Adapting verification processes to prevent wrong radiology events
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Field, Cynthia, author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, September 2018
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Diagnostic Imaging -- statistics & numerical data Medical Errors -- statistics & numerical data Radiology -- statistics & numerical data Continuity of Patient Care Medical Errors -- prevention & control Patient Safety Radiation Exposure -- adverse effects Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Wrong radiology studies can expose patients to risks of harm, from unnecessary radiation exposure or contrast doses to delays in diagnosis or treatment. The Pennsylvania Department of Health reported that more than 16 million radiology studies were performed by Pennsylvania hospitals in 2016. This high frequency of studies and the complexities of the medical-imaging care continuum put patients at risk for wrong patient, wrong procedure, wrong site, wrong side events. The Pennsylvania Patient Safety Authority analyzed wrong radiology events reported from July 2016 through June 2017. Analysts identified 993 wrong radiology events, including near misses (i.e., events that did not reach the patient). The events occurred across the imaging process, from the initial step of ordering through performing the study to the final step of communicating results. Errors involved system failures related to identifying patients and ordering and verifying procedures, including study type, body site, and laterality. Contributing factors cited in event-report details included increased workload, miscommunication, complexities related to healthcare technologies, and studies performed outside of radiology departments. Developing and implementing verification processes specific to the medical-imaging care continuum is essential to reduce the risk of harm from wrong radiology events.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Extent:
- 1 online resource (1 PDF file (13 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101735829 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101735829