Development of minimum data set and dashboard for monitoring adverse events in radiology departments

Background

To reduce the risk of errors, patient safety monitoring in the medical imaging department is crucial. Interventions are required and these can be provided as a framework for documenting, reporting, evaluating, and recognizing events that pose a threat to patient safety. The aim of this study was to develop minimum data set and dashboard for monitoring adverse events in radiology departments.

Material and methods

This developmental research was conducted in multiple phases, including content determination using the Delphi technique; database designing using SQL Server; user interface (UI) building using PHP; and dashboard evaluation in three aspects: the accuracy of calculating; UI requirements; and usability.

Results

This study identified 26 patient safety (PS) performance metrics and 110 PS-related significant data components organized into 14 major groupings as the system contents. The UI was built with three tabs: pre-procedure, intra-procedure, and post-procedure. The evaluation results proved the technical feasibility of the dashboard. Finally, the dashboard's usability was highly rated (76.3 out of 100).

Conclusion

The dashboard can be used to supplement datasets to obtain a more accurate picture of the PS condition and to draw attention to characteristics that professionals might otherwise overlook or undervalue.

From omission to excellence: Reducing the percentage of incomplete trainee reports by ensuring documentation of comparison studies

The inclusion of comparison studies within radiology reports is an important, standard practice. Despite this, we identified that after-hours preliminary reports rendered by trainees within our institution often omitted reference to comparison studies for pediatric inpatient portable radiographs. We addressed this issue through a quality improvement project targeting pediatric radiographs. Key interventions included modifying the structured reports by removing default text in the comparison field, designating the comparison field as mandatory, and restructuring the report templates to remove extraneous information. We also initiated a targeted educational campaign. 392 reports before and 267 reports after intervention (total 732 reports) were evaluated to determine the number of reports lacking comparison information when comparisons were available. Following the interventions, there was a statistically significant decrease in incomplete reports from 12.5% to 6%. This project highlights the success of utilizing structured reporting to improve the quality of trainee reports.

Analyzing the Barriers of Incident Reporting in MRI Practice in Government Hospitals of Saudi Arabia

Background

In health care industry, incident reporting systems are considered effective instruments to learn from adverse events and errors and improve the quality of health care of all the stake holders. The present study has analyzed the challenges and barriers facing the medical staff to report incidents and events in magnetic resonance imaging (MRI) practices in government hospitals of Saudi Arabia.

Materials and Methods

A well-structured MRI safety questionnaire was the primary data collection method, utilizing a quantitative descriptive, cross-sectional survey to highlight the challenges and barriers to incidents reporting in MRI practices. Data were subjected to statistical analysis, and the results have been presented with comprehensive discussions.

Results

The data showed that the fear of retribution, fear of being questioned or interrogated, getting the supervisorons.ection method, reporting, and fear of damage to workers' reputation are the most significant parries that can prevent MRI personnel from reporting, leading to safety issues.

Conclusions

Our findings provide an overview of the hurdles to MRI event/incident reporting in the perceptions of governmental hospitals as well as a number of suggestions for how institutions might minimize these barriers to encourage MRI staff to report.

Health Systems Science - A Primer for Radiologists

Health systems science (HSS) is an educational framework designed to promote improved care through enhanced citizenship and the training of systems-fluent individuals trained in the science of health care delivery.  HSS education in residency builds upon foundations established during medical school, emphasizing practical skills development, and fostering a growth mindset among trainees.  The HSS framework organizes elements of system-based practice for radiology trainees, promoting practice-readiness for providing safe, timely, effective, efficient, equitable and patient centered radiological care. This paper serves as a primer for radiologists to understand and apply the HSS framework. Additionally, we highlight radiology-specific curricular elements aligned with the HSS framework, and provide teaching resources both for classroom education and for resident self-study.

Why don't we inform patients about the risk of diagnostic errors?

