1
|
Angcahan DZ, de Guzman AB. The radiology department as a sentinel in fall prevention among Filipino older adult patients. J Med Imaging Radiat Sci 2023; 54:S49-S52. [PMID: 37903708 DOI: 10.1016/j.jmir.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/22/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023]
Abstract
Accidental falls are a serious yet underreported form of adverse event in hospitals. Falls account for the leading cause of injury and mortality among older adults. The World Health Organization (WHO) in 2021 reported that an estimated 64,000 individuals die annually from falls globally. In the Philippines, about 53.6% of older Filipinos are experiencing falls from a small population-specific setting and they are more likely to experience functional declines than the younger population. The radiology departments and radiologic technologists (RTs) play a vital role in preventing accidental falls among Filipino older adult patients. Despite the existing safety standards promulgated by national health agencies, awareness of healthcare professionals such as radiologic technologists (RTs) in low- and middle-income countries (LMICs) such as the Philippines remains limited. As such, promoting a safety culture is deemed a main strategy for patient safety from adverse occurrences of falls among Filipino older adults. In doing so, there is a need to establish an incident reporting system for sentinel events, develop risk assessment tools, and define the needed competencies of RTs in preventing catastrophic falls involving Filipino older adult patients. To the authors' knowledge, this paper is the first of its kind to better understand the safety and predisposing risks for falling among older adults in the field of radiology in the Philippines.
Collapse
Affiliation(s)
- Darwin Z Angcahan
- The Graduate School, University of Santo Tomas, Manila, Philippines; Department of Diagnostic Imaging and Interventional Radiology, Rizal Medical Center, Pasig City, Philippines.
| | - Allan B de Guzman
- The Graduate School, University of Santo Tomas, Manila, Philippines; Research Center for Social Sciences and Education, University of Santo Tomas, Manila, Philippines
| |
Collapse
|
2
|
Bell SK, Dong ZJ, Desroches CM, Hart N, Liu S, Mahon B, Ngo LH, Thomas EJ, Bourgeois F. Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool. J Am Med Inform Assoc 2023; 30:692-702. [PMID: 36692204 PMCID: PMC10018262 DOI: 10.1093/jamia/ocad003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/27/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Patients and families are key partners in diagnosis, but methods to routinely engage them in diagnostic safety are lacking. Policy mandating patient access to electronic health information presents new opportunities. We tested a new online tool ("OurDX") that was codesigned with patients and families, to determine the types and frequencies of potential safety issues identified by patients/families with chronic health conditions and whether their contributions were integrated into the visit note. METHODS Patients/families at 2 US healthcare sites were invited to contribute, through an online previsit survey: (1) visit priorities, (2) recent medical history/symptoms, and (3) potential diagnostic concerns. Two physicians reviewed patient-reported diagnostic concerns to verify and categorize diagnostic safety opportunities (DSOs). We conducted a chart review to determine whether patient contributions were integrated into the note. We used descriptive statistics to report implementation outcomes, verification of DSOs, and chart review findings. RESULTS Participants completed OurDX reports in 7075 of 18 129 (39%) eligible pediatric subspecialty visits (site 1), and 460 of 706 (65%) eligible adult primary care visits (site 2). Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. In total, probable DSOs were identified by 7.5% of pediatric and adult patients/families with underlying health conditions, respectively. The most common types of DSOs were patients/families not feeling heard; problems/delays with tests or referrals; and problems/delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. CONCLUSIONS OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients/families identified DSOs and most of their OurDX contributions were included in the visit note.
Collapse
Affiliation(s)
- Sigall K Bell
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Zhiyong J Dong
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine M Desroches
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Hart
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Liu
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Brianna Mahon
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Long H Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Eric J Thomas
- Department of Medicine, UT Houston—Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, USA
- McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Fabienne Bourgeois
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Lacson R, Hooton S, Licaros A, Lynch E, Healey M, Eappen S, Khorasani R. A Comparison of Two Scheduling Models for Prompt Resolution of Diagnostic Imaging Orders. J Am Coll Radiol 2023; 20:218-221. [PMID: 36509219 DOI: 10.1016/j.jacr.2022.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Ronilda Lacson
- Associate Director of Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Associate Professor of Radiology, Harvard Medical School, Boston, Massachusetts.
