workflow and patient safety in computed tomography–guided procedures.	N/S
Fargen et al22	Enhanced staff communication and reduced near-miss errors with a neuro-interventional procedural checklist	Survey (Before/after)	To improve communication and reduce adverse events during neuro-interventional procedures by implementation of a procedural checklist developed from concepts derived from the WHO surgical checklist, specific for the unique demands of the neuro-interventional suite.	Endovascular Safety Checklist
Knight et al29	The evolution of universal protocol in interventional radiology	Discussion	To describe our clinical experience on developing a safe and effective means of verifying procedural site and implementing Universal Protocol in IR.	Universal Protocol
Koetser et al11	A checklist to improve patient safety in interventional radiology	Mixed methods (Observational, interviews)	To develop a specific RADiological Patient Safety System (RADPASS) checklist for IR and to assess the effect of this checklist on health care processes of radiological interventions.	RADPASS
Lee et al13	Patient safety in interventional radiology: a CIRSE IR checklist	Discussion	To produce a checklist for IR.	CIRSE IR Patient Safety Checklist
Munn et al30	Mixed methods study on the use of and attitudes towards safety checklists in interventional radiology	Mixed methods (Retrospective audit, focus groups)	To evaluate how safety checklists are used and completed in radiology departments within Australian hospitals.	N/S (Multiple)
Puttick et al31	Barriers to a safety checklist and methods to improve usage of the WHO safety checklist in interventional radiology	Mixed methods (Retrospective audit, focus groups)	To first assess uptake of the modified safety checklist for IR, identify obstacles to using the safety checklist, and then apply changes to local policy to reach maximum compliance.	Modified WHO
Rafiei et al23	Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health Committee	Discussion	N/S	SIR Pre-Procedure Patient Safety Checklist
Ross et al32	Highly reliable procedural teams: the journey to spread the universal protocol in diagnostic imaging	Survey	To adapt previous work on Universal Protocol implementation to improve patient safety in IR and mammography procedures.	‘Time Out’
Sidhu et al33	Image Gently, Step Lightly: promoting radiation safety in paediatric interventional radiology	Discussion	To educate the health care team and the public about reduction of radiation doses during paediatric IR procedures, thereby promoting radiation safety.	Step Lightly Checklist
Singhal et al34	Role of a checklist to improve patient safety in interventional radiology	Discussion	To assess the importance and benefits associated with the use of a well-formulated checklist while performing the various minimally invasive image-guided procedures.	N/S
Uppot et al35	A Verbal Electronic Checklist for Timeouts Linked to the Electronic Health Record	Mixed methods (Observational, survey)	Measure compliance, efficiency, and accuracy of information with checklists, both traditional (paper-based) and electronic (CADI)	N/S
Wong et al36	Impact and Culture Change After the Implementation of a Pre-procedural Checklist in an Interventional Radiology Department	Mixed methods (Retrospective audit, survey)	To evaluate the acceptance and culture change after the implementation of a pre-procedural checklist in the IR suite.	N/S

Most studies (n = 14, 87.5%) described checklist use for body/vascular IR. A single study described checklist development for each of paediatric IR and INR.^22,33 Three checklists were developed and endorsed by regulatory bodies (Figures 2–4).

Figure 2.

CIRSE IR Checklist.¹³

Figure 3.

RCR checklist.³⁷

Figure 4.

SIR pre-procedure checklist.²³

Study design

The studies included in this review had important limitations in their design (Table 1). Six studies (37.5%) utilised mixed methods design and three surveys (18.8%) were included. Six papers (37.5%) described checklist design or implementation but did not report any data related to checklist use.

No randomised controlled trials were identified. No formal quality assessment was performed, owing to heterogeneity in study design and a lack of observational studies.

Checklist items and domains

Checklist items and domains are shown in Table 2. The number of domains varied from 0 to 6, but most checklists (n = 7, 43.8%) had three domains; these typically corresponded to the “sign-in”, “time-out” and “sign-out” described in the WHO SSC. The number of checklist items ranged from 4 to 40 (mode = 20, 22). There was some variation in item selection (Supplementary Table 2).

Table 2.