The principles of autonomy and informed consent dictate that patients who undergo a radiological examination should actually be informed about the risk of diagnostic errors. Implementing such a policy could potentially increase the quality of care. However, due to the vast number of radiological examinations that are performed in each hospital each day, financial constraints, and the risk of losing trust, patients, and income if the requirement for informed consent is not imposed by law on a state or national level, it may be challenging to inform patients about the risk of diagnostic errors. Future research is necessary to determine if and how an informed consent procedure for diagnostic errors can be implemented in clinical practice.

Patient safety in radiology: Our experience

Background

Present-day radiology departments have very high footfall of patients and are prone to patient safety errors. This study analyses such errors in our hospital.

Methods

Observational cross-sectional analysis of errors over the last 30 months was performed. These were classified using the Eindhoven classification model into technical, organizational, and human errors. Technical errors focused on equipment safety. Organizational errors related to policies. Human errors were subclassified as per the skill rule knowledge model. Root cause analysis was performed wherever necessary, and possible mitigation strategies for ensuring safety were suggested. Errors peculiar to the Armed Forces environment were specifically addressed.

Results

Seventy-seven errors were analyzed. Two were equipment based including faulty pressure injector syringes and radiation leakage from the computed tomography gantry. Of 44 skill-based errors, 09 involved dispatch of wrong reports to dependents owing to identifying patients with serving personnel's name. Four were due to scanning wrong sites. Eleven involved reporting abnormality on the wrong side. Six involved underreporting due to not viewing specific images. The rest were due to failure to omit conflicting elements in the report. Rule-based errors included wrong protocol selection (9 errors), omitting a particular sequence due to individual preference (6 errors), and so on. Knowledge-based errors were due to misinterpretation of findings (4 errors), reporting an abnormality as normal (3 errors), and selection of wrong modality (3 errors).

Conclusion

The findings of this study highlights the importance of voluntary reporting, diligent recording, and in-depth analysis of errors for understanding the causes and formulating possible mitigation strategies.

Radiographers' perception of patient safety culture in radiology

INTRODUCTION

Radiographers play a central role in patient safety because of their knowledge of and responsibilities in relation to the imaging process. To maintain safe care, the workplace must create a safety culture that enables sustainable safety work.

AIM

This study aims to describe radiographers' perceptions of the patient safety culture in radiology units in Sweden.

METHODS

The Swedish Hospital Survey of Patients' Safety Culture (S-HSOPSC) was used to gather descriptive data from 171 Swedish registered radiographers working in five radiology clinics distributed across 15 units. Fifty-one questionnaire items and one open-ended question were analysed, comprising perceptions of the overall safety grade, the frequency of number of reported risks and events, and 14 composites regarding patient safety dimensions.

RESULTS

The radiographers' concerns surrounding the patient safety culture in their workplaces related to weaknesses regarding the safety dimensions "Staffing", "Frequency of error reporting", "Organizational learning - continuous improvement" and "Executive management support for patient safety". They perceived "Teamwork within the unit" to be a strength.

CONCLUSION

Despite some weaknesses in the patient safety culture, the radiographers perceived that the overall patient safety level was good, in part because of their ability to spot risks in time. The executive management, however, needed to improve their feedback on safety measures; and another reason for some weaknesses in the patient safety culture could be staffing issues such as lack of time for meetings for continuous improvement. Managers and leaders have a great responsibility to establish a patient safety culture through support and good leadership.

IMPLICATIONS FOR PRACTICE

An understanding of what creates a safety culture is important to prevent patient safety incidents.

The ACR Learning Network: Facilitating Local Performance Improvement Through Shared Learning

PURPOSE

The ACR Learning Network was established to test the viability of the learning network model in radiology. In this report, the authors review the learning network concept, introduce the ACR Learning Network and its components, and report progress to date and plans for the future.

METHODS

Patterned after institutional programs developed by the principal investigator, the ACR Learning Network was composed of four distinct improvement collaboratives. Initial participating sites were solicited through broad program advertisement. Candidate programs were selected on the basis of assessments of local leadership support, experience with quality improvement initiatives, intraorganizational relationships, and access to data and analytic support. Participation began with completing a 27-week formal quality improvement training and project support program, with local teams reporting weekly progress on a common performance measure.

