The System: how interventional radiology teams can work together to improve patient safety


The System, a collaborative film by the British Society of Interventional Radiology (BSIR) and the Health Foundation, an independent charity, traces the way in which a combination of factors are shown to converge during a biliary intervention procedure carried out on a patient.

The combination of factors leads to severe morbidity, or death, despite the skills and intentions of a qualified medical team. The main purpose of the film is to address the issue of patient safety. The System was made by a professional filming team (TVC Ltd) and used professional actors and actresses in a real interventional radiology theatre environment. A similar film was made by the Royal College of Surgeons (Engl) recently called The Journey with the same theme resulting in the death of a patient from a cholecystectomy.

Interventional News
spoke to Jon Moss (former secretary of BSIR) and Iain Robertson (current president of BSIR), both from Gartnavel Hospital, Glasgow, UK, about The System.

Moss said, “The BSIR was originally approached as a special interest group of the Royal College of Radiologists. We worked closely with Tony Giddings, a retired vascular surgeon, who produced The Journey and was very supportive. Each individual error in both films is one that actually happened in real life somewhere in the UK but the assembling of all the errors on one patient is fictitious. The film is aimed at healthcare workers at all levels both in the UK and other countries. I see this one being used by interventional radiologists, surgeons and nursing staff especially in theatres and anaesthetics.”

Robertson said “I felt there was also a very clear message from the film about the importance of true team working and respecting the relative roles of team members. The most technically brilliant operator needs a team of colleagues focused on patient safety to deliver a complete safe and successful patient journey. A lesson from the airline industry is that all team members have a “voice” within the team, regardless of their title particularly with respect to safety. An open culture within a team does not happen by accident and requires continuous work. The first report of the BSIR Biliary Registry has highlighted the very significant mortality associated with biliary intervention, and while there are many reasons for this finding, it is appropriate that the film features this particular commonly performed procedure.

The System will be screened at the
British Society of Interventional Radiology (BSIR) annual meeting on 14 November in Bournemouth, UK.

Extract from The System