Summary of items/components of checklists

Author	Checklist name	Subspecialty (body IR, paediatric IR, INR)	Number of items	Number of domains	Domains
Ariyanayagam et al25	WHO surgical safety checklist for radiological interventions37, a	Body	28	3	Sign in Time out Sign out
Athreya et al26	IRPaSS	Body	22	3	Patient information Pre-procedure Procedure-related events
Corso et al27	“Time Out”	Body	20	3	Sign in Time out Sign out
Dommaraju et al28	N/S	Body	At least 12b	0	N/A
Fargen et al22	Endovascular Safety Checklist	INR	20	3	Before induction of anaesthesia Before obtaining access Before patient leaves IR suite
Knight et al29	Universal Protocol	Body	9	0	N/A
Koetser et al11	RADPASS	Body	27	3	Planning and preparation Before procedure After procedure
Lee et al13	CIRSE	Body	32	3	Procedure planning Sign in Sign out
Munn et al30	N/S (Multiple)	Body	Between 4–20 in “Time Out”	N/S	N/A
Puttick et al31	Modified WHO	Body	24	3	Procedure planning Sign in Sign out
Rafiei et al23	SIR Pre-Procedure Patient Safety Checklist	Body	31	0	N/A
Ross et al32	“Time Out”	Body	40	6	Radiologist Technologist Scrub tech Registered nurse Patient Sign out/debriefing
Sidhu et al33	Step Lightly Checklist	Paediatric IR	19	0	N/A
Singhal et al34	N/S	Body	22	3	Pre-procedure Procedure Post-procedure
Uppot et al35	N/S	Body	At least 7b	0	N/A
Wong et al36	N/S	Body	16	2	Briefing Debrief

^aMultiple checklists. The most commonly used checklist (RCR/NPSA modified WHO checklist) was analysed.³⁷

^bComplete checklist not provided. The number of checklist items described or audited in each study is provided.

Checklist design

Checklist design or item selection were described in 11 (68.8%) studies (Table 3). There was significant variation in the way these checklists had been designed or adapted for use within interventional theatre. In most studies (n = 9, 56.3%), the checklist was adapted from established checklists or safety guidelines. Five checklists (31.3%) were adapted from the WHO checklist and three (18.8%) were designed using the Universal Protocol.³⁸ Five studies (31.3%) conducted a literature review to guide item selection and seven (43.8%) consulted an expert

Table 3.

Checklist design and item selection

Author	Overview of checklist design	Study setting/population	Item selection
			Literature review (Y/N)	Standards or guidelines (Y/N)	Expert panel (Y/N)	Patient consultation (Y/N)
Athreya et al26	Adapted from the WHO Surgical Safety Checklist	Single-centre	N	Y (WHO)	N	N
Corso et al27	Derived from the WHO England version for radiological intervention and CIRSE	Single-centre, all patients undergoing IR procedures	Y	Y (WHO, CIRSE)	Y	N
Fargen et al22	Using the WHO specific surgical checklist as foundation	Single centre, neuro-interventional procedures	N	Y (WHO)	N	N
Knight et al29	Revision of Universal Protocol	Single centre	Y	Y (Universal Protocol)	Y	N
Koetser et al11	Based on SURPASS	Single centre, IR procedures frequently performed (vascular, non-vascular, elective/semi-elective)	Y	Y (SURPASS)	Y	N
Lee et al13	Modified from RADPASS and WHO surgical checklist	Four centres	N	Y (WHO, RADPASS)	Y	N
Puttick et al31	Modified from WHO checklist specific to IR	Single centre, all patients who underwent an IR procedure in the interventional suite	N	Y (WHO/RCR)	N	N
Rafiei et al23	N/S	N/A	Y	Y (Universal Protocol)	Y	N
Ross et al32	N/S	Single centre, interventional radiology and mammography	Y	Y (Universal Protocol)	Y	N
Sidhu et al33	N/S	N/A	N	N	Y	N
Wong et al36	Based on surgical checklist, developed with input of an interventional radiologist, vascular surgeon, IR nurse, IR technologist and vascular trainee.	Three centres, consecutive IR procedures	N	N	Y	N

panel during checklist development. Despite the current focus on co-design and patient-centred care, no study described patient consultation during checklist development.³⁹

Outcome measures after checklist implementation

Two studies (12.5%) measured perioperative outcome after checklist implementation (Table 4). Corso et al²⁷ developed a 20 item ‘Time-Out’ checklist (derived from the CIRSE checklist) and implemented this in the angiography suite (Figure 5). No adverse events were reported during the first year of checklist use, compared to four adverse events the previous year. However, the number of procedures performed during this two-year period was not reported and the statistical significance of the result was not tested.

Table 4.