RESULTS

Four improvement collaborative topics were chosen for the initial cohort with the following numbers of participating sites: mammography positioning (6), prostate MR image quality (6), lung cancer screening (6), and follow-up on recommendations for management of incidental findings (4). To date, all sites have remained actively engaged and have progressed in an expected fashion. A detailed report of the results of the improvement phase will be provided in a future publication.

CONCLUSIONS

To date, the ACR Learning Network has successfully achieved planned milestones outlined in the program's plan, with preparation under way for the second and third cohorts. By providing a shared platform for improvement training and knowledge sharing, the authors are optimistic that the network may facilitate widespread performance improvement in radiology on a number of topics for years to come.

Evaluation of a national database of completed investigations into radiology service complaints in New Zealand: What can the radiologist, and radiology service providers, learn?

INTRODUCTION

The Health and Disability Commissioner (HDC) is responsible for dealing with most complaints from service users resulting from their interactions with a healthcare service provider in New Zealand. We analysed all published reports involving a radiologist or radiology service in order to gain insights that might promote safer working across the radiology community.

METHODS

We searched the entire HDC online report database choosing a limit of 'radiologist' as occupation.

RESULTS

Twenty-seven investigations were included, published between 1999 and 2021. Seventeen (63%) involved private radiology providers and 10 (37%) involved public providers. Ultrasound featured in 12 cases (44%), x-ray 6 (22%), CT 5 (19%), mammography 2 (7%), MRI 1 (4%) and interventional 1 (4%). Obstetric ultrasound accounted for 9 (75%) of the ultrasound cases. In 24 (89%) cases, the HDC felt an error had been made. Of the 34 radiologists investigated, 21 (62%) were found in breach of the HDC code, with adverse comment made regarding 4 (12%). A total of 46 incidences of different error types were identified including: communication 14 (30%), perceptual 11 (24%), technical 8 (17%) and interpretative 7 (15%). Forty-five incidences of contributing factors were identified, including organizational 9 (20%) and clinical information provided 7 (16%).

CONCLUSION

Errors in radiology practice, leading to complaints, are often multifactorial and systemic. Reflection on the myriad of error types and contributing factors (including 'human factors') is imperative to reduce errors. Multifaceted strategies are likely required for radiologists to enhance their systems and practice.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations

AIM

To describe factors that prevent patient safety incidents in connection with the radiological examination from the radiographer's perspective.

BACKGROUND

Radiology plays an important role in the care chain and involves diagnostic examinations and treatments using various radiation sources and different techniques. Risks for patient safety incidents exist in every phase of a radiological examination. Appropriate use of medical imaging requires a multidisciplinary approach involving staff of different categories to meet the medical objectives and the patient's care needs. In accordance with a Safety-II approach, it is therefore important to understand why things go right and ensure that they do by supporting the conditions for right things to happen.

DESIGN

A qualitative study with a descriptive design.

METHODS

Semi-structured interviews were conducted with 17 radiographers. The data were analysed using theoretical thematic analysis based on the Systems Engineering Initiative for Patient Safety model.

RESULTS

The analysis yielded 20 sub-themes, which describe different success factors contributing to patient safety.

CONCLUSION

Proactive work should focus on collaboration and sharing the necessary knowledge, internally and externally, for care in connection with the radiological examination. The radiological and peri-radiographic knowledge should include monitoring the patient's safety needs before, during and after the radiological examination. The referring clinician has a central role in writing relevant referrals and the radiographer's competence is crucial in monitoring the patient's safety needs. A good patient safety culture is required and working with standards is important.

