R E V I E W S & A N A LY S E S Applying the Universal Protocol to Improve Patient Safety in Radiology Services ABSTRACT INTRODUCTION Multiple failed organizational and Although much of the attention paid to patient and procedure verification has focused departmental processes may lead on surgery, occurrences of patient misidentification, procedure mistakes, and side or to wrong-patient, wrong-procedure, site confusion errors and near misses continue to surface outside the surgical suite. wrong-side, and wrong-site errors in Despite quality improvement efforts, the prevalence of these errors in other disciplines, radiology services. Explanations for such namely, radiology services, may be more common than generally expected and reported errors are linked to similarities in sites, in the literature.1 In 2009, the Pennsylvania Patient Safety Authority received reports of diagnostic studies, and patient names; 652 events specifically related to wrong-procedure or test (50%), wrong-patient (30%), breakdowns in communication or wrong-side (15%), and wrong-site (5%) radiology errors. Predominant testing modali- teamwork; patient and procedure fac- ties reported to the Authority included radiography (45%), computed tomography tors; and failed safety systems. Review (CT) scan (18%), mammography (15%), magnetic resonance imaging (MRI) (6%), and of events reported to the Pennsylvania ultrasound (5%). The Table outlines the number of wrong-patient, wrong-procedure, Patient Safety Authority in 2009 identi- wrong-side, and wrong-site events associated with each radiologic study. fied specific processes that exposed Ensuring correct patient identification is a recognized healthcare challenge, and the patients to potential harm, including acute care setting poses the greatest challenge because a wide range of interventions order and scheduling inaccuracies, are delivered in various locations by numerous staff who work in shifts.2 The radiol- patient misidentification, and inaccurate ogy staff—most notably, radiologic technologists—comes in contact with a significant procedure verification practices. Imple- number of patients on a daily basis. Failure to correctly identify patients and correlate menting and enforcing policies that their clinical information to an intended radiologic study continues to result in one of address patient identification and pro- four recognized wrong events: wrong patient, wrong procedure, wrong side, or wrong cedure verification processes to prevent site. Patient misidentification can lead to unnecessary risks, including overexposure to errors, as well as ensuring that staff are radiation, delay in diagnosis and treatment, and incorrect treatment. continually trained, provides radiology While such errors are preventable, they continue to occur and to contribute to services with opportunities for improve- national health and patient safety concerns. Establishing policies and standard prac- ments that not only can be observed tices similar to those developed for surgery and supported by key leadership may by providers but can be expected by help radiology providers in hospitals and outpatient centers reduce variability among patients. (Pa Patient Saf Advis 2011 individual care providers and teams in preventing unintended procedures and untow- Jun;8(2):63-9.) ard patient outcomes. Prevention of these events requires safety systems that ensure accurate procedure ordering and scheduling, as well as patient identification and veri- fication processes that work to ultimately prevent wrong-patient and wrong-procedure errors. It is essential that the effectiveness of implemented safety systems is continually observed, evaluated, and monitored to prevent future events. CAUSES OF THE FOUR WRONG EVENTS Review of the 652 events identified several failed processes that accounted for the wrong events experienced in radiologic services. These processes were categorized as follows: — Incorrect order or requisition entry — Failure to confirm patient identity — Failure to follow site and procedure verification or procedure qualification processes Incorrect Order or Requisition Entry Patients were erroneously subjected to a radiology study as a result of an inaccurate order entry originating from patient care areas (e.g., floor, emergency department [ED]) or radiology registration or clerical personnel or caused by a technologist who selected the wrong option that generated an inaccurate requisition form. Improper orders included order entries that did not specify whether a procedure was to be done with Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 63 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table. Wrong Events by Radiologic Study Reported to the Pennsylvania Patient Safety Authority, 2009 NUMBER OF PERCENTAGE OF RADIOLOGIC STUDY WRONG EVENT WRONG EVENTS WRONG EVENTS Wrong Wrong Wrong Wrong Patient Procedure Side Site Radiography 93 104 75 24 296 45.4% Computed tomography 36 69 