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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 9/1/2018 12:00:00 AM

This alert discusses the patient safety incidents which can occur with wrong radiology processes. The Pennsylvania Department of Health reported that more than 16 million radiology studies were performed by Pennsylvania hospitals in 2016. This high frequency of studies and the complexities of the medical-imaging care continuum put patients at risk for wrong patient, wrong procedure, wrong site, wrong side events. The Pennsylvania Patient Safety Authority analyzed wrong radiology events reported from July 2016 through June 2017. Analysts identified 993 wrong radiology events, including near misses (i.e., events that did not reach the patient). More than half of the wrong radiology errors (51.2%) were reports of wrong-patient and wrong-side events. Of the wrong-site radiology events, (65.1%) reached the patient. The most common wrong imaging events involved radiography studies (44.5%) and CT scans (24.5%). The events occurred across the imaging process, from the initial step of ordering through performing the study to the final step of communicating results. Over half of the events occurred during the procedure stage, and the three most common events types occurring during the procedure stage were wrong patient, 30.5%, wrong side, 23.5%, and wrong site, 21.9%. Errors involved system failures related to identifying patients and ordering and verifying procedures, including study type, body site, and laterality. Contributing factors cited in event-report details included increased workload, miscommunication, complexities related to healthcare technologies, and studies performed outside of radiology departments. Wrong radiology studies can expose patients to risks of harm, from unnecessary radiation exposure or contrast doses to delays in diagnosis or treatment. Developing and implementing verification processes specific to the medical-imaging care continuum is essential to reduce the risk of harm from wrong radiology events. A link to Authority resources for radiology imaging verification, an example of the Generations and Northern Manhattan Network's "Radiology Exam Verification and Time Out" form, and other guidance materials are provided in Supplemental Material in the alert.

Additional Details

Device:
MRI, CT, PET, X-Ray, chest tube, central IV line, endotracheal tube
Medication/Gas/Fluid:
contrast media, metformin, isotonic crystalline fluids, normal saline
Medication/IV List:
hypoglycemics, oral, radiocontrast agents, IV


Adapting Verification Processes to Prevent Wrong Radiology Events