Patient-centered Care and Integrated Practice Units: Embracing the Breast Care Continuum

Patient-centered care is a health care approach optimized for the needs of the patient. As patients have sought more autonomy in recent years, this model has been more frequently adopted. Breast radiologists aspiring to advance patient-centered care should seek greater ownership of the breast diagnostic imaging and intervention workflows, helping their patients navigate the complex breast care landscape with patients' preferences taken into account. Applying this approach to breast radiology will increase patient satisfaction and compliance while also limiting wasted health care dollars, unnecessary diagnostic delays, and overall confusion. Herein, the benefits of patient-centered breast radiology are discussed, and numerous suggestions and case examples are provided to help readers reshape their practice toward the priorities of their patients.

Strengthening the Clinical Learning Environment by Mandate-Implementing the ACGME Common Program Requirements

RATIONALE

Three years ago, the Accreditation Council for Graduate Medical Education (ACGME) introduced updated Common Program Requirements in recognition of the need to further promote resident and faculty member well-being and patient safety. The ACGME acknowledged residencies would need time to comply with new requirements. This grace period, however, concluded as of July 1, 2019, and programs now risk citations for failure to implement new requirements.

METHODS AND RESULTS

The authors, members of the Association of Program Directors in Radiology Common Program Requirements Ad Hoc committee, developed downloadable resources provided in the Appendix delineating the 2019 Common Program Requirements and offering sample resources as compliant solutions.

CONCLUSION

The resources offer a national standardized approach to educating trainees in these essential skills and should be especially helpful to programs with access to fewer resources. In addition to achieving compliance, incorporation of these resources into residency training will ensure the next generation of radiologists are equipped to add value while remaining physically and emotionally healthy.

Emergency Radiology: Evolution, Current Status, and Future Directions

Emergency Radiology is a clinical practice and an academic discipline that has rapidly gained increasing global recognition among radiology and emergency/critical care departments and trauma services around the world. As with other subspecialties, Emergency Radiology practice has a unique scope and purpose and presents with its own unique challenges. There are several advantages of having a dedicated Emergency Radiology section, perhaps most important of which is the broad clinical skillset that Emergency Radiologists are known for. This multi-society paper, representing the views of Emergency Radiology societies in Canada and Europe, outlines several value-oriented contributions of Emergency Radiologists and briefly discusses the current state of Emergency Radiology as a subspecialty.

Use of a PACS Embedded System for Communicating Radiologist to Technologist Learning Opportunities and Patient Callbacks

OBJECTIVE

This study aimed to determine effect of modality, care setting, and radiology subspecialty on frequency of diagnostic image quality issues identified by radiologists during image interpretation.

METHODS

This Institutional Review Board-exempt retrospective study was performed 10/1/18-6/30/20 at an academic radiology practice performing 700,000+ examinations annually. A closed-loop communication tool integrated in PACS workflow enabled radiologists to alert technologists to image quality issues. Radiologists categorized communications as requiring patient callback, or as technologist learning opportunities if image quality was adequate to generate a diagnostic report. Fisher's exact test assessed impact of imaging modality, radiology subspecialty, and care setting on radiologist-identified image quality issues.

RESULTS

976,915 imaging examinations were performed during the study period. Radiologists generated 1,935 technologist learning opportunities (0.20%) and 208 callbacks (0.02%). Learning opportunity rates were highest for MRI (0.60%) when compared to CT (0.26%) and radiography (0.08%) (p<0.0001). The same was true for patient callbacks (MRI 0.13%, CT 0.02%, radiography 0.0006%; p<0.0001). Outpatient examinations generated more learning opportunities (1479/637,092; 0.23%) vs. inpatient (305/200,206; 0.15%) and Emergency Department (151/139,617; 0.11%) (p<0.0001). Abdominal subspecialists were most likely to generate learning opportunities when compared to other subspecialists and cardiovascular imagers were most likely to call a patient back.

CONCLUSIONS

Image quality issues identified by radiologists during the interpretation process were rare and 10 times more commonly categorized as learning opportunities not interfering with a clinically adequate report than as requiring patient callback. Further work is necessary to determine if creating learning opportunities leads to fewer patients requiring repeat examinations.