4 6 115 17.6 Mammography 7 87 4 0 98 15.0 Magnetic resonance 7 27 5 0 39 6.0 imaging Ultrasound 13 13 6 3 35 5.4 Nuclear medicine 4 8 0 1 13 2.0 Interventional 3 3 0 0 6 0.9 Dexa scan 1 1 0 0 2 0.3 Positron emission 1 0 0 0 1 0.2 tomography Not specified 31 14 2 0 47 7.2 Total Number of 196 326 96 34 652 Events Total Percentage of 30.1% 50.0 14.7 5.2 100 Events or without contrast and order specifica- and the test completed. Requisition Events originating from the physician tions that were the opposite of what was did not state, “no oral contrast.” office include the following: intended. These types of electronic order Event reports submitted to the Authority A test order was received for dobuta- entry errors occurred because of the lack in 2009 also revealed that physician offices mine nuclear cardiac scan. The scan of verification between the placed order often lacked established protocols for was started, and when the patient and the reason for the imaging study verifying clinical information before sched- was able to exercise, [staff] called and because order entry, for the most uling a patient for a radiologic study or [physician’s] office. The physician’s part, was not performed by the ordering procedure. These inadequate protocols led office stated that they realized they physician. Such errors contributed to the to one of the four wrong events, usually had ordered the incorrect study. procedure-type errors that accounted for because of one of the following factors: 50% of the reviewed events (see Table). A script was checked for “bone whole — The physician did not confirm body” but the physician’s office wanted The following are some of the reported orders before a staff member sched- an ankle brachial index instead. The order entry events: uled a procedure. script was incorrectly marked. A physician ordered bilateral hands — Two forms of patient identification A patient arrived for a scheduled and wrist x-rays. The registrar incor- were not used by the ordering staff MRI of the cervical spine. The physi- rectly entered orders for bilateral hands member for the receiving radiology cian’s order was for the thoracic spine. and feet. The technician did not verify staff to verify. MRI of thoracic spine was completed. the physician’s order and completed — An incorrect radiologic study or site The physician’s office notified MRI bilateral hands/wrists and feet x-rays. of study was ordered by the physi- when they received results of incorrect A CT scan of the abdomen and cian and accuracy of the study was test. Test was scheduled correctly, but pelvis were ordered with intravenous not verified, requiring additional physician’s order was incorrect. contrast and no oral contrast. The scanning of the correct site or perfor- patient was prepped for oral contrast mance of the correct study. Page 64 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority One of the most common studies inac- distinct patient identification (e.g., rather performed at the same location for the curately ordered or scheduled from the than using a patient’s name and date of patient. In the events in which a patient physician’s office was mammograms. A birth, for example, patients were identi- had a radiologic study performed under total of 98 near-miss events (i.e., a medical fied using room numbers, or procedure another patient’s name and information, event that could have harmed a patient, or radiologic studies). Other identifica- radiologists subsequently interpreted stud- but harm did not occur as a result of tion mistakes resulted when radiology ies for the wrong patient. Interception of chance, prevention, or mitigation) were staff selected the wrong patient from a the error was usually made by the radiolo- reported pertaining to the improper order, hospital room because the patient misun- gist when comparing the new study to 59 (60%), or scheduling, 39 (40%), of derstood the name called, patients were previous films, after reviewing records, or mammogram services. Physicians ordered not actively engaged in the identification after noting the patient’s birthdate. The a screening rather than a diagnostic mam- process, or the patient for whom a study following events are examples of failed mogram in 43 (73%) events, a diagnostic was intended had been transferred to identification processes: mammogram was ordered instead of another unit, and the new patient occupy- Patient came into the hospital to a screening in 10 (17%) events, and in ing the bed was taken for the radiologic have an ultrasound done. A [radiol- 6 (10%) events, which study had been study instead. Similarly, orders may not ogy] staff member went out to the improperly ordered was not specified. have been canceled for a patient before waiting room to get an outpatient for In other instances, physician orders were transfer to another location, and the a chest x-ray and called for “Mary.” accurate, but scheduling errors occurred: technologist assumed