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Kneifati-Hayek JZ, Geist E, Applebaum JR, Dal Col AK, Salmasian H, Schechter CB, Elhadad N, Weintraub J, Adelman JS. Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? BMJ Qual Saf 2024; 33:132-135. [PMID: 38071526 PMCID: PMC10872565 DOI: 10.1136/bmjqs-2023-016162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/24/2023] [Indexed: 12/22/2023]
Abstract
Studying near-miss errors is essential to preventing errors from reaching patients. When an error is committed, it may be intercepted (near-miss) or it will reach the patient; estimates of the proportion that reach the patient vary widely. To better understand this relationship, we conducted a retrospective cohort study using two objective measures to identify wrong-patient imaging order errors involving radiation, estimating the proportion of errors that are intercepted and those that reach the patient. This study was conducted at a large integrated healthcare system using data from 1 January to 31 December 2019. The study used two outcome measures of wrong-patient orders: (1) wrong-patient orders that led to misadministration of radiation reported to the New York Patient Occurrence Reporting and Tracking System (NYPORTS) (misadministration events); and (2) wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder (RAR) measure, a measure identifying orders placed for a patient, retracted and rapidly reordered by the same clinician on a different patient (near-miss events). All imaging orders that involved radiation were extracted retrospectively from the healthcare system data warehouse. Among 293 039 total eligible orders, 151 were wrong-patient orders (3 misadministration events, 148 near-miss events), for an overall rate of 51.5 per 100 000 imaging orders involving radiation placed on the wrong patient. Of all wrong-patient imaging order errors, 2% reached the patient, translating to 50 near-miss events for every 1 error that reached the patient. This proportion provides a more accurate and reliable estimate and reinforces the utility of systematic measure of near-miss errors as an outcome for preventative interventions.
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Affiliation(s)
| | - Elias Geist
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jo R Applebaum
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Alexis K Dal Col
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Hojjat Salmasian
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Noémie Elhadad
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Joshua Weintraub
- Department of Radiology, Columbia University, New York, New York, USA
| | - Jason S Adelman
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, New York, USA
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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.
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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
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Hannafin C, Ponce L, Dahiya N, Utecht C, DeYoung D, Flug J. DMAIC Quality Improvement Project to Reduce Specimen-Related Safety Events in Ultrasound. Curr Probl Diagn Radiol 2023; 52:469-473. [PMID: 37495482 DOI: 10.1067/j.cpradiol.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/12/2023] [Accepted: 06/28/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Cathy Hannafin
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Lisa Ponce
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | | | - Charles Utecht
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Dyan DeYoung
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Jonathan Flug
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ.
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Bowman CL, De Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. BMJ Open Qual 2023; 12:e002264. [PMID: 37364940 PMCID: PMC10314656 DOI: 10.1136/bmjoq-2023-002264] [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: 01/17/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable? METHODS For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework. RESULTS Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy). CONCLUSIONS To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.
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Affiliation(s)
- Cara L Bowman
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Ria De Gorter
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Joanna Zaslow
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jacqueline H Fortier
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Gary Garber
- Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, Ontario, Canada
- Department of Medicine, and School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Elliott JEG. The value of case reports in diagnostic radiography. Radiography (Lond) 2023; 29:416-420. [PMID: 36796147 DOI: 10.1016/j.radi.2023.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE - This paper sought to explore the value of case reports in diagnostic radiography with regards to current usage, relevance to evidence-based radiography, and educational benefits. KEY FINDINGS Case reports are short accounts of novel pathologies, trauma or treatment with a critical review of relevant literature. Examples within diagnostic radiography include the appearances of COVID-19 alongside examination-level scenarios involving image artefacts, equipment failure and patient incidents in radiology. With greatest risk of bias and lowest generalisability, they are considered as low-quality evidence with generally poor citation rates. Despite this, there are examples of significant discoveries or developments initiated with case reports with important patient care implications. Furthermore, they offer educational development for both reader and author alike. Whereas the former learns about an unusual clinical scenario, the latter develops scholarly writing skills, reflective practice and may generate further, more complex, research. Radiography-specific case reports could capture the diverse imaging skills and technological expertise currently under-represented in traditional case reports. Potential avenues for cases are broad and may include any imaging modality where patient care or safety of other persons may illicit a teaching point. This encapsulates all stages of the imaging process, before, during and after patient interaction. CONCLUSION Despite being low-quality evidence, case reports contribute to evidence-based radiography, add to the knowledge base, and foster a research culture. However, this is contingent upon rigorous peer-review and adherence to ethical treatment of patient data. IMPLICATIONS FOR PRACTICE With the drive to increase research engagement and output at all levels in radiography (student to consultant), case reports may act as a realistic grass-root activity for a burdened workforce with limited time and resources.