Error and cognitive bias in diagnostic radiology

The above article was posted prematurely on 31 August 2021. The article will be made fully available at a later date.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

Patient safety incidents in radiology: frequency and distribution of incident types

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.

Clinicians' Perceptions of Picture Archiving and Communication System (PACS) Use in Patient Care in Eastern Province Hospitals in Saudi Arabia

Purpose

The picture archiving and communication system (PACS) is one of the most important tools used in patient care in many hospitals worldwide. It allows clinicians to remotely communicate and consult with other clinicians on patient cases and view diagnostic images from different angles, thus facilitating patient diagnosis and treatment. Several studies have been conducted in Saudi Arabia to evaluate different aspects of PACS use; however, no comprehensive study has been conducted in its Eastern Province. This study aimed to investigate clinicians’ perceptions of the advantages and disadvantages of the use of PACS in Eastern Province hospitals in Saudi Arabia and identify the factors that affect their perceptions and its use. In addition, it aimed to gather recommendations of clinicians for improving the system and its implementation.

Methods

A qualitative approach with grounded theory method was employed. A sample of 18 residents, radiologists, and consultants from three Eastern Province hospitals in Saudi Arabia participated in the study. Data were collected using semi-structured interviews over a period of 7 months.

Results

The perceived advantages of PACS included providing quality images and the ability to manipulate their resolution, whereas the perceived barriers included low-speed internet connections and technical problems. Participants recommended providing clinicians remote access to the system and implementing a mobile PACS application. The theory that emerged from the analysis revealed that demographic, system-related, and hospital-related factors affected participants’ perspectives of PACS and its use.

Conclusion

The results of this study and its theoretical model can help identify areas of improvement and inform policy and strategic planning for the effective implementation of PACS in patient care in Saudi Arabia.

Interventional radiology in gynecology and obstetric practice: Safety issues

Interventional radiology is continuing to reshape current practice in many specialties of clinical care and the fields of gynecology and obstetrics are no exception. Imaging skills, clinical knowledge as well as vascular and non-vascular interventional technical ability, are essential to practice interventional radiology effectively. Patient safety is of paramount importance in interventional radiology as in all branches of medicine. Potential failures occur throughout successful procedures and are attributed to a spectrum of errors, including equipment unavailability, planning errors, and communication errors. These are mainly preventable by improved preprocedural planning and teamwork. Of all the targeted and effective actions that can be undertaken to reduce adverse events, the use of safety checklists might have a prominent role. The advantage of a safety checklist for interventional radiology is that it guarantees that human error in terms of forgetting key steps in patient preparation, intraprocedural care, and postoperative care are not forgotten.

Radiology Trainees' Perceptions of Speaking up Culture Related to Safety and Unprofessional Behavior in Their Work Environments

OBJECTIVE. The purpose of this study was to compare radiology trainees' perceptions of the culture regarding speaking up about patient safety and unprofessional behavior in the clinical environment and to assess the likelihood that they will speak up in the presence of a medical hierarchy. MATERIALS AND METHODS. The study included radiology trainees from nine hospitals who attended a communication workshop. Trainees completed questionnaires assessing their perceptions of the support provided by their clinical environment regarding speaking up about patient safety and unprofessional behavior. We also queried their likelihood of speaking up within a team hierarchy about an error presented in a hypothetical clinical vignette. RESULTS. Of 61 participants, 58 (95%) completed questionnaires. Of these 58 participants, 84% felt encouraged by colleagues to speak up about safety concerns, and 57% felt encouraged to speak up about unprofessional behavior (p < .001). Moreover, 17% and 34% thought speaking up about safety concerns and unprofessional behavior, respectively, was difficult (p < .02). Trainees were less likely to agree that speaking up about unprofessional behavior (compared with speaking up about safety concerns) resulted in meaningful change (66% vs 95%; p < .001). In a vignette describing a sterile technique error, respondents were less likely to speak up to an attending radiologist (48%) versus a nurse, intern, or resident (79%, 84%, and 81%, respectively; p < .001). Significant predictors of the likelihood of trainees speaking up to an attending radiologist included perceived potential for patient harm as a result of the error (odds ratio [OR], 6.7; p < .001), perceptions of safety culture in the clinical environment (OR, 5.0; p = .03), and race or ethnicity (OR, 3.1; p = .03). CONCLUSION. Radiology trainees indicate gaps in workplace cultures regarding speaking up, particularly concerning unprofessional behavior and team hierarchy.