the new patient Mary got up and followed her to 16 (41%) were scheduled as screening occupying the same bed was the former the x-ray department where the staff mammograms instead of diagnostic, 1 (3%) patient. Requiring patients to actively member did a two-view chest x-ray. was scheduled as a diagnostic instead of a respond to questions (i.e., “What is your The staff member did not verify the screening study, and in 22 (56%) events, name?”) rather than passively confirm- patient’s last name or date of birth. the type of study (screening or diagnostic) ing the patient’s information (i.e., “Are It was the wrong Mary. that was erroneously scheduled was not you Jane Doe?”), and accepting a “yes” or “no” answer or a head nod, invites Transport called to bring patient specified. All the reports indicated that the A to radiology. Transport brought proper mammogram study was ultimately opportunities for misidentification errors. As specified by the Joint Commission’s patient B with patient A’s medical performed because staff recognized the record. Technologist verified the need to suggest the more appropriate study. NPSG, the patient’s room number or physical location should never to be used name on medical record and asked as an identifier because a patient’s loca- patient if her name was patient A. Failure to Confirm Patient Patient responded “yes.” The exam tion may change during his or her stay.4 Identity Patient misidentification errors commonly was performed. Nurse then called and Patient misidentification accounted delayed the prescribed procedure for the informed technologist that the wrong for about 30% of the radiology events correct patient or allowed an unnecessary patient was transported to the [radiol- reported to the Authority in 2009, as procedure to be conducted on a patient. ogy] department. noted in the Table. Joint Commission’s Patient was inadvertently scanned in first National Patient Safety Goal (NPSG), Additional factors that contributed to patients receiving inappropriate error. Radiology requested this patient “Improve the accuracy of patient iden- in the central transport tracking tification,” was established to eliminate radiographic studies from failed misiden- tification processes were transporting the system not realizing there were two the errors caused when a procedure or patients with the same name. This treatment is performed on the wrong wrong patient to radiology with the right patient chart, performing a radiographic patient was brought to the scanner patient. NPSG 01.01.01, “Use at least two by transport and verified that he identifiers when providing care, treatment study using the wrong patient name, selecting the wrong patient from the work was this patient (by name only). The and services,” has been in effect since second identifier (date of birth) was January 2003 and is applicable to all three list, misinterpreting the patient’s name or confusing patients having similar- not checked. A short time later, it Joint Commission accreditation programs was discovered that the wrong patient (hospital, ambulatory health care, and sounding names, placing an order on the wrong patient chart, canceling a request had been scanned. office-based surgery).3 The events reported to the Authority consistently noted that on the wrong patient, and mistaking a technologists failed to use two forms of family member who had previous studies Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 65 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Failure to Follow Site and A patient arrived for an upper exter- Patients were also subjected to unneces- Procedure Verification or nal arterial ultrasound exam. The sary or inappropriate radiology studies as Procedure Qualification technologist identified the patient and a result of inadequate screening before Processes began asking the patient about her an imaging study. Failed screening for leg symptoms. The patient described MRI, pregnancy, and renal function Issues of side or site discrepancy—usually symptoms of the lower extremities, often jeopardized patient safety. Patient as a result of inadequate verifica- which seemed appropriate for the recollections of shunts, implants, and tion—made up about 20% of the four exam. The technologist was inter- other forms of metal (e.g., stents, surgical wrong radiology events. Performance of rupted by phone calls and, distracted, clips, bullet shards) or current use of a radiologic studies were often met with performed a lower extremity exam medication that may be contraindicated such challenges of laterality, including without first verifying the physician’s for the procedure (e.g., metformin) were performing of bilateral studies when order. The error was discovered after often inaccurate. In addition, patients only one side was ordered and vice versa, the end of the exam and the patient were given the wrong type of contrast misidentification of the correct body part, was rescheduled. or