| | - Stuart Hooton
- Director of Radiology Care Coordination Services, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andro Licaros
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elyse Lynch
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Healey
- Assistant Professor of Radiology, Harvard Medical School, Boston, Massachusetts; Associate Chief Medical Officer, Brigham and Women's Physicians Organization, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sunil Eappen
- Harvard Medical School, Boston, Massachusetts; Senior Vice President, Medical Affairs; Chief Medical Officer; Interim President, Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ramin Khorasani
- Vice Chair of Radiology, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Distinguished Chair, Medical Informatics, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Director of Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Professor of Radiology, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
4
|
Al-Khafaji J, Townsend RF, Townsend W, Chopra V, Gupta A. Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework. BMJ Open 2022; 12:e058219. [PMID: 35487728 PMCID: PMC9058772 DOI: 10.1136/bmjopen-2021-058219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To apply a human factors framework to understand whether checklists reduce clinical diagnostic error have (1) gaps in composition; and (2) components that may be more likely to reduce errors. DESIGN Systematic review. DATA SOURCES PubMed, EMBASE, Scopus and Web of Science were searched through 15 February 2022. ELIGIBILITY CRITERIA Any article that included a clinical checklist aimed at improving the diagnostic process. Checklists were defined as any structured guide intended to elicit additional thinking regarding diagnosis. DATA EXTRACTION AND SYNTHESIS Two authors independently reviewed and selected articles based on eligibility criteria. Each extracted unique checklist was independently characterised according to the well-established human factors framework: Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0). If reported, checklist efficacy in reducing diagnostic error (eg, diagnostic accuracy, number of errors or any patient-related outcomes) was outlined. Risk of study bias was independently evaluated using standardised quality assessment tools in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS A total of 30 articles containing 25 unique checklists were included. Checklists were characterised within the SEIPS 2.0 framework as follows: Work Systems subcomponents of Tasks (n=13), Persons (n=2) and Internal Environment (n=3); Processes subcomponents of Cognitive (n=20) and Social and Behavioural (n=2); and Outcomes subcomponents of Professional (n=2). Other subcomponents, such as External Environment or Patient outcomes, were not addressed. Fourteen checklists examined effect on diagnostic outcomes: seven demonstrated improvement, six were without improvement and one demonstrated mixed results. Importantly, Tasks-oriented studies more often demonstrated error reduction (n=5/7) than those addressing the Cognitive process (n=4/10). CONCLUSIONS Most diagnostic checklists incorporated few human factors components. Checklists addressing the SEIPS 2.0 Tasks subcomponent were more often associated with a reduction in diagnostic errors. Studies examining less explored subcomponents and emphasis on Tasks, rather than the Cognitive subcomponents, may be warranted to prevent diagnostic errors.
Collapse
Affiliation(s)
- Jawad Al-Khafaji
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ryan F Townsend
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Whitney Townsend
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ashwin Gupta
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| |
Collapse
|
5
|
Lacson R, Khorasani R, Fiumara K, Kapoor N, Curley P, Boland GW, Eappen S. Collaborative Case Review: A Systems-Based Approach to Patient Safety Event Investigation and Analysis. J Patient Saf 2022; 18:e522-e527. [PMID: 35188937 PMCID: PMC8855947 DOI: 10.1097/pts.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were to assess a system-based approach to event investigation and analysis-collaborative case reviews (CCRs)-and to measure impact of clinical specialty on strength of action items prescribed. METHODS A fully integrated CCR process, co-led by radiology and an institutional patient safety program, was implemented on November 1, 2017, at our large academic medical center for evaluating adverse events involving radiology. Quality and safety teams performed reviews for events identified with other departments who maintained their existing processes. This institutional review board-approved study describes the program, including percentage of CCR from an institutional Electronic Safety Reporting System, percentage of CCR per specialty, and action item completion rates and strength (e.g., stronger) based on a Veterans Administration-designed hierarchy. χ2 analysis assessed impact of clinical specialty on strength of action prescribed. RESULTS Seventy-three CCR in 2018 generated 260 action items from 10 specialties. Seventy percent (51/73) were adverse events identified through Electronic Safety Reporting System. The specialty most frequently associated with CCR was radiology (16/73, 22%). Most action items (204/260, 78%) were completed in 1 year; stronger action items were completed in 71 (27%) of 260. Radiology was responsible for 61 action items; 25 (41%) of 61 were strong versus all other specialties with strong action items in 46 (23%) of 199 (P < 0.01). CONCLUSIONS An integrated multispecialty CCR co-led by the radiology department and an institutional patient safety program was associated with a higher proportion of CCR, stronger action items, and higher action item completion rate versus other hospital departments. Active engagement in CCR can provide insights into addressing adverse events and promote patient safety.