Outcomes of checklist implementation

Author/citation	Total number of procedures	Outcome measures	Process measures	Evidence of harm
Corso et al27	213	Y - no adverse events related to IR procedures reported during the first year of checklist implementation.	N/S	N/S
Dommaraju et al28	100	N/S	Y – safety issues identified in 18% of cases, postponement in 1% of cases, procedural delay greater than 3 min in 3% of cases	N/S
Fargen et al22	131	Y - reduced adverse events from 35.2 to 10.0%	Y – quality of communication improved	N/S
Koetser et al11	195	N/S	Y – process deviations decreased from 24 to 5%. Postponements and cancellations decreased from 10 to 0%.	N/S

Figure 5.

Time-out checklist.²⁷

Fargen et al. developed a 20 item Endovascular Safety Checklist (based on the WHO surgical safety checklist) and implemented this in their INR department (Figure 6).²² A before-and-after survey was conducted to assess the impact of the checklist on patient safety. Seventy-one procedures were performed during the month prior to checklist implementation, and 60 procedures were performed during the month after institution of the checklist. Staff members were surveyed regarding near-miss adverse events. The total number of reported events was reduced from 35.2 to 10.0%, and this difference was statistically significant (p = 0.001). However, the analysed events included several process measures, such as wrong items being opened at the beginning of the procedure, and so-called “near misses” as well as outcome measures.

Figure 6.

Endovascular Safety Checklist.²²

Process measures after checklist implementation

Two studies (12.5%) measured process measures after checklist implementation (Table 4). Dommaraju et al. prospectively assessed the impact of a checklist on patient safety during 100 computed-tomography (CT) guided procedures.²⁸ The checklist identified process issues in 18% of cases. Procedural delay and postponement were caused in 3 and 1% of cases, respectively. Koetser et al’s 27-item RADPASS checklist was tested in 195 body IR procedures.

Implementation of the checklist was associated with a reduction in process deviations from 24 to 5% (Figure 7).¹¹ Procedural postponements and cancellations decreased from 10 to 0% after checklist implementation.

Figure 7.

RADPASS checklist.¹¹

No studies reported evidence of harm after checklist implementation.

Attitudes toward checklists

Ten studies (62.5%) reported attitudes of healthcare providers toward checklist use during image-guided interventions (Table 5). Checklists were generally perceived as important tools to improve teamwork, communication and patient safety. In Dommaraju et al’s survey of 132 healthcare providers, more than 90% felt the checklist helped identify errors and improved teamwork and communication.²⁸ Similarly, Fargen et al. found that more than 95% of healthcare professionals felt the INR checklist improved communication and safety.²²

Table 5.

Attitudes toward and barriers to checklist use

Author/citation	Attitudes toward checklist	Barriers to checklist implementation
Ariyanayagam et al25	“Generally perceived as valuable” “View that important safety checks depend on the particular procedure”	“Inadequate time to complete checklists within appointment lots” “Perception that … checklists were not appropriate for minor procedures” “Resources to scan paper checklists onto an information system” “A feeling it is superfluous to patient care” “Different levels of commitment by individuals or staff groups” “Checklist used is too lengthy and not all data are necessary”
Corso et al27	Satisfaction and ease of use were overall rated acceptable 73.3% considered the SC useful 73.4% considered the SC safer for the patient 73.2% considered the SC ‘not burdened by excessive or unnecessary information’ 86.6% did not consider the SC redundant	46.6% considered the checklist a further bureaucratic burden
Dommaraju et al28	96% believe improves teamwork 98% believe enhances communication 93% believe helps to identify and resolve problems and ambiguities 90% believe provides an educational opportunity for trainees 99% believe that checklist should be routinely performed	93% felt it causes trivial delay to the procedure workflow
Fargen et al22	‘Uniformly positive’ 95% of individuals indicated that the checklist should be continued 100% believed the checklist improved communication 95.2% believed the checklist made performing procedures in IR safer for patients and prevented medical errors and/or near misses	4.8% felt the checklist was too long and/or burdensome
Knight et al29	“All members began to participate and buy into the process”	‘Resistance occurred around the requirement of site marking and the time-out process’
Koetser et al11	100% agreed the checklist improved safety 90.9% considered the checklist user friendly 81.8% would rather work with the checklist than without it 63.6% agreed that the checklist improved efficiency	N/S
Munn et al30	‘Despite some of the challenges faced, it was the view of most of the participants that there was certainly a need for the checklist process’	“Cause of frustration that the patient was not involved in the checklist process” “Lack of teamwork involved in the process” “Radiologists lamented that not all items on the checklist were always checked” “Business mentality in radiology, with a focus on speed and throughput, sometimes at the expense of patient care” “Participants spoke of the need for a culture change of radiology with a shift to a team approach” “The importance of having a tailored checklist was stressed repeatedly … did not view positively the use of the WHO checklist” “Length of the checklist” “Lack of understanding of the importance of the checklist” “Lack of education” “Lack of association support”
Puttick et al31	Barriers only	A lack of awareness about the SC. Lack of training in how to complete the SC. Lack of leadership -no team member had been given the role of promoting the SC and collecting and collating the SC. Attitude of staff - some team members felt that the SCs were time consuming and further bureaucracy. Out-of-hours procedures involved staff from outside departments who were not familiar with the SC. Paper copies of the completed SCs were being misplaced.
Ross et al32	Perception of the safety climate improved 25% Perception of teamwork climate decreased 5.4%	N/S
Uppot et al35	Perceived accuracy of paper timeout varied from 3.48 to 4.25 out of 5, depending on item.	N/S
Wong et al36	“Survey showed favourable attitudes towards the checklist” Most staff agreed that the checklist served as an important communication tool (mean 4.4/5) and was in the patient’s best interests (mean, 4.7/5). Checklist appreciated as a tool to improve collaboration among staff (mean, 4.1/5) and reduce medical errors (mean, 4.4/5) Generally regarded as having little effect on time delay between cases (mean 1.8/5)	N/S