contrast was given before laboratory and radiographing of additional body A patient arrived with physician results were checked for renal function. parts when not ordered (e.g., cervical and order for an abdominal x-ray to view Additional information on failed screen- thoracic spine imaged when only cervical the kidneys, ureters, and bladder ings may be accessed and reviewed in the ordered). Radiographic errors commonly (KUB) with other modifiers on the following Advisory issues: MRI (March occurred as a result of misinterpreting the form, “left ulcer lower extremity rule 2009), pregnancy (March 2008), and renal order or prescription (e.g., MRI instead of out osteomyelitis.” When the patient function (March 2007). CT scan), administering contrast when no contrast was ordered or, conversely, not was questioned, he insisted on a his- A patient was ordered an obstruc- administering contrast when it had been tory of abdominal pain and the need tion series. The patient was taken ordered, scanning of a particular body for KUB. A KUB was done. After to the radiology department where part when another had been ordered, the incident, the supervisor was noti- she was asked if she was pregnant, misreading an order or the technologist’s fied. The doctor’s office was called to and she responded with a “no.” Staff failure to verify an order, duplicating pro- clarify order. Left leg [radiograph] was person was not aware that a serum cedures because previous test completion needed, not a KUB. The patient was pregnancy test had been ordered. X-ray was not realized by a technologist, and called to return for the correct films. series was completed when the positive mislabeling images. Site misidentification A review of the event reports found that pregnancy test results were received. instances were noted to occur when four (1.2%) of the wrong procedures were An elderly patient with right lower (1) technologists were distracted during performed when an order was misinter- quadrant pain [was in radiology] the procedure, (2) technologists relied on preted because handwritten chart notes, for a CT scan of the abdomen and the direction and symptomatology of the orders, or prescriptions were illegible. pelvis. Technologist injected iodine patient when an order was not available contrast into patient who had a or when the order or physician’s prescrip- A patient registered with a bilateral rib order; [staff] misunderstood the creatinine [level] of 2.4. After the tion referenced an alternate side or site, patient [was questioned] for consent and (3) student technologists were indi- script [because] writing was sloppy. [The technologist] did the x-ray and for intravenous [access], he stated he rectly supervised. was not diabetic and had no history then realized that the script really Staff printed report and noted addi- said “just right side” after a bilateral of kidney dysfunction or disease. [Pre- tional [breast] views needed so the study was completed. vious] labs were normal. Technologist additional [studies] were performed. did not check for current lab results When staff came out to take the A patient came over to the radiology until after the test was done. images to the radiologist, [it was] dis- department with an order for a cervi- covered that she had read the wrong cal spine x-ray. After completion, the THE ROLE OF COMMUNICATION report from the printer. This patient ED called over and said that a lum- IN PREVENTING WRONG needed only to have imaging on the bar spine was supposed to be done EVENTS left breast. Staff did two images of instead. The order was not written clearly and was mistaken for a cervi- In a study that reviewed a prospective the right breast as well as the left. cal spine x-ray. database of physician self-reported occur- The physician was made aware. rences, Colorado researchers found that Page 66 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority wrong-site and wrong-patient surgical A patient was admitted complaining exam performed by another technolo- and procedure errors continue to occur of abdominal pain. The physician gist. The patient was then returned to despite implementation of protocols ordered anterior/posterior CT scan the floor with chart documentation intended to prevent them (i.e., Joint views. Oral contrast was sent to the completed. Radiology received a call Commission Universal Protocol) and all patient. The patient was preoperative; indicating that the wrong patient wrong-patient cases involved errors in the surgeon was upset because now had been transported to the depart- communication.5 Based on their findings surgery is delayed due to contrast. ment. Miscommunication between during the January 2002 to June 2008 The nurse and [unit] secretary did not technologists occurred with patient study period, the authors concluded that inform [radiology] that the CT scan verification. “non-surgical disciplines equally contrib- was ordered without contrast. ute