Abstract No. 129 Pilot initiative of tube labeling in interventional radiology as a means to reduce medical errors and improve overall understanding among referring services

Abstract

To evaluate if routine labeling of all drains placed in interventional radiology (IR) reduces medical errors, improves accuracy of daily charting, and improves overall understanding regarding the drain’s location and purpose An anonymous 10-question survey was sent to intensive care unit (ICU) staff who manages IR drains and tubes at our single institution. These questions aimed to assess general understanding of the tubes function and location, accuracy of tube output documentation, occurrence of medical errors due to tube mismanagement, and effectiveness of tube labeling in reducing medical errors. Survey options ranged from strongly disagree, disagree, neutral, agree, and strongly agree. Each question had a weighted average score of 1 (strongly disagree) to 5 (strongly agree). Our survey received 81 responses, including 5 attending providers, 7 advanced practice providers, 68 nurses, and 1 other. Prior to the tube labeling initiative, 27.5% (22/80) disagreed or strongly disagreed with having a good understanding of where the tube was located internally. Following the labeling initiative, only 4.9% (4/81) had that same response with a mean weighted average increase of 19.3% from 3.36 to 4.01. 57.5% (46/80) of respondents reports improved accuracy in recording output in the medical records, with weighted average 3.65. Before the initiative, 27.2% (22/81) reported having knowledge of medical errors related to a tube. However, after the labeling initiative, only 14.8% (12/81) reported knowledge of medical errors related to drains/tubes. 77.8% (63/81) of people either agreed or strongly agreed that labeling significantly reduced the risk of misidentification when more than one tube was present, with weighted average 4.06. Lastly, 72.8% (59/81) believe tube labeling has improved clinical practice and should be continued, with weighted average 4.00. The tube labeling initiative at our institution improved overall understanding of the location of the tube, reducing both misidentification of the tube and medical errors related to the tube. The overall consensus was that tube labeling has improved clinical practice and should be continued moving forward. As a result of this pilot program, a hospital wide policy of tube labeling has been adopted in our institution.