Barriers to checklist use were described in seven studies (43.8%) (Table 5). Munn et al³⁰ identified barriers towards checklist use using focus groups of Australian radiologists. These included checklist length, lack of leadership, education and poor awareness of the importance of checklists. The culture of radiology, with a focus on efficiency and throughput, was also identified as an important barrier. Puttick et al³¹ conducted interviews with radiologists and radiographers and identified similar barriers, including staff attitude and a lack of leadership, training and awareness. Similar barriers were described in the other five studies.

Compliance with checklists

Seven studies (43.8%) examined compliance with checklists and found substantial variation in both checklist use and item completion when used (Table 6). The largest study, was a national audit of UK safety checks conducted by Ariyanayagam et al²⁵. Out of 109 UK trusts, 48% used safety checklists for all interventions, a further half used checklists for some procedures, and 2% did not use a checklist. Checklist use varied significantly by procedure.

Table 6.

Checklist Use and Completion

Author/citation	Checklist use	Checklist completion
Ariyanayagam et al25	48% for all procedures 50% for some procedures 2% do not use checklists	N/S
Corso et al27	89.3% initially, 89.2% at 3 months	64.5% initially, 84.4% at 3 months
Dommaraju et al28	100%	60% (omissions identified in 40% of cases)
Munn et al30	54%	28% (Mean percentage completion items on the checklist was 64%)
Puttick et al31	79% initially, 100% at 3 months	100% (No partially filled checklists)
Uppot et al35	N/S	N/S Compliance with each aspect of time out ranged from 3.1 to 100%
Wong et al36	92, 89 and 74% at the three centres	N/S

Checklist use ranged from 54 to 100%. Checklist completion was also variable, ranging from 28 to 100%. There was substantial variation in the completion of individual checklist items. No study measured the engagement of staff with safety checklists.

Discussion

This systematic review has identified a range of current checklists designed for use during radiological interventions. There were limited data on their acceptance, their impact on practice or their efficacy for improving patient safety. Only two studies reported outcomes after checklist implementation and both had important limitations.^22,27 Fargen et al²² demonstrated a reduction in adverse events (or near misses) after checklist implementation during INR procedures. However, the primary outcome measure was a combination of process and outcome measures and included “near misses”, and the independence of each adverse event in relation to individual patients was unclear. The safety outcomes reported in this study were assessed using responses from surveys of staff. Corso et al²⁷ also reported a reduction in complications during body IR procedures but had too few events to allow any conclusions to be drawn.

We identified substantial variation in the approach to modification and implementation of surgical checklists for use in interventional theatre. The WHO Surgical Safety Checklist is arguably more than just a checklist – it is also a tool designed to improve communication and teamwork within the operating room. As indicated, it follows that the benefits of its use during surgery depends not just on whether all items are checked, but on the way in which it is used, and in particular on the extent to which all members of the team engage positively in this process.^40,41 It is reasonable to assume that similar considerations would apply to checklist use during image-guided interventions. It follows that introduction of a procedural checklist to a radiology department should be well managed and followed by evaluation, which should include an assessment of how well the checklist is being used.