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Affiliation(s)
- J E G Elliott
- School of Allied and Public Health Professions, Canterbury Christ Church University, Kent, United Kingdom
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Arad D, Finkelstein A, Rozenblum R, Magnezi R. Perceptions of surgical never events among interdisciplinary clinicians: Implications of a qualitative study for practice. Collegian 2022. [DOI: 10.1016/j.colegn.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Flug JA, Stellmaker JA, Tollefson CD, Comstock EM, Buelna E, Truman B, Ponce L, Milosek A, McCabe J, Jokerst CE. Improving Turnaround Time in a Hospital-based CT Division with the Kaizen Method. Radiographics 2022; 42:E125-E131. [PMID: 35622490 DOI: 10.1148/rg.210128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Kaizen method is an approach to lean process improvement that is based on the idea that small ongoing positive changes can lead to major improvements in efficiency and reduction of waste. The hospital-based CT division at Mayo Clinic Arizona had been receiving numerous concerns of delays in the performance of examinations from inpatients, outpatients, and patients presenting to the emergency department. These concerns, along with a planned hospital expansion, provided the impetus to perform a process improvement project with the goal of reducing inpatient, emergency department, and outpatient turnaround times by 20%. Kaizen process improvement was chosen because of the emphasis on reduction of waste, standardization, and empowerment of frontline staff. The project was led by a process improvement coach who was trained in lean process improvement and A3 thinking. At the end of a weeklong Kaizen event, inpatient turnaround time decreased by 54%, emergency department turnaround time decreased by 29%, and outpatient turnaround time decreased by 45%. These results were achieved and sustained by establishing standardized work, developing frontline problem solvers, instituting visual management, aligning with relevant metrics, emphasizing patient and staff satisfaction, and reducing lead time and non-value-added work. When done properly, a Kaizen event can be an effective tool for process improvement in the health care setting. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jonathan A Flug
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Jessica A Stellmaker
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Chris D Tollefson
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Elaine M Comstock
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Efren Buelna
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Brooke Truman
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Lisa Ponce
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Amy Milosek
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - John McCabe
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
| | - Clinton E Jokerst
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., C.D.T., E.M.C., E.B., B.T., L.P., A.M., J.M. C.E.J.); and Department of Radiology, Mayo Clinic Rochester, Rochester, Minn (J.A.S.)
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Flug JA, Stellmaker JA, Sharpe RE, Jokerst CE, Tollefson CD, Bowman AW, Nordland M, Hannafin CL, Froemming AT. Kaizen Process Improvement in Radiology: Primer for Creating a Culture of Continuous Quality Improvement. Radiographics 2022; 42:919-928. [PMID: 35333633 DOI: 10.1148/rg.210086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Kaizen process improvement is an element of lean production that is an approach to creating continuous improvement. Kaizen is based on the idea that small ongoing positive changes in workflow and elimination of waste can yield major improvements over time. A focused Kaizen event, or rapid process improvement event, can lead to sustainable process improvement in health care settings that are resistant to change. This approach has been proven to be successful in health care. These events are led by a trained facilitator and coach who provides appropriate team education and engagement. To ensure success, the team must embrace the Kaizen culture, which emphasizes the development of a "learning organization" that is focused on relentless pursuit of perfection. The culture empowers all staff to improve the work they perform, with an emphasis on the process and not the individual. Respect for individual people is key in Kaizen. In radiology, this method has been successful in empowering frontline staff to improve their individual workflows. A 5-day Kaizen event has been successful in increasing on-time starts, decreasing lead time, increasing patient and staff satisfaction, and ensuring sustainability. Sustainable success can occur when the team stays true to lean principles, engages leaders, and empowers team members with the use of timely data to drive decision making. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jonathan A Flug
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Jessica A Stellmaker
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Richard E Sharpe
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Clinton E Jokerst
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Chris D Tollefson
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Andrew W Bowman
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Michelle Nordland
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Cathy L Hannafin
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Adam T Froemming
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
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Rosier AS, Tibor LC, Turner MA, Phillips CJ, Kurup AN. Improving Root Cause Analysis of Patient Safety Events in Radiology. Radiographics 2021; 40:1434-1440. [PMID: 32870771 DOI: 10.1148/rg.2020190147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patient safety events occur in health care, and root cause analysis (RCA) meetings held after these incidents often reveal valuable insights into systemic barriers between optimal processes or stated policies and actual practice, providing critical opportunities for improvement. The patient safety team that facilitates RCA meetings in the radiology department at the authors' institution received feedback suggesting dissatisfaction with the RCA process. The team followed a structured process improvement framework to analyze the root causes of this dissatisfaction and create a better system. Using a post-RCA survey to target satisfaction scores as an improvement goal, the team successfully increased participant and facilitator satisfaction levels with sustained results. The patient safety team applied structured process improvement methodologies to their own daily work, learning lessons about measuring difficult processes and choosing appropriate metrics, the benefits of standardized work, and how to continuously improve a quality program. In the course of improving the satisfaction of employees participating in the RCA process, a more robust, continuously improving patient safety program has emerged to enhance the ability of those within the department to report, learn from, and hopefully prevent patient safety events in the future.©RSNA, 2020.