Establishing a magnetic resonance safety program

Establishing a magnetic resonance (MR) safety program is crucial to ensuring the safe MR imaging of pediatric patients. The organizational structure includes a core safety council and broader safety committee comprising all key stakeholders. These groups work in synchrony to establish a strong culture of safety; create and maintain policies and procedures; implement device regulations for entry into the MR setting; construct MR safety zones; address intraoperative MR concerns; guarantee safe scanning parameters, including complying with specific absorption rate limitations; adhere to national regulatory body guidelines; and ensure appropriate communication among all parties in the MR environment. Perspectives on the duties of the safety council members provide important insight into the organization of program oversite. Ultimately, the collective dedication and vigilance of all MR staff are crucial to the success of a safety program.

Patient safety in nuclear medicine: identification of key strategic areas for vigilance and improvement

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.

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital

BACKGROUND

Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety.

OBJECTIVE

To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role.

MATERIALS AND METHODS

All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities.

RESULTS

In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%).

CONCLUSION

Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.

A new complication registration system for errors in radiology: Initial 5-year experience in a tertiary care radiology department

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.

Consensus survey on pre-procedural safety practices in radiological examinations: a multicenter study in seven Asian regions

OBJECTIVE

To understand the status of pre-procedural safety practices in radiological examinations at radiology residency training institutions in various Asian regions.

METHODS

A questionnaire based on the Joint Commission International Accreditation Standards was electronically sent to 3 institutions each in 10 geographical regions across 9 Asian countries. Questions addressing 45 practices were divided into 3 categories. A five-tier scale with numerical scores was used to evaluate safety practices in each institution. Responses obtained from three institutions in the United States were used to validate the execution rate of each surveyed safety practice.

RESULTS

The institutional response rate was 70.0% (7 Asian regions, 21 institutions). 44 practices (all those surveyed except for the application of wrist tags for identifying patients with fall risks) were validated using the US participants. Overall, the Asian participants reached a consensus on 89% of the safety practices. Comparatively, most Asian participants did not routinely perform three pre-procedural practices in the examination appropriateness topic.

CONCLUSION

Based on the responses from 21 participating Asian institutions, most routinely perform standard practices during radiological examinations except when it comes to examination appropriateness. This study can provide direction for safety policymakers scrutinizing and improving regional standards of care.

ADVANCES IN KNOWLEDGE

This is the first multicenter survey study to elucidate pre-procedural safety practices in radiological examinations in seven Asian regions.

Customer Service in Radiology: Satisfying Your Patients and Referrers

Radiology has long been a service-oriented specialty. Although physicians in other specialties have direct interactions with patients, radiologists' interactions with patients are often indirect, most often occurring as a direct result of another provider's order. As such, radiology practices have had to focus on two distinct groups, patients and ordering providers, to grow their businesses and retain their patients. One could argue that during the past 2 decades, many of the most visible customer service initiatives in radiology practices have been directed toward the ordering provider. These initiatives have included implementing picture archiving and communication systems to improve image distribution and availability, voice dictation systems to decrease report turnaround time, computerized order entry to ease the ordering process, and structured reporting to improve the readability of the radiology report. As the practice of radiology is evolving to become more patient oriented, it is clear that the specialty needs to pivot and implement more initiatives that directly benefit patients. In this article, the concepts of customer service and a radiology department's primary customer are defined and discussed, and the concept of service quality is introduced. In addition, the author highlights the five dimensions of service quality: reliability, assurance, tangibles, empathy, and responsiveness. Each dimension is described in detail, first by using an archetypal business example and then by using an example of a project that has been successfully implemented in the author's radiology department. ^©RSNA, 2018.