Collapse
Affiliation(s)
- Ronilda Lacson
- From the Department of Radiology, Brigham and Women’s Hospital
- Harvard Medical School
| | - Ramin Khorasani
- From the Department of Radiology, Brigham and Women’s Hospital
- Harvard Medical School
| | | | - Neena Kapoor
- From the Department of Radiology, Brigham and Women’s Hospital
- Harvard Medical School
| | - Patrick Curley
- From the Department of Radiology, Brigham and Women’s Hospital
| | - Giles W. Boland
- From the Department of Radiology, Brigham and Women’s Hospital
- Harvard Medical School
| | - Sunil Eappen
- Harvard Medical School
- Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
6
|
Holmberg O, Pinak M. How often does it happen? A review of unintended, unnecessary and unavoidable high-dose radiation exposures. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:R189-R201. [PMID: 34157693 DOI: 10.1088/1361-6498/ac0d64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
High-dose radiation exposures of humans occur every year around the world, and may lead to harmful tissue reactions. This review aims to look at the available information sources that can help answering the question of how often these events occur yearly on a global scale. In the absence of comprehensive databases of global occurrence, publications on radiation accidents in all uses of radiation and on rates of high-dose events in different medical uses of radiation have been reviewed. Most high-dose radiation exposures seem to occur in the medical uses of radiation, reflecting the high number of medical exposures performed. In therapeutic medical uses, radiation doses are purposely often given at levels known to cause deterministic effects, and there is a very narrow range in which the medical practitioner can operate without causing severe unacceptable outcomes. In interventional medical uses, there are scenarios in which the radiation dose given to a patient may reach or exceed a threshold for skin effects, where this radiation dose may be unavoidable, considering all benefits and risks as well as benefits and risks of any alternative procedures. Regardless of if the delivered dose is unintended, unnecessary or unavoidable, there are estimates published of the rates of high-dose events and of radiation-induced tissue injuries occurring in medical uses. If this information is extrapolated to a global scenario, noting the inherent limitations in doing so, it does not seem unreasonable to expect that the global number of radiation-induced injuries every year may be in the order of hundreds, likely mainly arising from medical uses of radiation, and in particular from interventional fluoroscopy procedures and external beam radiotherapy procedures. These procedures are so frequently employed throughout the world that even a very small rate of radiation-induced injuries becomes a substantial number when scaled up to a global level.
Collapse
Affiliation(s)
- Ola Holmberg
- Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria
| | - Miroslav Pinak
- Radiation Safety and Monitoring Section, International Atomic Energy Agency, Vienna, Austria
| |
Collapse
|
7
|
Kasalak Ö, Yakar D, Dierckx RAJO, Kwee TC. Patient safety incidents in radiology: frequency and distribution of incident types. Acta Radiol 2021; 62:653-666. [PMID: 32600067 DOI: 10.1177/0284185120937386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patient safety incidents may be a valuable source of information to learn from and to prevent future errors. PURPOSE To determine the distribution of patient safety incident types in radiology according to the International Classification for Patient Safety (ICPS), and to comprehensively review those incidents that were either harmful or serious in terms of risk of patient harm and reoccurrence. MATERIAL AND METHODS The most recent five-year database (2014-2019) of a radiology incident reporting system was evaluated. RESULTS A total of 480 patient safety incidents were included. Top three ICPS incident types were clinical administration (119/480, 24.8%), resources/organizational management (112/480, 23.3%), and clinical process/procedure (91/480, 19.0%). Harm severities were none in 457 (95.2%) cases, mild in 14 (2.9%), moderate in 4 (0.8%), severe in 3 (0.6%), and unknown in one case. Subsequent Prevention Recovery Information System for Monitoring and Analysis (PRISMA) reviews were performed in 4 (0.8%) cases. The three patient safety incidents that caused severe harm (of which one underwent PRISMA review) involved resources/organizational management (n = 1), clinical process/procedure (n = 1), and medication/IV fluids (n = 1). Three other cases (with no harm in two cases and moderate harm in one case) that underwent PRISMA review involved resources/organizational management (n = 2) and medical device/equipment/property (n = 1). CONCLUSION Radiology-related patient safety incidents predominantly occur in three ICPS domains (clinical administration, resources/organizational management, and clinical process/procedure). Harmful/serious incidents are relatively rare. The standardly and transparently reported findings from this study may be used for healthcare quality improvement, benchmarking purposes, and as a primer for future studies.