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Affiliation(s)
- Ashley S Rosier
- From the William J. von Liebig Center for Transplantation and Clinical Regeneration (A.S.R.) and Departments of Radiology (C.J.P., A.N.K.), Radiation Oncology (L.C.T.), and Quality Management Services (M.A.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Laura C Tibor
- From the William J. von Liebig Center for Transplantation and Clinical Regeneration (A.S.R.) and Departments of Radiology (C.J.P., A.N.K.), Radiation Oncology (L.C.T.), and Quality Management Services (M.A.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Mara A Turner
- From the William J. von Liebig Center for Transplantation and Clinical Regeneration (A.S.R.) and Departments of Radiology (C.J.P., A.N.K.), Radiation Oncology (L.C.T.), and Quality Management Services (M.A.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Carrie J Phillips
- From the William J. von Liebig Center for Transplantation and Clinical Regeneration (A.S.R.) and Departments of Radiology (C.J.P., A.N.K.), Radiation Oncology (L.C.T.), and Quality Management Services (M.A.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - A Nicholas Kurup
- From the William J. von Liebig Center for Transplantation and Clinical Regeneration (A.S.R.) and Departments of Radiology (C.J.P., A.N.K.), Radiation Oncology (L.C.T.), and Quality Management Services (M.A.T.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Zygmont ME, Gilyard S, Hanna TN, Johnson JO, Herr KD. Using Point-of-Care Patient Photographs With Musculoskeletal Radiography to Identify Errors of Laterality in Emergency Department Imaging. Curr Probl Diagn Radiol 2020; 50:787-791. [PMID: 33243454 DOI: 10.1067/j.cpradiol.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/19/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the utility of point-of-care patient photographs accompanying musculoskeletal (MSK) radiography to identify errors in laterality. MATERIALS AND METHODS In this Institutional Review Board-approved study, 347 consecutive MSK radiograph-photograph combinations and corresponding radiography provider orders between October 1, 2018 and January 31, 2019, were retrospectively reviewed. Photographs were obtained simultaneously with the radiographs using the PatCam System (Camerad Technologies, Decatur, GA). In each case, laterality was recorded for all photographs, radiograph side markers, and radiography orders, and any laterality discrepancy among these variables was recorded. The side indicated on the provider order was taken as the gold standard. RESULTS Three hundred and forty-seven consecutive MSK radiograph-photograph combinations from 253 unique patients consisted of 129 upper extremity and 218 lower extremity radiographs. Two discrepancies (0.58%) in laterality were identified. The first discrepant case consisted of a left foot radiograph, which was labeled as "R" on the radiograph and left on the order. In this case, the patient photograph confirmed with certainty that the incorrect side marker was placed. The second discrepant case was a hip radiograph, in which 1 of 3 images had discrepant L/R labeling; the patient was covered with a sheet, both hips were included in the photograph, but a monitoring device on the patient's left side in the photograph also included on the radiographs determined which film was incorrectly labeled. CONCLUSIONS Patient photographs obtained concurrently with MSK radiographs can provide a valuable quality tool in identifying errors of laterality. In our study, over 1 in 200 patients was identified as having such an error.
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Affiliation(s)
- Matthew E Zygmont
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Shenise Gilyard
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Tarek N Hanna
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Jamlik-Omari Johnson
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Keith D Herr
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
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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.