to patient injuries related to wrong-site Patients were susceptible to unnecessary USE OF THE UNIVERSAL procedures” and suggested that the proto- radiation exposure not only because they PROTOCOL IN RADIOLOGY col be expanded to nonsurgical specialties. or a body part was misidentified, but The principles of the Universal Protocol Poor communication is responsible for because failure to communicate changes for Preventing Wrong Site, Wrong Proce- many preventable medical errors.6 Com- or other relevant information permitted dure, Wrong Person Surgery™ outlined munication failures that contribute to technologists to perform studies that had by the Joint Commission8 can be trans- discontinuity of care stem from a variety already been performed or had been can- ferred to disciplines other than surgery of causes, ranging from a lack of interper- celed, as in the following event: to prevent unintended procedures and sonal communication skills to barriers in Order for abdominal ultrasound was patient complications.6 The Universal the work environment to suboptimal use in the “to do” box for the ultrasound Protocol was created to ensure that of computer networking tools.7 The com- technologist. The procedure was com- patients were accurately identified and munication errors in the events reported pleted. Afterward, the technologist procedures correctly scheduled and to the Authority resulted from the follow- found a “cancel” order in the system performed. All healthcare institutions ing types of misinformation: transmission when attempting to complete docu- across all specialties—not just surgical of incomplete or inaccurate information mentation. The technologist found disciplines—have been urged to adhere to (e.g., the ordering physician requested the “cancel” order in the recycle bin. the Universal Protocol as a standardized the wrong procedure, procedures were quality assurance tool.5 scheduled without proper patient infor- Communication programs can success- fully improve the safety culture and Implementation of consistent processes mation), inadequate documentation (e.g., performance in radiology. The role of the that promote safe and accurate verifica- completed studies or canceled orders were technologist is not only to gather, docu- tion in diagnostic radiology is especially not documented), and failure to effec- ment, and transmit patient information; important. Although laterality becomes an tively perform a preprocedure verification he or she must also verify procedures to issue in a limited number of procedures in or time-out (e.g., proper forms of patient be performed or those already completed interventional radiology,9 the four wrong identification were not used and com- by communicating with other personnel events involving an invasive procedure pared to other documents, the ordering or and the patient to ensure that the correct may cause major complications result- referring physician was not contacted to or intended procedure is received and ing in hospital admission, unplanned clarify unclear orders). the correct site is chosen. It may not be increase in the level of care, prolonged In radiology, inadequate communication enough to simply provide tools (e.g., hospitalization, permanent adverse may result in such patient consequences patient handoff forms), because despite sequelae, or death.10 In addition to the as anaphylactic shock when allergies to tools designed to assist communication, Universal Protocol, the National Patient contrast media are overlooked, delay of practices could fail if the proper interac- Safety Agency, in conjunction with the critical treatments if radiographic studies tive communication skills are not used in World Health Organization, implemented are not performed at the correct loca- conjunction with them, as in the follow- a surgical safety checklist especially for tion or the wrong physician is notified of ing event: interventional radiology, which can be patient results, and unnecessary radiation accessed at http://www.nrls.npsa.nhs.uk/ exposure when the wrong body part is Patient arrived in the ED and radiol- resources/?entryid45=73612.10 examined or when the wrong patient is ogy with “hand-off” communication form verified by nurse and transpor- Guidelines for use or adaptation of the selected for a procedure.8 tation for patient. The chart was Universal Protocol for invasive radiology verified by one technologist and the Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 67 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S procedures where determination of later- maintain compliance. (See a sample accuracy of documentation, verifica- ality is required include the following: policy in the toolkit available from tion, and transmission of patient and — Apply the protocol for proper patient the Authority at http://patientsafety procedural information. identification. authority.org/EducationalTools/ — Ensure that two unique patient