Martinsburg VA Medical Center Upgrades Patient Safety with Checklist Time Out Boards
Martinsburg VA Medical Center Upgrades Patient Safety with Checklist Time Out Boards

The Martinsburg VAMC Patient Safety Officer recognized the potential for a problem. “We were concerned about a potential patient safety issue,” said PSO Kent Wagoner. “There wasn't a consistent process for performing a pre-procedure time-out. Our Checklists in use consisted of a variety of methods and inconsistent content. In addition, then VA wanted to be in compliance with the directives 2010-023 and VHA 1039
The Directive 1039 has guidelines to ensure all surgery and invasive procedures in the clinical setting are performed:
  • On the correct patient
  • The correct procedure is performed
  • Performed at the correct side/site
  • And if applicable, that the correct device/implant is used
  • Several other items are included in the policy directive
PSO Wagoner contacted Checklist Board President, Rick Taylor, to upgrade their existing Checklist protocols. The Martinsburg VAMC team had a clear vision of what they wanted to include on their custom designed Checklist Boards. Collaborating with the Checklist Boards team and incorporating content from other checklists, a consistent content and format was developed that could be used throughout the Martinsburg VAMC across several procedural areas. Checklist boards were developed and deployed in the OR, pre-procedure, Endoscopy, ED and other areas.
The Martinsburg VAMC new Checklist Boards were implemented in the following procedure areas:
  1. A Simple Checklist Board for Simple Procedures
  2. A Pre-Procedure/Post-Procedure Checklist Board
  3. Pre-Procedure Checklist for Interventional Radiology
  4. Pre-Procedure Checklist for General Surgery
  5. A 20-item Comprehensive Checklist Board including Fire Risk
  6. A 20-item Comprehensive Checklist Board for Gastroenterology
Now after full implementation, a new culture of patient safety is developing. Comments from the Martinsburg VA staff included: “I can’t imagine not using them.”
As surgical Time-Outs and Checklist Boards become routine for all invasive procedures, the instance of Never Events should decrease and the improvement in patient and staff satisfaction should increase.  

Doug Hall, August 2015

Checklist Board Design: http://www.checklistboards.com/Images_Content/Site1/Files/Designs/VAHealthcareMartinsburg.pdf

For More Designs: http://www.checklistboards.com/products.cfm?Page=Products&Product=VISN%205%20VA%20Capitol%20Health%20Care%20Network&PagePath=0,21
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Hospitals use checklists to reduce errors