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Khalatbari H, Menashe SJ, Otto RK, Hoke AC, Stanescu AL, Maloney EJ, Iyer RS. Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital. Pediatr Radiol 2020; 50:1409-1420. [PMID: 32681235 DOI: 10.1007/s00247-020-04711-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/08/2020] [Accepted: 05/10/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Hedieh Khalatbari
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA.
| | - Sarah J Menashe
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA
| | - Amy C Hoke
- Patient Safety Department, Seattle Children's Hospital, Seattle, WA, USA
| | - A Luana Stanescu
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA
| | - Ezekiel J Maloney
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA
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Schwartz M, Osborn H, Palmieri J, Patel B, Flug JA. Reducing Errors in Radiology Specimen Labeling Through Use of a Two-person Check. Curr Probl Diagn Radiol 2020; 49:351-354. [PMID: 32113747 DOI: 10.1067/j.cpradiol.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 12/03/2019] [Accepted: 01/06/2020] [Indexed: 11/22/2022]
Abstract
Improper specimen labeling of biopsy samples can cause substantial harm to patients through diagnostic delays, administration of inappropriate treatments, and can result in a loss of trust in the healthcare system. Specimen labeling errors are considered a relevant safety metric in our department and tracked on a rolling basis. One imaging section was noted to have nearly completely eliminated these errors through implementation of a 2-person check prior to submission to pathology. The purpose of this intervention was to identify the causes of continued specimen labeling errors in radiology and to standardize the specimen labeling workflow across the department of radiology to include the best practice identified in breast imaging utilizing a 2-person check. Preintervention, 31 specimen labeling errors were reported by the procedural staff over a period of 149 weeks resulting in an error rate of 0.21 errors per week. Postintervention, 3 specimen labeling errors occurred in the next 46 weeks resulting in a rate of 0.07 errors per week, a 68.8% decrease in the specimen labeling error rate. This quality improvement project highlights the process flaws which contribute to medical errors and demonstrates a potential pathway to try and reduce these errors and patient harm without significant investment in capital or new technology.
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Affiliation(s)
| | - Howard Osborn
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
| | | | - Bhavika Patel
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ
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Delfino JG, Krainak DM, Flesher SA, Miller DL. MRI-related FDA adverse event reports: A 10-yr review. Med Phys 2019; 46:5562-5571. [PMID: 31419320 DOI: 10.1002/mp.13768] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/11/2019] [Accepted: 08/06/2019] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To provide an overview of the types of adverse events reported to the US Food and Drug Administration (US FDA) for magnetic resonance (MR) systems over a 10-yr period. METHODS Two reviewers independently reviewed adverse events reported to FDA for MR systems from 1 January 2008 to 31 December 2017 and manually categorized events into eight event types. Thermal events were further subcategorized by probable cause. Objects that became projectiles were also categorized. RESULTS FDA received 1568 adverse event reports for MR systems between 1 January 2008 and 31 December 2017. This analysis included 1548 reports. Thermal events were the most commonly reported serious injury (59% of analyzed reports). Mechanical events - defined as slips, falls, crush injuries, broken bones, and cuts; musculoskeletal injuries from lifting or movement of the device - (11%), projectile events (9%), and acoustic events (6%) were also observed. CONCLUSIONS Adverse events related to MR systems consistent with the known hazards of the MR environment continue to be reported to FDA. Increased awareness of the types of adverse events occurring for MR imaging systems is important for prevention.
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Affiliation(s)
- Jana G Delfino
- Division of Radiological Health, Center for Devices and Radiological Health, US Food and Drug Administration, 10903 New Hampshire, Ave WO66-Rm 4236, Silver Spring, MD, 20993, USA
| | - Daniel M Krainak
- Division of Radiological Health, Center for Devices and Radiological Health, US Food and Drug Administration, 10903 New Hampshire, Ave WO66-Rm 4236, Silver Spring, MD, 20993, USA
| | - Stephanie A Flesher
- Division of Radiological Health, Center for Devices and Radiological Health, US Food and Drug Administration, 10903 New Hampshire, Ave WO66-Rm 4236, Silver Spring, MD, 20993, USA
| | - Donald L Miller
- Office of In Vitro Devices and Radiological Health, Center for Devices and Radiological Health, US Food and Drug Administration, 10903 New Hampshire, Ave WO66-Rm 4236, Silver Spring, MD, 20993, USA
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