PatientSafetyTools/Pages/home.aspx.) identifiers are consistently obtained — Mark the site and side of the pro- posed procedure. — Verify that both the requisition and verified by two independent — Perform a preprocedure time-out to and the medical record order are technologists to accurately identify verify the nature of the procedure consistent in the acute care setting. patients, as well as conform to the once the patient is on the procedure For outpatients, consider placing Joint Commission’s NPSG 01.01.01. or examination table. the physician’s order on top of the Acceptable identifiers may be the requisition form so technologists patient’s name, birthdate, medical — Use the time-out to ensure proper can review both documents and record number, or other patient-spe- patient identification has been compare them for consistency before cific identifier (e.g., home telephone entered into the imaging equipment, performing any procedure. Review number).4 Assess staff competency in to establish proper patient position- all available documentation, includ- sustaining error-free patient identifi- ing, and to confirm correlation ing the patient’s history, reason cation and compliance with policy. between the guidance system image for radiologic study, and previous — Provide technologists with the neces- and the patient’s orientation. medical imaging studies. Include a sary training to perform radiologic — Involve all personnel assigned to the checklist with the radiology requisi- studies correctly. Quality of radiation procedure in the time-out process. tion to reduce risks of overradiation, procedures is directly linked to the delay in diagnosis and treatment, or skill and competence of those that are STRATEGIES THAT MITIGATE incorrect treatment. (See the afore- entrusted to performing them.12 The PREVENTABLE WRONG EVENTS mentioned Authority toolkit for a American Registry of Radiologic Tech- Mitigation of preventable errors in radi- sample assessment tool.) Consider nologists (ARRT) recognizes qualified ology requires the implementation of software programs that can “red flag” individuals in medical imaging, inter- system safeguards that improve order and examinations that have been per- ventional procedures, and radiation scheduling practices, patient identifica- formed on the same patient within a therapy.13 Verify that technologists tion, and procedure verification protocols. given time frame. have been appropriately credentialed Consider the following strategies, which — Empower staff to verify orders that through ARRT and can provide are based on a review of events submitted are unclear, illegible, or inconsistent evidence of completing the required to the Authority and on the literature, with patient expectations with the continuing education program. when implementing fail-safe, risk reduc- ordering physician before performing — Advise referring physicians and tion systems: any study. If issues go unresolved, physician practices to actively — Appoint strong leadership within the consult a radiologist to determine acknowledge misidentified patient clinical radiology team to advocate whether a patient should undergo reports or unordered results received the development and implementa- a given procedure. Avoid assump- and notify radiologists so that they tion of policies and procedures that tions by implementing verbal “read can accurately report the miscom- ensure that the right patient and the back” to reconfirm verbal orders and municated information to the proper right site undergo the right proce- improve the effectiveness of commu- referring physician.14 dure before any intervention begins, nication when scheduling radiologic — Develop a campaign to promote and communicate the appointed studies or procedures as defined patient awareness of identification leader to the radiology staff. Observ- by the Joint Commission: “Before protocols. The Authority’s “Did You ing and enforcing compliance of taking action on a verbal order or ID Me” materials (see aforemen- procedures and patient identification verbal report of a test result, staff tioned toolkit), for instance, not only policies is essential for these practices uses a record and ‘read back’ process encourages compliance with verifica- to be effective. Solicit feedback from to verify the information.”11 All tion practices but also serves as a those directly affected by the policy members of the radiology team (i.e., fail-safe mechanism for patients to to determine if the policy is working radiologists, nursing staff, technolo- ask staff about proper identification as intended and if it provides staff gists, clerks, and referring physicians) before the radiologic procedure. with the necessary information to are accountable for ensuring Page 68 Pennsylvania Patient Safety Advisory Vol. 8, No. 2—June 2011 ©2011 Pennsylvania Patient Safety Authority — Survey patients to determine to (1) identify potential failures in opportunities, affect or may