Several studies in this review measured compliance and completion of safety checklists. Checklist use was as low as 54% in some studies and checklist completion ranged from 28 to 100%. Similar findings have been described in the surgical literature.⁴² However, no study provided a measure for the engagement of interventional teams with checklists. The WHOBARS is a tool for this purpose that is agnostic to the actual items on a checklist, and so could be used in the IR context, at least for those checklists that are based on the WHO Safe Surgery Checklist.⁴³ It is designed to provide clear guidance on aspects of checklist use thought important in the original development of the WHO Safe Surgery Checklist. We would encourage interventional teams to regularly audit their checklist compliance and to measure the engagement of staff with safety checklists.

This review has identified several barriers to checklist use in image-guided intervention, including checklist length and staff attitude as well as a lack of leadership, education and awareness of the importance of safety checks. Similar barriers have been described in the surgical literature.⁴⁴ Possible interventions relate to education about the rationale for checklist use, highlighting values that align the IR suite with the checklist, and directly addressing staff concerns.⁴⁵ The use of a multidisciplinary team to lead the checklist should be encouraged, and staff should be empowered to speak up if there are safety concerns.⁴⁵

Our review also identified barriers to checklist use which were specific to radiological procedures. These included concerns about item selection and a lack of applicability of surgical safety checklists to image-guided procedures.³⁰ These concerns could be minimised by the development of local checklists, with involvement from radiologists, as suggested by the RCR, CIRSE and SIR. Use of modified checklists is typically encouraged, to reflect the specific needs of a particular department or hospital and to fit local context. However, use of a standardised checklist may help with consistency of approach when staff change hospitals, and allow comparisons between different centres. The choice between a standardised versus modified checklist will ultimately depend upon the specific department in which the checklist will be used.

Focus groups also raised concern about the culture of radiology, as a specialty which is focussed on efficiency and workflow, which may be valued above patient safety.³⁰ This suggests a culture change may be necessary for procedural checklists to be successfully implemented in radiology.

Both IR and INR are increasingly reliant on complex imaging to guide interventions. As the complexity and length of procedures increases, so too does the risk of radiation exposure.⁴⁶ This carries significant risk of harm to patient and staff, particularly in paediatric IR. Despite this, only four checklists were identified which included items related to radiation safety.^22,23,33,37 Checklist items relating to radiation safety would be expected to reduce radiation exposure and we would encourage their inclusion in local checklists.

Safety checklists are designed to reduce complications by preventing human errors. An understanding of the incidence and nature of complications is critical to the development of an effective safety checklist. Medical errors are poorly characterised in the IR literature. A comprehensive systematic review by Rawf et al⁴⁷ identified only three studies examining rates of medical error in IR. These studies suggested that most errors in IR are non-technical and that 55 to 84% are preventable. The body of evidence is limited, particularly when compared to the surgical literature, and we would encourage further research to characterise the nature of error during radiological interventions. The information from this research would be invaluable in guiding the design of future checklists.

There are several weaknesses to this study. Studies were included regardless of study type, and thus several technical notes and letters to the editor were evaluated. There was significant variation in study design, and few studies presented observational data regarding checklist use. The studies which presented observational data were typically small and retrospective. There may be checklists that are in use but have not been reported in the literature. We also excluded checklists for central venous access and cardiac catheterisation. These procedures are image-guided, but are not necessarily performed by radiologists. Three studies which described checklists designed for use in the event of intra or post-operative complications were also excluded.^48–50 We did not directly compare checklist use between radiological subspecialties (body IR, paediatric IR and INR) because most studies focussed on body/vascular procedures. Strengths include the use of two reviewers and a comprehensive search strategy.

This systematic review has summarised experience with checklist use during radiological interventions. We found a paucity of studies examining the efficacy of checklists for improving patient safety during radiological interventions. This finding justifies further work towards understanding the relationship between checklist use and patient safety in IR. We also found variable compliance and completion of checklists, and a variety of barriers to their use. These findings might be used to modify existing checklists and optimise their use during radiological procedures. We could only find one report of checklist use in paediatric IR and INR. Further work is needed to evaluate checklist use in these subspecialties.

In conclusion, we found few reports of the use of checklists in radiological procedures. The included studies varied significantly in design and evaluation has been limited. There seems to be considerable potential to improve the effective use of checklists in IR. Future studies should aim to demonstrate the effectiveness of checklists in IR, using robust study design.