Acing the Joint Commission Regulatory Visit: Running an Effective and Compliant Safety Program

Ensuring the safety of patients and staff is a core effort of all health care organizations. Many regulatory agencies, from The Joint Commission to the Occupational Safety and Health Administration, provide policies and guidelines, with relevant metrics to be achieved. Data on safety can be obtained through a variety of mechanisms, including gemba walks, team discussion during safety huddles, audits, and individual employee entries in safety reporting systems. Data can be organized on a scorecard that provides an at-a-glance view of progress and early warning signs of practice drift. In this article, relevant policies are outlined, and instruction on how to achieve compliance with national patient safety goals and regulations that ensure staff safety and Joint Commission ever-readiness are described. Additional critical components of a safety program, such as department commitment, a just culture, and human factors engineering, are discussed. ^©RSNA, 2018.

Just Culture: Practical Implementation for Radiologist Peer Review

Peer review is a cornerstone of quality improvement programs and serves to support the peer learning process. Peer review in radiology incorporates the review of diagnostic imaging interpretation, interventional procedures, communication, and the evaluation of untoward patient events. A just culture is an environment in which errors and near-miss events are evaluated in a deliberately nonpunitive framework, avoiding a culture of blame and responsibility and focusing instead on error prevention and fostering a culture of continuous quality improvement. Adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to ensure future systems improvements and a culture of safety. The authors describe the practical implementation of a just culture framework for peer review in an academic radiology department and highlight its application to interpretive, noninterpretive, and procedural domains through case examples.

Reporting of Perioperative Adverse Events by Pediatric Anesthesiologists at a Tertiary Children's Hospital: Targeted Interventions to Increase the Rate of Reporting

BACKGROUND

Incident reporting systems (IRSs) are important patient safety tools for identifying risks and opportunities for improvement. A major IRS limitation is underreporting of incidents. Perioperative anesthesia IRSs have been established at multiple pediatric institutions and a national pediatric anesthesia IRS for perioperative serious adverse events (SAEs) is maintained by Wake Up Safe (WUS), a patient safety organization dedicated to pediatric anesthesia quality improvement. A confidential, electronic, perioperative IRS was instituted at our tertiary children's hospital, which is a WUS member. The primary study aim was to increase the rate of incident reporting by anesthesiologists at our institution through a series of interventions. The secondary aim was to characterize our reporting behavior relative to national practice by referencing SAE data from WUS.

METHODS

Perioperative adverse events reported over a 71-month period (November 2010 to September 2016) were categorized and the monthly reporting rates determined. Effects of 6 interventions targeted to increase the reporting rate were analyzed using control charts. Intervention 5 involved interviewing pediatric anesthesiologists to ascertain incident reporting barriers and motivators. A key driver diagram was developed and used to guide an improvement initiative. Incidents that fulfilled WUS criteria for SAEs were identified and categorized. SAE reporting rates over a 27-month period for 12 WUS member institutions were determined.

RESULTS

2689 perioperative adverse events were noted in 1980 of 72,384 anesthetics. Mean monthly adverse event case rate was 273 (95% confidence interval, 250-297) per 10,000 anesthetics. A subgroup involving 54,469 cases had 529 SAEs in 440 anesthetics; a mean monthly SAE case rate of 80 (95% confidence interval, 69-91) per 10,000 anesthetics. Cardiac, respiratory, and airway events predominated. Relative to WUS peer members, our institution is a high-reporting outlier. The rate of incident reporting per 10,000 anesthetics was sustainably increased from 149 ± 35 to 387 ± 73 (mean ± SD) after implementing mandatory IRS data entry and Intervention 5 quality improvement initiative. Barriers to reporting included concern for punitive repercussions, feelings of incompetence, poor education about what constitutes an event, lack of feedback, and the perception that reporting had no value. These were addressed by IRS education, cultivation of a culture of safety where reporting is encouraged, reporter feedback, and better inclusion of anesthesiologists in patient safety work.

