Pleural Procedure LocSSIP Checklist Documentation Audit
Clinical audit of LocSSIP compliance in pleural procedures. Analyzes documentation rates for consent, site marking, and coagulation checks to improve safety.
Pleural Procedures Documentation Audit
Compliance with the LocSSIP Checklist
Presented to Medical Consultants | April 2026
Background & Context
Understanding the Audit
What is LocSSIP?
Local Safety Standards for Invasive Procedures, an NHS-mandated safety protocol based on NatSSIPs.
Designed to explicitly prevent wrong-site and wrong-procedure clinical errors.
Why Pleural Procedures?
Pleural interventions (aspiration, chest drain, thoracoscopy) carry significant risk: pneumothorax, haemorrhage, infection.
BTS guidelines mandate strictly structured pre, peri, and post-procedure documentation.
Why This Audit?
Ensure our local department meets the current, rigorous NHS safety standards.
Identify critical documentation gaps and subsequently drive sustained clinical improvement.
Audit Objectives & Methodology
Assess compliance with LocSSIP checklist documentation across pleural procedures
Identify specific steps most frequently missed
Compare performance against BTS/NatSSIP standards
Provide actionable recommendations
Retrospective case note review
All pleural procedures performed over a defined audit period
Data collected against each LocSSIP phase: pre-procedure, intra-procedure, post-procedure
BTS Pleural Disease Guidelines & local LocSSIP policy
Audit Data & Results
Total Procedures Reviewed
47
Overall Checklist Completion
73%
Patient ID confirmed
95%
Consent documented
78%
Site marked / laterality confirmed
82%
Ultrasound performed & documented
70%
Coagulation / anticoagulation checked
58%
Post-procedure plan documented
65%
Specimen labelling
88%
Equipment check
72%
Clinical Audit Review
Key Findings
Summary of the most critical observations and compliance rates from the LocSSIP checklist audit.
Coagulation checks most frequently missed
Only 58% compliance, posing a significant procedural bleeding risk
58%
Post-procedure documentation inconsistent
65% compliance, frequently missing documented follow-up management plans
65%
Ultrasound documentation gaps
70% compliance despite BTS mandating pre-procedure USS
70%
Consent documentation improving but not complete
22% of analysed cases proceeded without formally documented patient consent
78%
No serious adverse events recorded
Patient safety maintained with only 2 minor complications (pneumothorax) in the period
0
Recommendations
Standard Target
≥95% compliance with all LocSSIP checklist items (BTS/NatSSIPs)
1
Mandatory Checklist Use
Enforce LocSSIP checklist use for ALL pleural procedures via departmental policy.
2
Targeted Training
Targeted training on coagulation/anticoagulation assessment before procedures.
3
Standardise Documentation
Implement a standard post-procedure documentation template in clinical notes.
4
Embed Ultrasound Details
Integrate required ultrasound documentation directly into the procedure proforma.
5
6-Month Re-audit
Perform a follow-up clinical audit in 6 months to assess compliance improvement.
Thank You
Questions & Discussion
For further information, contact the Clinical Audit Team
- clinical-audit
- locssip
- pleural-procedures
- medical-safety
- patient-safety
- nhs-standards
- bts-guidelines