Collapse
Affiliation(s)
- Ömer Kasalak
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Derya Yakar
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Rudi AJO Dierckx
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Thomas C Kwee
- Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands
| |
Collapse
|
8
|
Hricak H, Abdel-Wahab M, Atun R, Lette MM, Paez D, Brink JA, Donoso-Bach L, Frija G, Hierath M, Holmberg O, Khong PL, Lewis JS, McGinty G, Oyen WJG, Shulman LN, Ward ZJ, Scott AM. Medical imaging and nuclear medicine: a Lancet Oncology Commission. Lancet Oncol 2021; 22:e136-e172. [PMID: 33676609 PMCID: PMC8444235 DOI: 10.1016/s1470-2045(20)30751-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/13/2022]
Abstract
The diagnosis and treatment of patients with cancer requires access to imaging to ensure accurate management decisions and optimal outcomes. Our global assessment of imaging and nuclear medicine resources identified substantial shortages in equipment and workforce, particularly in low-income and middle-income countries (LMICs). A microsimulation model of 11 cancers showed that the scale-up of imaging would avert 3·2% (2·46 million) of all 76·0 million deaths caused by the modelled cancers worldwide between 2020 and 2030, saving 54·92 million life-years. A comprehensive scale-up of imaging, treatment, and care quality would avert 9·55 million (12·5%) of all cancer deaths caused by the modelled cancers worldwide, saving 232·30 million life-years. Scale-up of imaging would cost US$6·84 billion in 2020-30 but yield lifetime productivity gains of $1·23 trillion worldwide, a net return of $179·19 per $1 invested. Combining the scale-up of imaging, treatment, and quality of care would provide a net benefit of $2·66 trillion and a net return of $12·43 per $1 invested. With the use of a conservative approach regarding human capital, the scale-up of imaging alone would provide a net benefit of $209·46 billion and net return of $31·61 per $1 invested. With comprehensive scale-up, the worldwide net benefit using the human capital approach is $340·42 billion and the return per dollar invested is $2·46. These improved health and economic outcomes hold true across all geographical regions. We propose actions and investments that would enhance access to imaging equipment, workforce capacity, digital technology, radiopharmaceuticals, and research and training programmes in LMICs, to produce massive health and economic benefits and reduce the burden of cancer globally.
Collapse
Affiliation(s)
- Hedvig Hricak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Radiology, Weill Cornell Medical College, New York, NY, USA.
| | - May Abdel-Wahab
- International Atomic Energy Agency, Division of Human Health, Vienna, Austria; Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt; Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Rifat Atun
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Diana Paez
- International Atomic Energy Agency, Division of Human Health, Vienna, Austria
| | - James A Brink
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Lluís Donoso-Bach
- Department of Medical Imaging, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | | | | | - Ola Holmberg
- Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria
| | - Pek-Lan Khong
- Department of Diagnostic Radiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jason S Lewis
- Department of Radiology and Molecular Pharmacology Programme, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Departments of Pharmacology and Radiology, Weill Cornell Medical College, New York, NY, USA
| | - Geraldine McGinty
- Departments of Radiology and Population Science, Weill Cornell Medical College, New York, NY, USA; American College of Radiology, Reston, VA, USA
| | - Wim J G Oyen
- Department of Biomedical Sciences and Humanitas Clinical and Research Centre, Department of Nuclear Medicine, Humanitas University, Milan, Italy; Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, Netherlands; Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Lawrence N Shulman
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Zachary J Ward
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Andrew M Scott
- Tumour Targeting Laboratory, Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia; Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia; School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
9
|
Patient safety in nuclear medicine: identification of key strategic areas for vigilance and improvement. Nucl Med Commun 2020; 41:1111-1116. [PMID: 32769813 PMCID: PMC7556244 DOI: 10.1097/mnm.0000000000001262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective To determine the types of patient safety incidents and associated harm in nuclear medicine practice. Methods This study included 147 patient safety incidents related to nuclear medicine practice and submitted to the incident reporting system of a tertiary care nuclear medicine department between 2014 and 2019. Results The top-three incident types according to the International Classification for Patient Safety (ICPS) were medication/IV fluids (36/147, 24.5%), clinical administration (28/147, 19.0%), and clinical process/procedure (27/147, 18.4%), altogether comprising 61.9% of incidents. Within the medication/IV fluids domain, half of incident subtypes were attributable to supply/ordering, omitted medicine or dose, and wrong dose/strength of frequency. Within the clinical administration domain, appointment and wrong patient represented the majority of incident subtypes. Within the clinical