later affect whether staff followed implemented systems, (2) discuss the successes and patient well-being. protocols and whether patients felt barriers of implemented processes, Although the causes of errors in radio- involved in the process. Questions and (3) ensure that the premise of logic services may differ from those errors addressing understanding of the safety is at the forefront for all staff. in surgical settings, they are all rooted in procedure performed, patient iden- communication inadequacies and lack of tification practices, involvement in CONCLUSION effective safety systems. Prevention of radi- procedure verification, and ability to Implementation of quality and safety ology-related iatrogenic injuries requires ask questions may serve to monitor strategies poses a significant challenge for the development of safety strategies and communication efforts as well as pro- radiology services, yet provides opportu- initiatives aimed at improving order or vide staff with constructive feedback. nities for improvement. The four wrong scheduling practices, patient identifica- — Share adverse events and near misses events of wrong patient, wrong procedure, tion, and procedure verification protocols with staff at departmental meetings wrong side, and wrong site occur more before any radiologic study or invasive to learn from and improve existing frequently than healthcare providers and procedure. Such initiatives, however, are risk reduction mechanisms. (See a patients may realize, and it is unclear effective only if they are followed by all collection of event examples in the whether their consequences, including who come in contact with patients. Authority toolkit.) Event examples unnecessary exposure to radiation, delay can be used in staff training sessions in treatment, and other possible missed NOTES 1. Seiden S, Barach P. Wrong-side/wrong of a prospective database of physician 10. WHO surgical safety checklist: for radio- site, wrong-procedure, and wrong-patient self-reported occurrences. Arch Surg 2010 logical interventions only [online]. 2010 adverse events: are they preventable? Arch Oct;145(10):978-84. Apr [cited 2010 Dec 7]. Available from Surg 2006 Sep;141(9):931-9. 6. Brook OR, O’Connell AM, Thornton Internet: http://www.nrls.npsa.nhs.uk/ 2. Patient identification. PA PSRS Patient E, et al. Quality initiatives: anatomy and resources/?entryid45=73612. Saf Adv [online]. 2004 Jun [cited 2010 pathophysiology of errors occurring in 11. Joint Commission. PC.02.01.03, EP 20. Nov 12]. Available from Internet: http:// clinical radiology practice. Radiographics In Comprehensive Accreditation Manual for patientsafetyauthority.org/ADVISORIES/ 2010 Sep;30(5):1401-10. Hospitals. Oakbrook Terrace (IL): Joint AdvisoryLibrary/2004/jun1(2)/Pages/ 7. Scott, A. Improving communication for Commission; 2010 Jan. 08.aspx. better patient care. Radiol Technol 2007 12. Ensuring safe, accurate medical radiation 3. US Department of Veterans Affairs. 2010 Jan/Feb;78(3):205-18. procedures: statement by the American Joint Commission national patient safety 8. Joint Commission. The universal protocol Society of Radiologic Technologists. [San- goals ensure review of all elements of for preventing wrong-site, wrong-proce- dra Hayden testimony online]. 2010 Feb performance [online]. 2010 Jan/Feb [cited dure, and wrong-person surgery [poster 26 [cited 2010 Oct 12]. Available from 2010 Nov 17]. Available from Internet: online]. [cited 2010 Oct 12]. Available Internet: http://republicans.energycom- http://www4.va.gov/ncps/TIPS/Docs/ from Internet: http://www.jointcommis- merce.house.gov/Media/file/Hearings/ TIPS_JanFeb10Poster.pdf. sion.org/assets/1/18/UP_Poster.pdf. Health/2010-02-26/ 4. Joint Commission. Standards FAQ 9. Angle JF, Nemcek AA Jr, Cohen AM, et Hayden%20Testimony%20(ASTRO).pdf. details [online]. [cited 2010 Oct 12]. Avail- al. Quality improvement guidelines for 13. American Registry of Radiologic Technol- able from Internet: http://www.joint preventing wrong site, wrong procedure, ogists. Our mission [online]. [cited 2011 commission.org/standards_information/ and wrong person errors: application of May 19]. Available from Internet: https:// jcfaqdetails.aspx?StandardsFaqId=145& the Joint Commission “universal pro- www.arrt.org/. ProgramId=1. tocol for preventing wrong site, wrong 14. Watch for these common radiology 5. Stahel PF, Sabel AL, Victoroff MS, et al. procedure, wrong person surgery” to the mistakes. Healthc Risk Manag 2010 Wrong-site and wrong-patient procedures practice of interventional radiology. J Vasc May;32(5):57. in the universal protocol era analysis Interv Radiol 2008 Aug;19(8):1145-51. Vol. 8, No. 2—June 2011 Pennsylvania Patient Safety Advisory Page 69 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 2—June 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2011 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. 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