CONCLUSIONS

Electronic mandatory IRS data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in the adverse event reporting rate. These strategies to minimize underreporting enhance IRS value for learning and may be generalizable.

Reducing Functional MR Imaging Acquisition Times by Optimizing Workflow

Functional magnetic resonance (MR) imaging is a complex, specialized examination that is able to noninvasively measure information critical to patient care such as hemispheric language lateralization ( 1 ). Diagnostic functional MR imaging requires extensive patient interaction as well as the coordinated efforts of the entire health care team. We observed in our practice at an academic center that the times to perform functional MR imaging examinations were excessively lengthy, making scheduling of the examination difficult. The purpose of our project was to reduce functional MR imaging acquisition times by increasing the efficiency of our workflow, using specific quality tools to drive improvement of functional MR imaging. We assembled a multidisciplinary team and retrospectively reviewed all functional MR imaging examinations performed at our institution from January 2013 to August 2015. We identified five key drivers: (a) streamlined protocols, (b) consistent patient monitoring, (c) clear visual slides and audio, (d) improved patient understanding, and (e) minimized patient motion. We then implemented four specific interventions over a period of 10 months: (a) eliminating intravenous contrast medium, (b) reducing repeated language paradigms, (c) updating technologist and physician checklists, and (d) updating visual slides and audio. Our mean functional MR imaging acquisition time was reduced from 76.3 to 53.2 minutes, while our functional MR imaging examinations remained of diagnostic quality. As a result, we reduced our routine scheduling time for functional MR imaging from 2 hours to 1 hour, improving patient comfort and satisfaction as well as saving time for additional potential MR imaging acquisitions. Our efforts to optimize functional MR imaging workflow constitute a practice quality improvement project that is beneficial for patient care and can be applied broadly to other functional MR imaging practices. ^©RSNA, 2017.

Radiology Research in Quality and Safety: Current Trends and Future Needs

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.

Implementation and Validation of PACS Integrated Peer Review for Discrepancy Recording of Radiology Reporting

The purpose of this work is to demonstrate the possibility of implementation of a PACS-integrated peer review system based on RADPEER™ classification providing a step-wise implementation plan utilizing features already present in the standard PACS implementation and without the requirement of additional software development. Furthermore, we show the usage and effects of the system during the first 30 months of usage. To allow fast and easy implementation into the daily workflow the key-word feature of the PACS was used. This feature allows to add a key-word to an imaging examination for easy searching in the PACS database (e.g. by entering keywords for different kinds of pathology). For peer review we implemented a keyword structure including a code for each of the existing RADPEER™ scoring language terms and a keyword with the phrase "second reading" followed by the name of the individual radiologist. The use of the short-keys to enter the codes in relation to the peer review was a simple to use solution. During the study 599 reports were peer reviewed. The active participation in this study of the radiologists varies and ranges from 3 to 327 reviews per radiologist. The number of peer review is highest in CT and CR. There are no significant technical obstacles to implement a PACS-integrated RADPEER™ -system based on key-words allowing easy integration of peer review into the daily routine without the requirement of additional software. Peer review implemented in a non-random setting based on relevant priors could already help in increasing the quality of radiological reporting and serve as continuing education among peers. Decisiveness, tact and trust are needed to promote use of the system and collaborative discussion of the results by radiologist.

Applications of process improvement techniques to improve workflow in abdominal imaging

Major changes in the management and funding of healthcare are underway that will markedly change the way radiology studies will be reimbursed. The result will be the need to deliver radiology services in a highly efficient manner while maintaining quality. The science of process improvement provides a practical approach to improve the processes utilized in radiology. This article will address in a step-by-step manner how to implement process improvement techniques to improve workflow in abdominal imaging.