process/procedure domain, the majority of incident subtypes fell in the categories: specimens/results and incomplete/inadequate. There was no patient harm in 145 (98.6%) of cases, mild patient harm in 1 (0.7%) case, and in 1 (0.7%) case, it remained unclear if there was patient harm. In 4 (2.7%) cases, a Prevention Recovery Information System for Monitoring and Analysis evaluation was performed because of the high risk of reoccurrence and patient harm. Conclusions The majority of patient safety incidents in nuclear medicine occur in three main ICPS categories (medication/IV fluids, clinical administration, and clinical process/procedure, in order of decreasing frequency). These can be considered as key strategic areas for incident prevention and patient safety improvement. Nevertheless, the rate of actual patient harm was very low in our series.
Collapse
|
10
|
Rogith D, Satterly T, Singh H, Sittig DF, Russo E, Smith MW, Roosan D, Bhise V, Murphy DR. Application of Human Factors Methods to Understand Missed Follow-up of Abnormal Test Results. Appl Clin Inform 2020; 11:692-698. [PMID: 33086395 DOI: 10.1055/s-0040-1716537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE This study demonstrates application of human factors methods for understanding causes for lack of timely follow-up of abnormal test results ("missed results") in outpatient settings. METHODS We identified 30 cases of missed test results by querying electronic health record data, developed a critical decision method (CDM)-based interview guide to understand decision-making processes, and interviewed physicians who ordered these tests. We analyzed transcribed responses using a contextual inquiry (CI)-based methodology to identify contextual factors contributing to missed results. We then developed a CI-based flow model and conducted a fault tree analysis (FTA) to identify hierarchical relationships between factors that delayed action. RESULTS The flow model highlighted barriers in information flow and decision making, and the hierarchical model identified relationships between contributing factors for delayed action. Key findings including underdeveloped methods to track follow-up, as well as mismatches, in communication channels, timeframes, and expectations between patients and physicians. CONCLUSION This case report illustrates how human factors-based approaches can enable analysis of contributing factors that lead to missed results, thus informing development of preventive strategies to address them.
Collapse
Affiliation(s)
- Deevakar Rogith
- The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, Texas, United States
| | - Tyler Satterly
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States
| | - Dean F Sittig
- The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, Texas, United States.,UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, United States
| | - Elise Russo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Michael W Smith
- Department of Industrial and Mechanical Engineering, Universidad de las Americas Puebla, Cholula, Mexico
| | - Don Roosan
- Department of Pharmacy Practice and Administration, College of Pharmacy Western University of Health Sciences, Pomona, California, United States
| | - Viraj Bhise
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States
| | - Daniel R Murphy
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States.,Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States
| |
Collapse
|
11
|
Lacson R, Gujrathi I, Healey M, Fanning K, Morisset F, Hooton S, Landman A, Eappen S, Boland GW, Khorasani R. Closing the Loop on Unscheduled Diagnostic Imaging Orders: A Systems-Based Approach. J Am Coll Radiol 2020; 18:60-67. [PMID: 33031782 PMCID: PMC7796989 DOI: 10.1016/j.jacr.2020.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/05/2022]
Abstract
Objective: To: 1) describe a System for Coordinating Orders for Radiology Exams (SCORE) which aims to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry (CPOE), 2) assess the impact of SCORE and other related factors (e.g., demographics) on rate of unscheduled orders, and 3) assess the clinical necessity of orders canceled, expired, scheduled and performed. Methods: This Institutional Review Board-approved retrospective study was conducted in a large academic institution between 10/1/2017–7/1/2019. The design and implementation of SCORE is described, including people (e.g., competencies), processes (e.g., standardized procedures) and tools (e.g., EHR interfaces, dashboard). Rate of unscheduled imaging orders was compared pre-SCORE (10/1/17–9/30/18) and post-SCORE (10/1/18–6/30/19) using chi-square analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR and factors related to order resolution were assessed via multivariable analysis. Finally, clinical necessity was manually assessed by two physicians. Results: Pre-SCORE, 52,204/607,020 exam orders were unscheduled (8.6% of orders), compared to 20,900/475,000 exam orders (4.4% of orders) post-SCORE (χ2, p<0.00001), a 49% reduction in unscheduled orders. Among 447 randomly selected orders, orders were addressed via cancellation (57%), expiration (21%), scheduling (1%) and performance (11%). Order resolution was not significantly associated with other factors. 31.9% of cancellations and 27.7% of expired orders remained clinically necessary and were attributed to scheduling and patient-related factors. Conclusion: SCORE significantly reduced unscheduled diagnostic imaging orders. This patient safety initiative may help reduce errors resulting from diagnostic delays due to unscheduled exam orders.
Collapse
Affiliation(s)
- Ronilda Lacson
- Director of Education, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Isha Gujrathi
- Harvard Medical School, Boston, Massachusetts; Research Fellow, Center for Evidence-Based Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Healey
- Harvard Medical School, Boston, Massachusetts; Associate Medical Director, Department of Medicine, Brigham and Women's Physicians Organization; Chief Medical Information Officer, Outpatient Clinical Services, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kelly Fanning
- Vice President, Ambulatory Services and Patient Experience, Ambulatory and Community Health Services, Brigham and Women's Hospital, Boston, Massachusetts
| | - Fauvette Morisset
- Senior Consultant, Analytics, Planning, Strategy, and Improvement, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart Hooton
- Director of Radiology Care Coordination, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adam Landman
- Harvard Medical School, Boston, Massachusetts; Vice President; Chief Information Officer; Digital Innovation Officer, Brigham Health, Boston, Massachusetts
| | - Sunil Eappen
- Harvard Medical School, Boston, Massachusetts; Senior Vice President, Medical Affairs; Chief Medical Officer, Brigham and Women's Hospital, Boston, Massachusetts
| | - Giles W Boland
- Harvard Medical School, Boston, Massachusetts; Chair of the Department of Radiology; President, Brigham and Women's Physicians Organization, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ramin Khorasani
- Harvard Medical School, Boston, Massachusetts; Director of the Center of Evidence Imaging and Vice Chair of Quality/Safety, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
12
|
A new complication registration system for errors in radiology: Initial 5-year experience in a tertiary care radiology department. Eur J Radiol 2020; 130:109167. [PMID: 32682253 DOI: 10.1016/j.ejrad.2020.109167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/12/2020] [Accepted: 07/05/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe and evaluate our initial 5-year experience with a new complication registration system for errors in radiology. MATERIALS AND METHODS This study reviewed all cases that were submitted to a new complication registration system of a tertiary care radiology department between 2015-2019. RESULTS Sixty-seven cases were included. In the group of diagnostic complications/errors (n = 34), there were 21 perceptual errors and 13 cognitive errors. This 61.8 % (21/34) perceptual error rate was not significantly different (P = 0.297) from the 70 % perceptual error rate known from previous literature. In the group of interventional complications (n=19), most cases (47.4 % [9/19]) concerned symptomatic or major hemorrhage. In the group of organizational complications/errors (n=14), the leading incident type according to the International Classification System for Patient Safety was clinical process/procedure with wrong body part/side/site as subclassification (35.7 % [5/14]). Harm severities were none (n=35), mild (n=10), moderate (n=10), severe (n=6), death (n=5), and unknown (n=1). Harm severity of interventional complications was significantly higher (P < 0.05) than that of organizational complications, while there were no significant differences in harm severities between other groups of complications. CONCLUSION It is feasible to implement the radiologic complication registration system that was described in this study. Perceptual mistakes, hemorrhage, and procedures on the wrong body part/side/site dominated in the categories of diagnostic, interventional, and organizational complications/errors, respectively, and these should be the topic of vigilance in clinical practice and further research. Future studies are also required to determine whether this complication registration system reduces radiologic errors and improves healthcare quality.
Collapse
|